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Systematic Review Paper
Dental Implants
Is flapless implant surgerya viable option in posteriormaxilla? A reviewN.Doan, Z. Du, R. Crawford, P. Reher, Y. Xiao: Is flapless implant surgery a viableoptionin posteriormaxilla?A review. Int.J. OralMaxillofac.Surg. 2012;41:10641071.# 2012 International Association of Oral and Maxillofacial Surgeons. Published byElsevier Ltd. All rights reserved.
N. Doan1, Z. Du1,2, R. Crawford1,P. Reher3, Y. Xiao1
1Institute of Health and BiomedicalInnovation, Queensland University ofTechnology, Brisbane, Australia; 2School andHospital of Stomatology, Fujian MedicalUniversity, Fuzhou, China; 3School ofDentistry and Oral Health, Griffith University,Gold Coast, Australia
Abstract. This article reviews the literature on the outcome of flapless surgery fordental implants in the posterior maxilla. The literature search was carried out inusing the keywords: flapless, dental implants and maxilla. A hand search andMedline search were carried out on studiespublishedbetween 1971 and 2011. Theauthors included research involving a minimum of 15 dental implants with a follow-up period of 1 year, an outcome measurement of implant survival, but excludedstudies involving multiple simultaneous interventions, and studies with missingdata. The Cochrane approach for cohort studies and Oxford Centre for Evidence-Based Medicine were applied. Of the 56publishedpapers selected, 14papers on theflapless technique showed high overall implant survival rates. The prospectivestudies yielded 97.01% (95% CI: 90.7299.0) while retrospective studies or caseseries illustrated 95.08% (95% CI: 91.097.93) survival. The average ofintraoperative complications was 6.55% using the flapless procedure. The limiteddata obtained showed that flapless surgery in posterior maxilla areas could be aviable and predictable treatment method for implant placement. Flapless surgerytends to be more applicable in this area of the mouth. Further long-term clinicalcontrolled studies are needed.
Key words: dental implants; flapless surgery;complications; maxilla; survival; success; effi-cacy; effectiveness; guided surgery; review.
Accepted for publication 8 June 2012Available online 9 July 2012
The introduction of osseointegration in1977 by Branemark et al.1 revolutionizedoral rehabilitation in partially and fullyedentulous patients. This concept wasbased on the utilization of a mucoperios-teal flap. The flap was designed for thevisualization of underlying bone byreflecting the alveolar crest soft tissuefor placement and closure with sutureon completion of theprocedure. This con-cept implies that implants should be cov-ered by soft tissue to warrant primarystabilization and decrease infection as a
standard of care. For many practitioners,the flap technique has remained the main-stay of implant surgery as it allows bettervisualization, particularly in areas ofinadequate bone quantity, and it permitsthe manipulation of soft tissue in aestheticregions. Despite their popularity, flaptechniques have disadvantages includinggingival recession,bone resorption aroundnatural teeth,2,3 soft tissue deficiency fromflap raising, and negative implant aestheticoutcomes, especially in the anterior max-illa.4
Over the last three decades, there havebeen many modifications to implant flapdesign, including the flapless surgicaltechnique. In contrast to the flap techni-que, implant flapless surgery does notrequire reflection of a mucoperiosteal flapwhile perforating the alveolar mucosa andbone. Therefore, flapless surgery gener-ates less postoperative bleeding, less dis-comfort for the patient, surgery time isshorter, and healing time is reduced. Thepatients heal with minor, or no, swel-ling.5,6 The flapless technique uses rotary
Int. J. Oral Maxillofac. Surg. 2012; 41: 10641071http://dx.doi.org/10.1016/j.ijom.2012.06.002, available online at http://www.sciencedirect.com
0901-5027/0901064+ 08 $36.00/0 # 2012 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.ijom.2012.06.002http://dx.doi.org/10.1016/j.ijom.2012.06.002http://dx.doi.org/10.1016/j.ijom.2012.06.002http://dx.doi.org/10.1016/j.ijom.2012.06.002http://dx.doi.org/10.1016/j.ijom.2012.06.0027/29/2019 1-s2.0-S0901502712002676-main
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burs or a tissue punch to gain access tobone without flap elevation, so the vascu-lar supply and surrounding soft tissue arewellpreserved. The flapless technique hasbeen well established in immediate extrac-tion and site preservation with minimalcomplication.7 With the advance of flap-less surgery, the traditional flap method is
being challenged because it is being per-ceived as unnecessary.Traditionally, flapless surgery has been
