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Clinical Case Presentation          Majd Hasanin, Level XI, 42620112
Patient’s Personal Data•   Age: Fifteen Years Old•   Gender: Female•   Nationality: Eritrean•   Occupation: Student (High ...
Chief Complaint‫”أبغى أصلح سني األمامي اللي فوق، الحشوة طاحت، وسني‬                   “‫تحت يألمني‬ “I need my upper tooth...
Chief Complaint                  4
Chief Complaint                  5
Medical History Patient and her guardian (the mother) stated  that the patient is free from any medical  condition.Family...
Past Dental History Single previously endodontically treated  and restored tooth, about a year and a half ago.           ...
Past Dental History                      Single endodontically tx                         & restored tooth                ...
Habits and Oral Hygiene Activities   Patient rarely brushes her teeth.   Technique of brushing: Horizontal Scrub.   Use...
Pretreatment Photographs                           10
Extra-oral Photographs                         11
Intra-oral Photos “Frontal”                              12
Intra-oral Photos “Upper Arch”                                 13
Intra-oral Photos “Lower Arch”                                 14
Intra-oral Photos “Right Side”                                 15
Intra-oral Photos “Left Side”                                16
Diagnostic Aids                  17
Panoramic Radiograph                       18
Radiographs-BitewingsRt                      Lt                             19
Radiographs-PeriapicalsU Rt                       U LtL Rt                       L Lt                                  20
Mounted Diagnostic Casts                           21
Mounted Diagnostic Casts Rt                        Lt                                22
Diagnostic Casts         Maxillary Occlusal View        Mandibular Occlusal View                                   23
Clinical Examination                       24
Extra-oral ExaminationTransverse “non-smile”: Symmetrical face.                          25
Extra-oral Examination• Antro-posterior, Vertical: Slightly convex profile. Class I extra-orally. Competent lips. Norm...
Intra-oral ExaminationTongue, floor of the mouth, Palate and Mucosa areall with-in the normal limit (WNL).               ...
Intra-oral ExaminationGeneralized Inflammation of The Gingiva.                                            28
Intra-oral ExaminationGeneralized Plaque Accumulation, especially in thecervical third of the teeth.                     ...
Intra-oral ExaminationFlaring and slight rotation of the Upper AnteriorTeeth, along with over eruption of the lower ones....
Intra-oral Examination Lower midline is deviated to the right around 3.0mm in comparison to the upper midline.           ...
Intra-oral Examination Several rotated teeth. Multiple carious teeth.                            32
Clinical Examination Generalized presence of Pulp Stones.                                         33
Clinical Examination PSR (Periodontal Screening and Recording):     2 = Pocket Depth < 3.5 mm, bleeding upon probing, cal...
Clinical Examination     Gingival Index (GI):                  By: “Leo and Silness,1963”    18   17   16   15   14   13 ...
Clinical Examination     Plaque Index (PI):               By: “Silness & Loe”,1964    18   17   16   15   14   13   12   ...
Clinical Examination Periodontal Charting (FM): Upper Arch     B     M-     CEJ     M-BP                 333   333   333 ...
Clinical Examination Periodontal Charting (FM): Lower Arch     B     M-     CEJ     M-BP                 333   333   333 ...
Clinical Examination Calculus Index: is: “ Heavy, localized, unilateral, accumulation supra- gingivally” with “Heavy, loc...
Clinical Examination                                                             Key:                                     ...
Clinical Examination                                               Key:                                                   ...
Clinical Examination  Pulpal and Periapical Tests for suspected teethTooth # Cold Test         Vertical Percussion   Hori...
Laboratory Investigations CRT (Caries Risk Test)  Saliva Flow Rate :        12 ml in 5 min = 2.4 ml/min (above standard)...
Laboratory Investigations CRT (Caries Risk Test) Measuring the Acid Production by the  microorganism in the saliva;  Acc...
Laboratory Investigations CRT (Caries Risk Test) Results have revealed the following:  •S.M = 2 < 100,000 CFU Low Risk ...
Diagnosis and Treatment        Planning                          46
Treatment Objectives• Chief Complain.• Oral Hygiene Motivation.• To Restore:   Function.   Structure.   Esthetics.     ...
