6 MOUTH PREPARATION

As the scope of fixed prosthodontics has expanded, it has become increasingly clear that failures are often attributable to inadequate mouth preparation. In this case, mouth preparation refers to the dental procedures that need to be accomplished before fixed prosthodontics can be properly undertaken. Rarely are crowns or fixed dental prostheses provided without initial therapy of a multidisciplinary and often extensive nature, because the etiologic factors that lead to the need for fixed prosthodontics also promote other pathologic conditions (caries and periodontal disease are the most common). These must be corrected as an early phase of treatment. Fixed prosthodontics is successful only if restorations are placed on well-restored teeth in a healthy environment, a fact that can become obscured in the misguided attempt to try to help a patient by accelerating treatment; unfortunately, such action often leads to unforgivable failure.

This chapter reviews the ways in which treatment by the different dental disciplines relates to fixed prosthodontics. Detailed descriptions of the particular procedures are obviously beyond the scope of this text.

Comprehensive treatment planning ensures that mouth preparation is undertaken in a logical and efficient sequence aimed at bringing the teeth and their supporting structures to optimum health. Equally important is the need to educate and motivate the patient to maintain long-term dental health through meticulous oral hygiene practices. As a general plan, the following sequence of treatment procedures in advance of fixed prosthodontics should be adhered to:

1. Relief of symptoms (chief complaint).

2. Removal of etiologic factors (e.g., excavation of caries, removal of deposits).

3. Repair of damage.

4. Maintenance of dental health.

The following list describes a typical sequence in the treatment of a patient with extensive dental disease, including missing teeth, retained roots, caries, and defective restorations:

Preliminary assessment (Fig. 6-1A)

Emergency treatment of presenting symptoms (Fig. 6-1B)

Oral surgery (Fig. 6-1C)

Caries control and replacement of existing restorations (Fig. 6-1D)

Endodontic treatment (Fig. 6-1E)

Definitive periodontal treatment, possibly in conjunction with preliminary occlusal therapy (Fig. 6-1F)

Orthodontic treatment

Definitive occlusal treatment

Fixed prosthodontics (Fig. 6-1G and H)

Removable prosthodontics (Fig. 6-1I)

Follow-up care

Fig. 6-1 Sequence of treatment. A, The patient has pain that seems to originate from the maxillary right central incisor. In addition, several teeth are missing, and retained roots, caries, calculus, and defective restorations are present. B, Relief of the acute problem by endodontic treatment of the incisor. C, Removal of deposits and unrestorable teeth. D, Caries are controlled, and defective restorations are replaced. The progress of ongoing disease has been halted. E, Endodontic treatment is undertaken, and post and cores and an interim restoration are placed. F, Definitive periodontal treatment is performed. G, Teeth are prepared for the final restoration. H, The fixed restorations are completed. I, Active phase of the treatment has been accomplished. Note that predictable management of complex prosthodontics involving fixed and removable dental prostheses can be facilitated by adopting the technique described on p. 102.

However, the sequence of preparatory treatment should be flexible. Two or more of these phases are often performed concurrently. Carious lesions or defective restorations often prevent proper oral hygiene measures, and their elimination or correction must be a part of preparatory treatment. If caries control results in a pulpal exposure or exacerbates an existing chronic pulpitis, endodontic treatment may be needed earlier than anticipated. When the primary symptoms have been eliminated, the occlusal needs of the patient are carefully evaluated through clinical examination and the study of articulated diagnostic casts. Extensive treatment of both arches simultaneously may be beyond the scope of the nonspecialist, and the use of cross-mounted diagnostically mounted casts should be considered (see p. 102). This enables treatment of each arch to be accomplished predictably and independently. Only when preparatory occlusal treatment is completed will the patient be ready for definitive restorative care.

ORAL SURGERY

Soft Tissue Procedures

Any soft tissue abnormalities that may necessitate surgical intervention should be recognized during the initial or radiographic examination. If necessary, the patient can be referred to an oral surgeon for further consultation and/or treatment. Diagnosis of pathologic conditions can be difficult, and the general practitioner should make the appropriate referral to a specialist when there is doubt.

Elective soft tissue surgery may include alteration of muscle attachments, removal of a wedge of soft tissue distal to the molars, increase of the vestibular depth, or modification of edentulous ridges to accommodate fixed or removable partial prostheses (Fig. 6-2).