regarded as having multiple limitationssuch as: poor control of precise drillingdepth due to difficulty in observing thedrilling direction of the alveolar bone;inability to preserve keratinized gingivawith a tissue punch perforation; and poorability to assess the implant point of entrydue to the lack of direct vision of therecipient bone. Therefore, it is difficult tocorrect intraoperative peri-implant defects.This implies that flapless surgery is mainly
used
for
cases
where
there
is
sufficientquantity and quality of bone, as well as adecent quantity of keratinized gingiva.8
Maxilla posterior areas can satisfy theseflapless surgery requirements.Reviewing publications on animal stu-
dies aids understanding of flapless surgeryandhelps to improve theflapless technique.For example, the biological width long-itudinal dimension at the buccal aspectwere higher in the flap group than in theflapless group in minipigs9; flapless sur-gical implantation into freshly extractedsockets did not aid in the avoidance of
alveolar bone
resorption
and
had
no
influ-ence in the dimensional differences of thealveolar process after tooth extraction incontrasted to the traditional implantplace-ment using mucoperiosteal flaps10; andflapless implant surgery can be utilizedfor the placement dental implants, andthe application of a tissue punch larger thanthe diameter of the implants is not recom-mended, as it can endanger the result of theimplantation process.11
The posterior maxilla is defined as theback part of the upper jaw, anteriorlyboundedby the upper canine teeth,poster-iorly by the maxillary tuberosities,bucallyby buccal mucosa and medially by thepalate. The supporting alveolar bone inthis area is usually wide enough forimplant placement, particularly in themolar region.Following tooth loss, resorption has
been shown to adhere to a predictablepattern: the alveolar labial aspect of theridge is the main site of resorption, whichdiminishes first in width then in height.1214 The posterior maxilla has differentanatomy and bone quality, and distinctivebuccal andpalatal resorptionpatterns.12,15
When the maxillabecomes edentulous, itsshape changes according to the extent ofresorption. The cortical bone in the max-illa becomes thinner and more porousposteriorly in an agedpopulation.16 Usingcomputed tomography, trabecular bonedensity varies markedly with potentialimplant site in the anterior
(516 132 Hounsfield units, HU) andposterior (332 136 HU) regions, whichmay compromise the clinical outcome ofdental implants in the posterior maxilla.Fuh et al.17 indicated that female maxillaeshowed a smaller amount and a lowerdensity of cancellous bone than male max-illae.The literature reveals limited and con-
flicting information concerning dentalimplant treatment in poor quality boneof the posterior maxilla. Although thereis a slightly lower osseointegration suc-cess rate, poor quality bone is not an
absolute
contraindication
for
dentalimplant treatment.1821 The anatomicaland structural features of the posteriormaxilla, such aspoor quality and quantitybone due to its proximity to the maxillarysinus, may compromise the clinical out-come of dental implants.In recent years, the advance of three
dimensional (3D) dental imaging, particu-larly cone beam computed tomography(CBCT), and the associated planning soft-ware, used in conjunction with computergenerated surgical guides, has allowedmore efficient results when using flapless
techniques.
This
has
turned
flapless
implantsurgery into a predictable procedure withhigh success rates if patients are appropri-ately selected and an appropriate width ofbone is available for implant placement.2,22
These studies mainly focus on anteriorareas, in order to improve aesthetic results,to shorten in surgery time, and to decreasemorbidity after surgery. Few studies focuson the posterior areas, especially posteriormaxilla areas. There are some benefits forflapless surgery in this area, including: lessaesthetic demand; bone resorption patternresulting in wider width and less undercut;and minimal concern about nerve damage.Therefore, flapless surgery appears to havemore applications in the posterior maxillathan in anyother area.Thedifficulties in theposteriormaxilla are: lessbone density; thepositionof thesinus;and thedifficult accessto the mouth. The posterior maxilla hasbeen described as the most difficult andproblematic intraoral area confronting theimplant practitioner, which may influencethe results of flapless surgery.This article reviews the contemporary
literature relating to the outcome (effi-ciency and effectiveness) and surgical
challenges of flapless dental implant sur-gery in theposterior maxilla and indicatesthat flapless implant surgery is an accep-table technique in the posterior maxilla.