Preliminary “Emergency”                          48
Preliminary “Emergency”•   Diagnosis for tooth # 36      Non-restorable, remaining root.      Ill-defined radiolucent le...
Phase I (Restorative)                        50
Phase I: (Periodontic Therapy)• Diagnosis for the “Periodontium”:    Generalized Chronic Moderate Gingivitis, resulting f...
Phase I: (Periodontic Therapy)• Proposed Tx.   Scaling and root planning, by ultrasonic scaling and hand    instruments. ...
Phase I: (Periodontic Therapy)• Oral Hygiene Instructions:    Includes the demonstration of the right technique in     br...
Phase I: (Periodontic Therapy)• Oral Hygiene Instructions:    Flossing:                                  54
Phase I: (Periodontic Therapy)• Oral Hygiene Instructions:    General instructions regarding the tooth brush:            ...
Phase I: (Preventive Therapy)• Based upon the CRT the patient will need:   Diet Alteration (less Sweets,      CHO Balance...
Phase I: (Excavation of Caries and Restorations)• Diagnosis for tooth # 17:    Shallow Occlusal Caries (distally).    De...
Phase I: (Excavation of Caries and Restorations)• Diagnosis for tooth # 16:    Occlusal Caries with Palatal     Extension...
Phase I: (Excavation of Caries and Restorations)• Diagnosis for tooth # 15:    Occlusal Caries.    Mesial Caries.    Di...
Phase I: (Excavation of Caries and Restorations)• Diagnosis for tooth # 14:    Occlusal Caries.    Distal Caries.• Propo...
Phase I: (Excavation of Caries and Restorations)• Diagnosis for tooth # 12:    Mesial Caries.• Proposed Tx.    Class III...
Phase I: (Excavation of Caries and Restorations)• Diagnosis for tooth # 11:    Distal Caries.    Incisal Edge Caries.• P...
Phase I: (Excavation of Caries and Restorations)• Diagnosis for tooth # 21:    Mesial Caries.• Proposed Tx.    Excavatio...
Phase I: (Excavation of Caries and Restorations)• Diagnosis for tooth # 24:    Shallow Occlusal Caries.    Deep Intact F...
Phase I: (Excavation of Caries and Restorations)• Diagnosis for tooth # 25:    Occlusal Caries.    Distal Caries.• Propo...
Phase I: (Excavation of Caries and Restorations)• Diagnosis for tooth # 26:    Occlusal Caries with Palatal Extension.• P...
Phase I: (Excavation of Caries and Restorations)• Diagnosis for tooth # 27:    Shallow Occlusal Caries (distally).    De...
Phase I: (Excavation of Caries and Restorations)• Diagnosis for tooth # 37:    Occlusal Caries.• Proposed Tx.    Class I...
Phase I: (Excavation of Caries and Restorations)• Diagnosis for tooth # 35:    Shallow Occlusal Caries.    Deep Intact F...
Phase I: (Excavation of Caries and Restorations)• Diagnosis for tooth # 31:    Mesial Caries.• Proposed Tx.    Class III...
Phase I: (Excavation of Caries and Restorations)• Diagnosis for tooth # 41:    Mesial Caries.    Distal Caries.• Propose...
Phase I: (Excavation of Caries and Restorations)• Diagnosis for tooth # 42:    Distal Caries.• Proposed Tx.    Class III...
Phase I: (Excavation of Caries and Restorations)• Diagnosis for tooth # 43:    Mesial Caries.• Proposed Tx.    Class III...
Phase I: (Excavation of Caries and Restorations)• Diagnosis for tooth # 45:    Occlusal Caries .    Mesial Caries.    D...
Phase I: (Excavation of Caries and Restorations)• Diagnosis for tooth # 46:    Occlusal Caries .    Mesial Caries.    D...
Phase I: (Excavation of Caries and Restorations)• Diagnosis for tooth # 47:    Occlusal Caries .• Proposed Tx.    Class ...
Phase II (Endodontic)                        77
Phase II: (Endodontic Therapy)• Diagnosis for tooth # 21:• Pulpal Diagnosis:    Substandard RCT.• Periapical Diagnosis:  ...