Fig. 6-2 A to D, Soft tissue surgery to correct an unfavorable edentulous ridge before fixed dental prosthesis fabrication.

Hard Tissue Procedures

Simple tooth removal is the most common surgical procedure involving hard tissue. It should be performed as early during treatment as possible for maximum healing time and osseous recontouring.

Tuberosity reduction (Fig. 6-3) is also common, especially when there is inadequate space to accommodate a prosthesis. Although maxillary or mandibular tori (Fig. 6-4) seldom interfere with the fabrication of a fixed partial dental prosthesis, their excision may make it easier to design a removable partial dental prosthesis and occasionally improves access for oral hygiene measures.

Fig. 6-3 Tuberosity reduction was indicated for this patient to accommodate a mandibular removable dental prosthesis.

(Courtesy of Dr. J. Bergamini.)

Fig. 6-4 A, Mandibular torus necessitating surgical reduction before the fabrication of a partial removable dental prosthesis. B, Buccal torus that was interfering with oral hygiene.

Impacted or unerupted supernumerary teeth should be removed if damage to adjacent structures can be avoided.

Orthognathic Surgery

Candidates for orthognathic surgery require careful restorative evaluation and attention before treatment. Otherwise, an expected improvement in the facial skeleton may be accompanied by unexpected occlusal dysfunction. After surgery, the connection between plaque control, caries prevention, and periodontal health should be stressed to the patient.

Implant-Supported Fixed Prostheses

Successful implant dentistry requires meticulous selection of the patient and skillful execution of the chosen technique. A team approach to treatment is strongly recommended with close cooperation between the specialties (see Chapter 13).

CARIES AND EXISTING RESTORATIONS

Crowns and fixed dental prostheses are definitive restorations. They are time-consuming and expensive treatment options and should not be recommended unless an extended lifetime of the restoration is anticipated. Many teeth that require crowns are severely damaged or have large existing restorations. Any restoration on such teeth must be carefully examined and a determination made regarding its serviceability. If doubt exists, the restoration should be replaced. Time spent replacing an existing restoration that in retrospect might have been serviceable is a modest price to pay for the assurance that the foundation will be caries free and well restored. Studies have shown that accurately detecting caries beneath a restoration without its complete removal can be very difficult.¹^–³ Even on caries-free teeth, an existing restoration may not be a suitable foundation. Preparation design is different for a foundation than for a conventional restoration, particularly with regard to the placement of retention. In general, when a crown is needed, the dentist should plan to replace any existing restorations. Although most teeth in need of restoration require foundation restorations, small defects resulting from less extensive lesions can often be incorporated in the design of a cast restoration or can be blocked out with cement (Fig. 6-5). The latter is recommended on axial walls where an undercut would otherwise result. If a small defect is present on the occlusal surface, however, it may be better to incorporate it into the final restoration than to block it out. The difficulty, of course, is anticipating this during the preparatory phase of treatment. Assessment is more difficult when an existing crown or fixed dental prosthesis is being replaced. In that case, the extent of damage can be seen only after the defective restoration has been removed.

Fig. 6-5 Small defects (arrow) that would create undercuts are best blocked out intraorally with cement or resin.

FOUNDATION RESTORATIONS

A foundation restoration, or core, is used to build a damaged tooth to ideal anatomic form before it is prepared for a crown. With extensive treatment plans, the foundation may have to serve for an extended time. It should provide the patient with adequate function and should be contoured and finished to facilitate oral hygiene. Subsequent tooth preparation is greatly simplified if the tooth is built up to ideal contour. Then it can be prepared essentially as if it were intact. Guide grooves can be used to facilitate accurate occlusal and axial reduction (see Chapter 8), and the preparation design will be consistent from tooth to tooth. The skills learned preparing preclinical mannequins with “ideal” teeth can be readily transferred to clinical practice.

Selection Criteria

Selection of the foundation material depends on the extent of tooth destruction, the overall treatment plan, and the operator’s preference (Fig. 6-6). The effect of subsequent tooth preparation for the cast restoration on the retention and resistance of the foundation should be considered. Retention features such as grooves or pinholes should be placed sufficiently pulpally to allow adequate room for the definitive restoration. Adhesive retention may be helpful in preventing loss of the foundation during tooth preparation.