Materials and methods
A search for English publications was
carried out using Medline to search dentaljournals from 1971 to 2011. Major dentalimplant journals covering oral and max-illofacial surgery, dental implant,prostho-dontics, and periodontics, for a similarperiod, were searched by hand to findrelevant references. The reference searchwas conducted using a mixture of thefollowing keywords: dental implants,flapless surgery, complications, maxilla,survival, success, efficacy, effectiveness,guided surgery, review.Clinicalhuman studies published inEng-
lish in the last 40 years between 1971 and
2011 obtained
through
the
Medline
or
thehand search were categorized by studytypes (case report,preclinical, cohort, con-trol clinical trial, review and meta-analy-sis), and subjects (human versus animal).This review includedonly human studies ofthe posterior maxilla with 15 or moreimplants; expert and clinical opinion pub-lications were excluded. In order to applythe best available evidence gained from thescientific method to clinical decision mak-ing, the Oxford Centre for Evidence-BasedMedicine4 was used to weigh the level ofevidence in clinical studies.
In this
review,
conventional
implantsurgery refers to flap surgical techniquesthat require elevation of a mucoperiostealflap for thepurpose of implant surgery andimplant placement. Flapless implant sur-gery is defined as a surgical techniqueutilized toprepare the implant drilling sitefor surgicalplacement of the implant with-out the need to raise a mucoperiosteal flap.The information was organized into a
system of comparison in a table formatsimilar to that suggestedby Brodala4 con-taining type of study, number of partici-pants, dropouts, follow-up time, mean age,implant case, outcomes (survival), com-plications and failures. It was assumed thatthese patients had no adverse medicalconditions.
Statistical data management
The data retrieved from the selectedpaperswas managed according to the followingmethods. The mean values of the survivalrates were case weighted to have an evendistribution. Ideally, one would limit thesample to studies that use KaplanMeiermethods to estimate survival and include
Flapless implant surgery in posterior maxilla 1065
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the results of the few studies that meet thenew inclusion criteria.Owing to the limitednumber of publications available, retro-spective studies were included in thereview. To improve the validity of thesestudies, Oxford Centre for Evidence-BasedMedicines 2001 classification of levels ofevidence were used. The studies were orga-
nized, reported, and stratifiedby the levelsof evidence.
Results
Medline search results
The Medline search found 56 articles, 19were deemed to meet the inclusion cri-teria. Of these, five systemic reviews wereexcluded as they did not involve clinicalstudies (Fig. 1). Using Oxford Centre forEvidence-Based Medicines 2001 classi-fication, of the 14 remaining papers(Tables 13), six were level 2prospectivecohort studies, five were retrospective, onewas a non-randomized trial, and therewere two case studies (level 4) that looked
1066 Doan et al.
Medline search (Pubmed)
through database(n=56)
Records excluded according
to the criteria
(n = 37)
Full-text articles
assessed for eligibility(n = 19) Full-text articles excluded,
with no clinical data
(n = 5)
Number of studies
included after screening
(n = 14)
Full papers included in
this study(n = 14)
Articles via hand-searched
journals relative to dental
implant(n=0)
Fig. 1. Flowchart of article selection for review.
Table 1. Demographics of studies.
No. Authors
Study designand OxfordEvidencebased level
No. ofPatients
No.dropouts
Remainingimplantsafter
dropouts
No. ofterminalevents
Agerange(years)
Meanage
(years)
Follow-upperiod(months)
Successrate (%)
Meansurvivalrate (%)
1 Rocci et al.5 Prospectivecohort (level 2)
46 0 97 9 2477 51 36 91(prostheticload)94
(splint)
90.72
2 Becker et al.23 Prospectivecohort (level 2)
57 0 79 1 2486 NR 24 98.7 98.7
3 van Steenbergheet al.8
Prospectivecohort (level 2)
27 3 164 NR 3489 63 12 NR NR
4 Fortin et al.24 Prospectivecomparativecohort (level 2)
60 0 152 NR 1982 NR 6 days NR NR
5 Cannizzaro et al.25 Prospectivecohort (level 2)
35 0 202 2 3970 56.6 12 99 99
6 Malo et al.26 Prospectivecohort (level 2)
23 0 92 0 NR NR 21 98 (max)97(Md)
98
7 Campelo andCamara27
Retrospectivestudy (level 4)
377 18 770 37 2783 54.7 60 (1) 97.4(2) 100
95.25
8 Sanna et al.28 Retrospective
study (level 4)30 4 183 9 3874 56 36 98.9 (non-
smoker)81.2(smoker)
91.5
9 Sennerby et al.29 Retrospectivestudy (level 4)
43 0 117 6 NR 50 18 94.87 94.87
10 Katsoulis et al.30 Retrospectivestudy (level 4)
28 0 112 NR NR NR NR NR NR
11 Pomares Puig31 Retrospectivestudy (level 4)
195 0 194 4 3584 59.5 12 07.95 97.95
12 Oh et al.32 Non randomizedtrial (level 4)
24 0 24 NR 2572 45 6 NR NR
13 Merli et al.33 Case series(level 4)
13 0 89 5 NR NR 8 NR NR
14 Ozan et al.34 Case series
(level 4)5 0 14 1 NR NR 14 98.3 98.3
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at implant success and survival rate andother clinical variables. Of these, 10 wereshort-term studies (6 days) that evaluatedintraoperative complications such as mor-bidity and comfort (level 2). The onlylong-term clinical study (level 2) was aretrospective cohort study. The most com-mon features encountered in these studieswere the use of guided surgical techniquesduring the course of their treatment plan-
ning. The differences in study designswere either treatment in a single locationor multiple locations in the maxilla.