Phase III (Prosthetic Therapy)                                 79
Phase III (Prosthetic Therapy)• Diagnosis for tooth # 21:    Week Remaining Tooth Structure.    RCT.                    ...
Phase III (Prosthetic Therapy)• Diagnosis :     Missing Tooth (# 36).• Proposed Tx.       Implant (Ideal Tx).       Fix...
Phase III (Orthodontic      Therapy)                         82
Orthodontic Consultation• Orthodontic Problem List:• Antro-posterior:   Rt. Molar relationship: ½ unit class II.   Procl...
Orthodontic Consultation• Orthodontic Problem List:• Intra-Arch: Multiple rotations in the upper and lower arches. Mild ...
Orthodontic Consultation Objectives of the Orthodontic tx:   Correction of the Rt molar relationship into a class I.   ...
Phase IV (Maintenance)                         86
Phase IV (Maintenance)   Recall the patient every 4 months to:  •  Do periodontal maintenance.  •  Emphasize on the oral ...
Thank you all, for your kind attention            Any Questions?
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Transcript of "CasePresentation-III"

  1. 1. Clinical Case Presentation Majd Hasanin, Level XI, 42620112
  2. 2. Patient’s Personal Data• Age: Fifteen Years Old• Gender: Female• Nationality: Eritrean• Occupation: Student (High School, Grade 9).• Marital Status: Single• Patient’s Attitude: Cooperative• Patient’s File number: 25055 2
  3. 3. Chief Complaint‫”أبغى أصلح سني األمامي اللي فوق، الحشوة طاحت، وسني‬ “‫تحت يألمني‬ “I need my upper tooth fixed, the restoration fell and I feel pain in the lower one”History of chief complaint: The patient started complaining from the lower tooth about a year back since her first visit to the clinics. And the upper tooth restoration fell shortly after her treatment. 3
  4. 4. Chief Complaint 4
  5. 5. Chief Complaint 5
  6. 6. Medical History Patient and her guardian (the mother) stated that the patient is free from any medical condition.Family Medical History Not significant. 6
  7. 7. Past Dental History Single previously endodontically treated and restored tooth, about a year and a half ago. 7
  8. 8. Past Dental History Single endodontically tx & restored tooth 8
  9. 9. Habits and Oral Hygiene Activities Patient rarely brushes her teeth. Technique of brushing: Horizontal Scrub. Uses a “soft” brush. Doesn’t change her tooth brush very often. Doesn’t floss. Doesn’t visit the dentist nor the hygienist periodically. 9
  10. 10. Pretreatment Photographs 10
  11. 11. Extra-oral Photographs 11
  12. 12. Intra-oral Photos “Frontal” 12
  13. 13. Intra-oral Photos “Upper Arch” 13
  14. 14. Intra-oral Photos “Lower Arch” 14
  15. 15. Intra-oral Photos “Right Side” 15
  16. 16. Intra-oral Photos “Left Side” 16
  17. 17. Diagnostic Aids 17
  18. 18. Panoramic Radiograph 18
  19. 19. Radiographs-BitewingsRt Lt 19
  20. 20. Radiographs-PeriapicalsU Rt U LtL Rt L Lt 20
  21. 21. Mounted Diagnostic Casts 21
  22. 22. Mounted Diagnostic Casts Rt Lt 22
  23. 23. Diagnostic Casts Maxillary Occlusal View Mandibular Occlusal View 23
  24. 24. Clinical Examination 24
  25. 25. Extra-oral ExaminationTransverse “non-smile”: Symmetrical face. 25
  26. 26. Extra-oral Examination• Antro-posterior, Vertical: Slightly convex profile. Class I extra-orally. Competent lips. Normal NLA (Nasiolabial Angle “90⁰”). Normal lower facial height. 26
  27. 27. Intra-oral ExaminationTongue, floor of the mouth, Palate and Mucosa areall with-in the normal limit (WNL). 27
  28. 28. Intra-oral ExaminationGeneralized Inflammation of The Gingiva. 28