Fig. 6-6 The placement of a foundation restoration depends on the extent of damage to the tooth and should always be designed with the definitive restoration in mind. A, Cement. This is suitable when damage is minimal. B, Amalgam. C, Pin-retained amalgam. D, Cast gold. E, Post and core. (See Chapter 12.)

Dental amalgam

Despite its limitations, amalgam is still the material of choice for most foundation restorations on posterior teeth. It has good resistance to microleakage and is therefore recommended when the crown preparation will not extend more than 1 mm beyond the foundation-tooth junction.⁴ It can be shaped to ideal restoration form and serves well as an interim restoration. It has better strength than the glass ionomers, and retention can be provided by undercuts, pins, or slots. Adhesive bonding systems such as those based on 4-methacryloxyethyl trimellitate anhydride (4-META) are also available ⁵^–⁸ and may reduce leakage of the restoration.^9,¹⁰ Additional retention may be provided with the use of polymeric beads supplied with the Amalgambond system.¹¹ Amalgam requires an absolutely rigid matrix for proper condensation; otherwise the foundation will break. Matrix placement can be demanding when a tooth with little remaining coronal tissue is restored. This is discussed in the step-by-step procedure on p. 140. Amalgam has a longer setting time than do the other foundation materials. This normally delays crown preparation until a subsequent patient visit. When this presents a problem, a rapid-setting, high-copper, spherical alloy should be chosen. These can be prepared for a crown about 30 minutes after placement. Spherical amalgams are advantageous for foundation restorations because they have greater early strength than do admixed materials, which makes fracture soon after placement less of a possibility.¹²

Resin-modified glass ionomer cement

This is a suitable choice for a small lesion. The material sets rapidly, enabling crown preparation to be performed with limited delay. When placed correctly, it exhibits adhesion to dentin, although conventional undercut retention is needed to supplement this. It is important to select a material that has adequate radiopacity. A formulation that is more radiolucent than dentin should not be used as a core, because its radiographic appearance may suggest recurrent caries.¹³ The presence of fluoride in resin modified glass ionomers may help prevent recurrent caries. The chief disadvantage of glass ionomers is their comparatively low strength, which may make the material inferior to amalgam or composite resin for the longer term restoration of extensive lesions.^14,¹⁵

Composite resin

Composite resin exhibits many of the advantages of glass ionomers. It does not require condensation and sets rapidly. Formulations are available that release fluoride, which may provide an anticariogenic benefit.¹⁶ Bonding is achieved with a dentinal bonding agent or by etching a glass ionomer liner. Neither method develops the bond strengths needed to withstand high masticatory forces, and conventional undercut retention is also needed. There are concerns about continued polymerization of the resin and its high thermal expansion coefficient, which may lead to microleakage of the crown.¹⁷ Also of concern is the moisture sorption properties of composite resin that causes delayed expansion and may lead to axial binding of crowns made on composite resin cores.^18,¹⁹ Delayed expansion is not a problem with traditional glass ionomer,²⁰ but it is a problem with the resin–modified glass ionomers and the compomer materials.¹⁹ Conventional tooth-colored composite resin is not recommended as a foundation material, because it is difficult to discern the composite-tooth junction. Special colored core materials should be used.

Pin-retained cast metal core

A cast metal core should be considered for an extensively damaged tooth. The cemented foundation is retained by tapered pins. The preparation requires careful location and placement of the pinholes but otherwise is straightforward. The foundation is fabricated in the laboratory as an indirect procedure. This increases the complexity and expense of treatment but facilitates obtaining good preparation form.

Advantages and disadvantages of the available materials are summarized in Table 6-1.

Table 6-1 FOUNDATION RESTORATION MATERIALS

Step-by-Step Procedures

Amalgam core

1. Isolate the tooth. Rubber dam isolation is strongly recommended for moisture control, infection control, and optimum visibility. Placement follows techniques developed for conventional amalgam restorations, although with extensively damaged teeth, placing the dam can be a problem. Sometimes cotton roll isolation must suffice.