Implant survival rate
Life time analysis was calculated usingKaplanMeier methods to estimate survi-val.37 The obtained survival data werethen case weighed. In a long term study
of implant outcomes27 of 778patients and2040 implants over a mean studyperiod of19 months, the results indicated a fairlyhigh survival rate. Theprospective studiesyielded 97.01% (95% CI: 90.7299.0)while retrospective or case series evalua-tion showed 95.08% survival (95% CI:91.097.93). These results illustrated clin-ical efficacy with prospective studies andclinical effectiveness, respectively.
Flapless implant surgery in posterior maxilla 1067
Table 2. Study types and results.
No. Authors
No.singletooth
Partialedentulism
Completeedentulism
Maxillaand
implants
Mandibleand
implants Result I Result II
1 Becker et al.23 NR NR NR 47 32 No significant changes in PD,BI from 1 to 6.5 months
Bone loss = 0.07 mmdetected by X-rays was notsignificant
2 Campelo and
Camara27
NR NR NR 282 488 Overall implant failure: 37
(4.8%) over 10 years
Analgesics were not used:
90%3 Cannizzaro et al.25 0 0 33 33 0 Reported pain: none slight
(79%), moderate severe(21%)
Swelling post surgically:none slight (58%),moderate severe 42%
4 Fortin et al.24 NR NR NR NR NR Reported pain (VAS):significant less and of shorterPain duration found inflapless group, significant lessuse of analgesics with flaplesstechnique
NR
5 Malo et al.35,36 0 0 23 18 5 Overall implantsurvival = 98%; maxilla97%; mandible 100%
Bone loss detected by X-rays = 1.9 mm at 12 mo
6 Oh et al.32 24 0 0 24 0 Tendency for Papillary Index(PPI) to increase over 6months
No differences in ML, PD,mPI, mBI, WKM
7 Ozan et al.34 NR NR NR Yes Yes Total of 5 out of 5 implantssurvived at average 9 months
NR
8 Rocci et al.5 27 70 0 97 0 Implant cumulative survivalrate: 91% at 36 months
9 Sanna et al.28 0 0 30 26 4 Bone loss detected by X-raysat 4 years: 2.64 mm smokers;1.3 mm nonsmokers
Implant cumulative survivalrate 91.5% over 66 months
10 Sennerby et al.29 18 99 0 45 72 53% of implants had > 2 mmradiographic bone loss at;>3 mm radiographic boneloss at 37% implants
NR
11 van Steenbergheet al.
80 0 27 27 0 Bone loss 1.2 mm detectedby
X-rays at 12 monthsNR
12 Pomares Puig31 0 0 30 128 67 4 implants out of 195 failed in3 patients during the healing
period:
2
in
the
maxilla
and
2in the mandible. 3 of themwere replaced successfully
After 1 year of loading, therewere no dropouts and no
failure
of
the
definitiveprosthesis 12
13 Katsouliset al.30 0 0 40 184 0 28 patients (70%) withsufficientbone and 4 implantseach (112 implants); 12patients each have 6 implants(72 implants)
6 had insufficient bone toplace any implant and 6 havecombined sufficient bone andinsufficient bone
14 Merli et al.31 0 0 28 112 0 13 consecutive patients withatrophic maxillae weretreated with 89 implants (68implants per patient)
5 implants failed in 4patients.1 patient dropped out. 8months after loading, allprostheses were successful.11 out of 12patients reportedtheir quality of life andlifestyle had improved
PD =probing depth; BI =bleeding index; ML = attachment level, mPI = modified plaque index; mBI = modified bleeding index; AUC = area
under curve; WKM = width of keratinized mucosa; NR = not reported (modified from Brodala4).
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1068 Doan et al.
Table 3. Complication and failures.