  29. 29. Intra-oral ExaminationGeneralized Plaque Accumulation, especially in thecervical third of the teeth. 29
  30. 30. Intra-oral ExaminationFlaring and slight rotation of the Upper AnteriorTeeth, along with over eruption of the lower ones. 30
  31. 31. Intra-oral Examination Lower midline is deviated to the right around 3.0mm in comparison to the upper midline. 31
  32. 32. Intra-oral Examination Several rotated teeth. Multiple carious teeth. 32
  33. 33. Clinical Examination Generalized presence of Pulp Stones. 33
  34. 34. Clinical Examination PSR (Periodontal Screening and Recording): 2 = Pocket Depth < 3.5 mm, bleeding upon probing, calculus. 34
  35. 35. Clinical Examination  Gingival Index (GI): By: “Leo and Silness,1963” 18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28FLF 48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 Ramfjord “ 5” = 2 / Moderate Gingival Inflammation 35
  36. 36. Clinical Examination  Plaque Index (PI): By: “Silness & Loe”,1964 18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28FLF 48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 Ramfjord “ 5” = 2 / Moderate Plaque Accumulation 36
  37. 37. Clinical Examination Periodontal Charting (FM): Upper Arch B M- CEJ M-BP 333 333 333 333 333 323 323 322 223 323 333 333 323 233 CALF 18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 M- CEJ M-BP 333 333 333 333 333 333 333 333 333 333 333 333 333 333 CALL B 37
  38. 38. Clinical Examination Periodontal Charting (FM): Lower Arch B M- CEJ M-BP 333 333 333 333 333 323 323 322 223 323 333 333 233 CALL 48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 M- CEJ M-BP 333 333 333 333 333 333 333 333 333 333 333 333 333 CALF B 38
  39. 39. Clinical Examination Calculus Index: is: “ Heavy, localized, unilateral, accumulation supra- gingivally” with “Heavy, localized, accumulation sub- gingivally” in the lower lingual anterior segment. 39
  40. 40. Clinical Examination Key: Restoration Caries Root Canal Tx PA Leison Dental Charting “Upper Arch” Un-erupted Rotated Tooth Missing Surf.18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28 40
  41. 41. Clinical Examination Key: Restoration Caries Root Canal Tx PA Leison  Dental Charting “Lower Arch” Un-erupted Rotated Tooth48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 41
  42. 42. Clinical Examination  Pulpal and Periapical Tests for suspected teethTooth # Cold Test Vertical Percussion Horizontal Percussion Palpation Test# 21 Not-Applicable +ve -ve -ve Control Tooth# 11 +ve -ve -ve -ve 42
  43. 43. Laboratory Investigations CRT (Caries Risk Test)  Saliva Flow Rate : 12 ml in 5 min = 2.4 ml/min (above standard) Low Caries Risk  Saliva Viscosity : Watery  Saliva Buffer Capacity : Between 4.5-7 PH Low to Medium Caries Risk 43
  44. 44. Laboratory Investigations CRT (Caries Risk Test) Measuring the Acid Production by the microorganism in the saliva; According to the “Standard chart”: 1 and 2 = Low Risk 3 and 4 = High Risk S.M L.B 44
  45. 45. Laboratory Investigations CRT (Caries Risk Test) Results have revealed the following: •S.M = 2 < 100,000 CFU Low Risk •L.B = 3 > 100,000 CFU  High Risk S.M L.B 45
  46. 46. Diagnosis and Treatment Planning 46
  47. 47. Treatment Objectives• Chief Complain.• Oral Hygiene Motivation.• To Restore:  Function.  Structure.  Esthetics. 47
  48. 48. Preliminary “Emergency” 48
  49. 49. Preliminary “Emergency”• Diagnosis for tooth # 36  Non-restorable, remaining root.  Ill-defined radiolucent lesions at the apices of the tooth.• Proposed Tx.  Extraction. 49
  50. 50. Phase I (Restorative) 50