2. Design the tooth preparation with the intended cast restoration in mind. Be sure that the cast restoration does not eliminate retention of the foundation. The preparation differs somewhat from a conventional amalgam restoration. The ensuing discussion highlights these differences.²¹

3. Limit the extent of the outline form. In contrast to conventional amalgam preparations, which are extended to include unsupported enamel and the deep occlusal fissures, a less extensive outline is recommended for foundation restorations, because the fissures and contacts are removed during crown preparation. Although minimizing foundation outline can help conserve supporting tooth structure, the foundation should be adequate for the detection of any carious lesions (Fig. 6-7A).

4. Retain unsupported enamel if convenient. For a conventional amalgam tooth preparation, unsupported enamel must always be removed; otherwise, the enamel may fracture during function and leave a deficient margin. However, for a foundation restoration, the unsupported enamel may be preserved most effectively if it is substantial enough to withstand condensation forces and if the enamel-dentin junction is caries free. Preserving unsupported enamel may facilitate matrix placement and improve amalgam condensation (see Fig. 6-7B).

5. Finish the cavosurface margins. For conventional amalgam restorations, cavosurface margins of 90 degrees are needed to minimize the potential for fracturing the enamel and amalgam during function. However, for foundation restorations, the amalgam-tooth interface will not be subjected to high stresses (they are protected by the crown), and marginal fracture is not likely to be a problem. Therefore, a 46- to 136-degree margin is acceptable. Furthermore, such a margin conserves useful tooth substance and improves condensation (Fig. 6-7C).

6. Remove any carious dentin carefully and thoroughly with a hand excavator or large round bur in a low-speed handpiece. Discolored but hard dentin can be left on the pulpal wall, but caries-affected areas at the enamel-dentin junction should be removed completely. If a pulp exposure occurs during the preparation, whether carious or mechanical, endodontics or tooth removal is necessary. A direct pulp cap is not a good choice for a tooth requiring a fixed dental prosthesis; however, if endodontics is elected and the pulp cannot be extirpated immediately, a suitable sedative dressing should be placed.

7. Create optimum resistance form. Good resistance to masticatory forces is as crucial for a foundation as for a conventional restoration. Whenever possible, the tooth preparation should be perpendicular to the occlusal forces. If a sloping axial wall exists, it should be modified into a series of steps to enhance resistance form (Fig. 6-7D).

8. Be sure that the foundation restoration has adequate retention (augmented if necessary by pins, slots, or wells). Proper placement of retention features is essential to the preparation of a successful foundation. The features must be incorporated into the design so they are not eliminated during preparation of the crown (Fig. 6-7D and E).

Fig. 6-7 The principles of preparation design for an amalgam foundation restoration differ slightly from those for a conventional extensive amalgam restoration. A, The outline form of a foundation need not include fissures or proximal or occlusal contacts, provided complete caries removal can be accomplished. B, Unsupported enamel (arrow) can sometimes be left when a foundation restoration is prepared. It may facilitate matrix placement and is removed when the crown is prepared. C, Acute cavosurface margins are acceptable for a foundation restoration but not for a definitive amalgam. D, Resistance form is improved by preparing the tooth in a series of steps perpendicular to the direction of occlusal force. E, When pin retention is used, pinholes should be drilled slightly pulpally and at an angle to the root surface (solid line), in comparison with the way they are placed for a conventional extensive amalgam restoration (dashed line). This ensures that retention for the foundation remains after crown preparation.

This can be a particular problem with the extensive reduction necessary for a metal-ceramic restoration. Pin placement is dictated by root furcations and the size of the pulp chamber. In general, pins should be placed further pulpally than when conventional extensive pin amalgams are being provided; to prevent pulp perforation, they should be positioned at a slight angle to the long axis of the tooth. If a pin is slightly exposed during crown preparation, this may not be a problem—in contrast to the conventional pin-amalgam restoration. With a foundation restoration, the pin-amalgam interface receives little stress during function.

Retention can also be provided by slots or wells. These create less residual stress in the dentin and thus reduces the risk of pulp exposure or damage.²²^–²⁶ They should be placed pulpally to the intended crown margin, at a depth of about 1 mm, with a small carbide bur. Careful condensation of amalgam into the slots ensures good restoration retention.

Bonding agents can assist amalgam retention, but adhesion is not adequate to resist occlusal loading. Retention is currently best provided by conventional means. An example of the use of bonding agents appears in Figure 6-8. If bonding agents are used, the clinician should follow the manufacturer’s directions about storage and manipulation.