  51. 51. Phase I: (Periodontic Therapy)• Diagnosis for the “Periodontium”:  Generalized Chronic Moderate Gingivitis, resulting from local factors “Plaque” and “Calculus”, also “poor oral hygiene” of the patient, (Multi-factorial).• Prognosis: Diagnostic: Good. Therapeutic: Excellent. 51
  52. 52. Phase I: (Periodontic Therapy)• Proposed Tx.  Scaling and root planning, by ultrasonic scaling and hand instruments.  Prescribing 0.12% Chlorohexidine mouth wash, incase there was excessive bleeding, during scaling.  Modifying and emphasizing on the Oral Hygiene Instructions.  Re-evaluation in 4-6 weeks.  Maintenance every 6 months. 52
  53. 53. Phase I: (Periodontic Therapy)• Oral Hygiene Instructions:  Includes the demonstration of the right technique in brushing and flossing: Brushing “Modified Bass” technique 53
  54. 54. Phase I: (Periodontic Therapy)• Oral Hygiene Instructions:  Flossing: 54
  55. 55. Phase I: (Periodontic Therapy)• Oral Hygiene Instructions:  General instructions regarding the tooth brush: 55
  56. 56. Phase I: (Preventive Therapy)• Based upon the CRT the patient will need:  Diet Alteration (less Sweets, CHO Balance , more Protein & Vitamins).  Fissure Sealant (for intact deep fissured sound teeth). S.M L.B 56
  57. 57. Phase I: (Excavation of Caries and Restorations)• Diagnosis for tooth # 17:  Shallow Occlusal Caries (distally).  Deep Fissure.• Proposed Tx.  Preventive Resin Restoration (PRR). 57
  58. 58. Phase I: (Excavation of Caries and Restorations)• Diagnosis for tooth # 16:  Occlusal Caries with Palatal Extension.• Proposed Tx.  Class I Composite or Amalgam Restoration. 58
  59. 59. Phase I: (Excavation of Caries and Restorations)• Diagnosis for tooth # 15:  Occlusal Caries.  Mesial Caries.  Distal Caries.• Proposed Tx.  Class II Composite or Amalgam Restoration, (MOD). 59
  60. 60. Phase I: (Excavation of Caries and Restorations)• Diagnosis for tooth # 14:  Occlusal Caries.  Distal Caries.• Proposed Tx.  Class II Composite or Amalgam Restoration. 60
  61. 61. Phase I: (Excavation of Caries and Restorations)• Diagnosis for tooth # 12:  Mesial Caries.• Proposed Tx.  Class III Composite Restoration. 61
  62. 62. Phase I: (Excavation of Caries and Restorations)• Diagnosis for tooth # 11:  Distal Caries.  Incisal Edge Caries.• Proposed Tx.  Class IV Composite Restoration.  Class VI Composite Restoration. 62
  63. 63. Phase I: (Excavation of Caries and Restorations)• Diagnosis for tooth # 21:  Mesial Caries.• Proposed Tx.  Excavation of Caries. Placement of T.F. 63
  64. 64. Phase I: (Excavation of Caries and Restorations)• Diagnosis for tooth # 24:  Shallow Occlusal Caries.  Deep Intact Fissure.• Proposed Tx.  Preventive Resin Restoration (PRR). 64
  65. 65. Phase I: (Excavation of Caries and Restorations)• Diagnosis for tooth # 25:  Occlusal Caries.  Distal Caries.• Proposed Tx.  Class II Composite or Amalgam Restoration. 65
  66. 66. Phase I: (Excavation of Caries and Restorations)• Diagnosis for tooth # 26:  Occlusal Caries with Palatal Extension.• Proposed Tx.  Class I Composite or Amalgam Restoration. 66
  67. 67. Phase I: (Excavation of Caries and Restorations)• Diagnosis for tooth # 27:  Shallow Occlusal Caries (distally).  Deep Intact Fissure.• Proposed Tx.  Preventive Resin Restoration (PRR). 67
  68. 68. Phase I: (Excavation of Caries and Restorations)• Diagnosis for tooth # 37:  Occlusal Caries.• Proposed Tx.  Class I Composite or Amalgam Restoration. 68
  69. 69. Phase I: (Excavation of Caries and Restorations)• Diagnosis for tooth # 35:  Shallow Occlusal Caries.  Deep Intact Fissure.• Proposed Tx.  Preventive Resin Restoration (PRR). 69