Fig. 6-8 Adhesives such as AmalgamBond, a 4-methacryloxyethyl trimellitate anhydride (4-META) product, may be helpful in retaining amalgam foundations. A, Mandibular molar with extensive tooth structure loss prepared for foundation restoration. B, The dentin conditioner (10% citric acid, 3% ferric chloride) is applied in accordance with the manufacturer’s instructions. Then it is rinsed and lightly dried. C, The conditioner is primed, and the operator waits for 20 seconds. If puddles remain, the operator blows to eliminate them. It is not necessary to dry the primer. D to F, The adhesive is mixed, and the powder liner is incorporated and brushed into the prepared cavity. G, The amalgam is condensed while the liner is still wet. H, The finished restoration.

(Courtesy of Parkell Products, Inc., Farmingdale, New York.)

Glass ionomer core

1. Isolate the tooth. As with amalgam preparations, moisture control is critical with glass ionomer preparations (Fig. 6-10). The setting material is very sensitive to moisture. When it is set, it must not be allowed to dry out; otherwise, it deteriorates rapidly. The light-cured, resin-modified glass-ionomers are less sensitive to early moisture.²⁹

2. Prepare the tooth for a casting; then remove any existing restorations and bases, excavate caries, and create the undercut retention. Glass ionomer is best for small foundations on teeth with at least two axial walls of sound dentin remaining. Currently available glass ionomers are not strong enough to be used for large pin-retained foundations. (Often they are chosen when the foundation and crown preparation are completed during one visit.) After tooth preparation and the creation of undercuts, glass ionomer is used to build the tooth up to ideal preparation form, if any defects are relatively small. Adhesion to dentin can be enhanced by removing some of the smear layer with a chemical agent. However, excessive removal of the smear layer is not recommended, because it could lead to pulp irritation. A 20-second application with a dentin-conditioning agent that contains 10% polyacrylic acid should be sufficient. Dry the tooth with a cotton pledget before placing the ionomer; do not use an air syringe.

3. Using a syringe, apply the glass ionomer onto the tooth, being careful not to create voids at the cement-tooth interface. Remember that with the conventional self-hardening formulations, adhesion of glass ionomer to tooth structure occurs only if the cement is placed rapidly after mixing; 10 seconds should be allowed for loading the syringe and 10 seconds for placement and manipulation. Some manufacturers provide an encapsulated delivery system that helps place the cement rapidly. A matrix is not normally needed for a small cavity, inasmuch as the core materials do not slump. After injection, the cement can be rapidly manipulated to shape. However, manipulation beyond 3 or 4 seconds disturbs the developing bond and should be avoided. It is better to overfill slightly and reprepare the tooth after it has set (less than 5 minutes for the metal-containing cements). If a resin-modified glass ionomer is used, this is light-cured according to the manufacturer’s recommendations.

4. Finish the preparation as for other types of cores. Conventional glass ionomers are extremely sensitive to drying, even when they are set, a fact that should be kept in mind when the crown preparation is fabricated, the interim restoration is made, or the impression is made. Resin-modified formulations are less moisture sensitive. Vital teeth are also sensitive to desiccation, and so this consideration should not modify normal practice.

Fig. 6-10 The foundation restoration for this crown was a silver-containing glass ionomer.

Composite resin

Composite resin foundations are much stronger than glass ionomer foundations, a difference that correlates with the higher diametral tensile strength of the composite.³⁰ They are strong enough for larger pin-retained cores. However, the current materials have disadvantages, particularly their absorption of moisture and high thermal expansion, which has led many dentists to avoid composite resin foundations entirely.

Moisture control

Composite resins are sensitive to moisture contamination, and rubber dam isolation is strongly recommended.

Preparation

Because the material sets rapidly (about 5 minutes), composite resin is generally chosen if the dentist wishes to place the foundation and prepare the tooth during the same visit. The crown is prepared to approximate shape first, and then existing restorations and caries are removed. A glass ionomer is an appropriate choice of liner, with additional retention being provided by pins. For convenient access, the pinholes can be prepared and the liner placed before the pins are seated.

Placement

Both light-cured and chemically cured core composite materials are available. Light-cured composite materials have the convenience of extended working time, but there is concern about the adequacy of polymerization, especially around the pins.³¹ The autopolymerizing materials need to be mixed and placed quickly, preferably with the aid of a composite syringe (C-R® syringes).^* A Mylar matrix is used to confine them and provide good adaptation.

Finishing

Composite resin core materials are easily prepared with conventional tooth preparation diamonds.

Pin-retained cast core (Fig. 6-11)

As with glass ionomer and composite resin cores, cast cores are used to build a tooth to ideal preparation form without the need for matrix placement or condensation. However, they require the additional steps of an indirect procedure.

1. Prepare the tooth to approximate shape for a crown, removing any existing restorations and caries. Remove or block out all undercuts, and evacuate any weakly supported dentin.

2. Make pinholes, using the small-diameter twist drill that comes with self-threading pins. The locations for these pins are similar to those for self-threading pins, but all restorations with cast pins must have a common path of placement. Prepare a flat area around each pin location with a large tapered carbide, and make the starting point for the pinhole with a small round bur. Pilot holes 2 mm deep are made for each pin, with the small-diameter twist drill carefully oriented in the planned path of placement. Use of a mouth mirror to observe the angulation of the drills helps ensure correct alignment. Plastic patterns are available for both tapered and parallel-sided cast pins. We prefer the tapered pins because they allow some leeway in paralleling the holes, and their tapered shape provides strength where needed. However, the parallel design is more retentive. The plastic patterns are manufactured to match specific bur sizes, which are used to enlarge the pilot holes. To avoid overheating, always use low rotational speeds when drilling pinholes. Finally, a small countersink is created where the pinhole meets the gingival floor; this facilitates forming a die that is free of defects and helps prevent pin fracture.

3. Make the impression with an elastomeric material, using a lentulo to fill the pinholes. Place a small quantity of mold-release substance (e.g., die lubricant) into each pinhole with a paper point to prevent tearing of the impression. As an alternative, use the plastic pattern for the impression.

4. Fabricate an interim restoration. This procedure is described in Chapter 15. Place loose-fitting pins in the pinholes to provide retention. If retention is not a problem, avoid introducing luting agent into the pinholes when cementing the interim restoration.

5, 6, and 7. Dies, waxing, and casting. These steps present no special problems. Plastic patterns are used to form the pins. If a tapered pin fits loosely, it can be shortened with a scalpel until it fits properly. Retention of pins in the wax pattern is accomplished by flattening the heads of the pins with a heated instrument. The foundation should be waxed as exactly as possible to final preparation form, with particular attention paid to the occlusal reduction. If it is properly performed, a cast core should require minimum finishing in the mouth. If necessary, the die can be sectioned, trimmed, and mounted to facilitate this. The pattern is then invested and cast with the same regimen as for inlay castings (which generally require slightly less expansion than crowns). Factors that affect casting expansion are described in Chapter 22.

8. For try-in and cementation, do all grinding or adjustment of the casting before the cementation. The newly set cement may be damaged by vibration. To be acceptable, the fit of the cast foundation should be good, with complete seating and no discernible rock. A small marginal defect can be tolerated, provided that it is not indicative of incomplete seating, because the margins will be completely covered by the definitive restoration. During cementation, fill the pinholes completely with cement; this can be done with a lentulo.

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Tags: Contemporary Fixed Prosthodontics 4e

Jan 17, 2015 | Posted by mrzezo in Prosthodontics | Comments Off

Pocket Dentistry

Fastest Clinical Dentistry Insight Engine

6: MOUTH PREPARATION

ORAL SURGERY

Soft Tissue Procedures

Hard Tissue Procedures

Orthognathic Surgery

Implant-Supported Fixed Prostheses

CARIES AND EXISTING RESTORATIONS

FOUNDATION RESTORATIONS

Selection Criteria

Dental amalgam

Resin-modified glass ionomer cement

Composite resin

Pin-retained cast metal core

Step-by-Step Procedures

Amalgam core

Bases and varnishes

Matrix placement

Condensation

Contouring and finishing

Glass ionomer core

Composite resin

Moisture control

Preparation

Placement

Finishing

Pin-retained cast core (Fig. 6-11)

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Fastest Clinical Dentistry Insight Engine

6: MOUTH PREPARATION

Pin-retained cast core (Fig. 6-11)

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