  70. 70. Phase I: (Excavation of Caries and Restorations)• Diagnosis for tooth # 31:  Mesial Caries.• Proposed Tx.  Class III Composite Restoration. 70
  71. 71. Phase I: (Excavation of Caries and Restorations)• Diagnosis for tooth # 41:  Mesial Caries.  Distal Caries.• Proposed Tx.  Class III Composite Restoration. 71
  72. 72. Phase I: (Excavation of Caries and Restorations)• Diagnosis for tooth # 42:  Distal Caries.• Proposed Tx.  Class III Composite Restoration. 72
  73. 73. Phase I: (Excavation of Caries and Restorations)• Diagnosis for tooth # 43:  Mesial Caries.• Proposed Tx.  Class III Composite Restoration. 73
  74. 74. Phase I: (Excavation of Caries and Restorations)• Diagnosis for tooth # 45:  Occlusal Caries .  Mesial Caries.  Distal Caries.• Proposed Tx.  Class II Composite or Amalgam Restoration (MOD). 74
  75. 75. Phase I: (Excavation of Caries and Restorations)• Diagnosis for tooth # 46:  Occlusal Caries .  Mesial Caries.  Distal Caries.• Proposed Tx.  Class II Composite or Amalgam Restoration (MOD). 75
  76. 76. Phase I: (Excavation of Caries and Restorations)• Diagnosis for tooth # 47:  Occlusal Caries .• Proposed Tx.  Class I Composite or Amalgam Restoration. 76
  77. 77. Phase II (Endodontic) 77
  78. 78. Phase II: (Endodontic Therapy)• Diagnosis for tooth # 21:• Pulpal Diagnosis:  Substandard RCT.• Periapical Diagnosis:  Symptomatic Apical Periodontitis.• Proposed Tx.  Re-treatment. Tooth Cold Test Vertical Percussion Horizontal Palpation Test # Percussion # 21 Not- +ve -ve -ve Applicable 78
  79. 79. Phase III (Prosthetic Therapy) 79
  80. 80. Phase III (Prosthetic Therapy)• Diagnosis for tooth # 21:  Week Remaining Tooth Structure.  RCT. 2• Proposed Tx.  Post and Core (Casted or Prefabricated). 1  Full Ceramic Crown. 80
  81. 81. Phase III (Prosthetic Therapy)• Diagnosis :  Missing Tooth (# 36).• Proposed Tx.  Implant (Ideal Tx).  Fixed Bridge (3 unit).  RPD. Alternative Tx  Do Nothing!BL Width = Height = MD Length = 10 mm 6mm 9 mm 81
  82. 82. Phase III (Orthodontic Therapy) 82
  83. 83. Orthodontic Consultation• Orthodontic Problem List:• Antro-posterior: Rt. Molar relationship: ½ unit class II. Proclination of the upper incisors Overjet is about 7.0 mm. Infra-occlusal upper left canine.• Transverse: Lower midline is deviated around 3.0 mm to the right. 83
  84. 84. Orthodontic Consultation• Orthodontic Problem List:• Intra-Arch: Multiple rotations in the upper and lower arches. Mild crowding in the upper anterior segment, accompanied with mild diastema between the anterior teeth. Mild spacing in the upper posterior teeth. Mild spacing in the lower arches. 84
  85. 85. Orthodontic Consultation Objectives of the Orthodontic tx: Correction of the Rt molar relationship into a class I. Retroclination of the upper incisors. Decreasing the OJ. Correction of the deviated lower midline. Fix alignment of the rotated teeth “De-rotation”. Establish a favorable occlusal relationship. Proposed Orthodontic tx: Comprehensive Orthodontic treatment, non-surgical, non- extraction. 85
  86. 86. Phase IV (Maintenance) 86
  87. 87. Phase IV (Maintenance)  Recall the patient every 4 months to: • Do periodontal maintenance. • Emphasize on the oral hygiene. • Maintain good relationship with the patient. “Treat the patient as a whole, not a hole…” is very important to always keep in mind.  Recall the patient every 6 months to: • Do full mouth X-Ray, check all restorations and crowns. 87
  88. 88. Thank you all, for your kind attention Any Questions?

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