No. of complications
No. AuthorsIntraoperativecomplication
Postoperativecomplication
No. offailedimplants Biological Technical Aesthetics
1 Becker et al.23 NR NR 1 0 NR NR2 Campelo and Camara27 36perforation (21
fenestrations
15deshisences)
NR 37 NR NR NR
3 Cannizzaro et al.25 1 perforation 1treatment aborted
NR 2 5 (no. ofintermittentpain = 1,hyperplastictissue = 1, peri-implantmucositis = 1,peri-implant peri-implantitis = 2);all
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Three studies30,31,33 used flaplessmethod in conjunction with navigated sur-gical protocols, and the authors reportedsurvival rates ranging from 87.3% to97.8%. The authors concluded that thenavigated surgical technique might notbe appropriate for all types of bone mor-phology, but could be a viable and pre-
dictable treatment modality. Somecomplications arose during treatment, sothe technique could be sensitive to theoperators experience and a learning curveis required.
Post-surgical trauma discomfort
The level of intraoperative flapless surgi-cal trauma was found to be mini-mal.26,35,36 In the majority of thesestudies objective short-term evaluationof postoperative complications were verylimited or often omitted. One study was a
comparative
prospective
non-randomizedpilot study25 of patients morbidity (suchas pain and facial swelling) from 1 to 7days postoperatively using a visual analo-gue scale (VAS) following either a flap orflapless surgical technique. The authorsused 3D imaging to plan the proceduresand questionnaires were used to recordfeedback. All patients in the study hadan edentulous maxilla and each receivedsix implants. The authors found that theflapless surgery decreased the level ofpainand postoperative swelling significantly(p
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implants. Upper posterior implants weregrouped under the heading of maxilla andimplants, and only two studies31,35,36 illu-strated the success rates between maxillaand mandible (Table 2). Thus the overallresults of implants placed in the posteriormaxilla using the flapless technique are notclearly defined in these selected studies.
One major limitation in thispaper is thatthe flapless surgical procedures forimplant placement were used in variousclinical settings. Even though there werereports on the use of navigation and 3Dguided surgery in standard surgicalproce-dures, there was no clear indication on theuse of a surgical stent or guide.Correct application of flapless surgery
can help to lessen the morbidity and oper-ating time, especially, in the posteriormaxilla. With inadequate planning andimproper placement, flapless surgeryusually results in unsatisfactory outcomes
due
to
inappropriate
implant
position.
Theimplant clinician should use measures thatreduce complications in flapless surgeryincluding the use of advanced 3D dentalimaging such as CBCT and the associatedplanning software, used in conjunctionwith computer generated surgical guides.These have allowed better pre-treatmentplanning for flapless techniques making itmore efficient and avoiding hidden unfa-vourable anatomical and pathological pit-falls. This has made flapless implantsurgery a predictable procedure with highsuccess rates provided patients are
selected
appropriately
and
an
appropriatebone quantity and quality is available forimplant placement.20,19 Thorough treat-ment planning and operator experienceare important in reducing complications.As with any new technological advance,
theuser has to go through a studyperiod toperfect the technology. This usually bringsan understanding of nuances that must becomprehended to reduce complications.For instance, there isadanger inmisreadingCT information or incorrectly placing sur-gical stents in implant surgery, which cancause irretrievable damage. It is importantthat the implantologist should understandall the aspects of the new technology, anduseit at abasic stage prior to advancing intocomplex scenarios such as guided implantplacement. The implant practitioner shouldbe diligent, adaptable, and cautious withnew techniques and technology, to safe-guard against unforeseen complications inimplant dentistry.During the compilation of this review,
consideration was given to authorbias andother sources of bias (such as conflicts ofinterest) in the selected studies. TheCochrane review approach was used for
the appraisal of the validity of studiesinvolved. This paper stressed the possibi-lity ofbias in their outcomes, inparticularthe chance that they will overestimate orunderestimate the actual interventionpower. Furthermore, the authors wereaware of study-specific matters that maycause concern about thepossibility ofbias,
and attempted to express judgementsabout these. Several tools are availablefor evaluating the procedural value ofclinical trial studies. The utilization ofmeasures producing a summary score isnot recommended. Instead, this studyemployed the Cochrane Collaborationrecommended specific tool for assessingthe risk of bias in each included study.This comprises ajudgement and a supportfor the finding for each entry in a risk ofbias table, where each entry addresses aspecific feature of the study. The judge-ment for each item encompasses evaluat-
ing
the
risk
of
bias
as
low
risk,
highrisk, or unclear risk, with the lattergroup representing deficiency of data ordoubt over the potential for bias. Forexample, the prosthetic implant loadingprotocols differed vastly in the 14 studies,as loading couldbe immediate, delayed, orconventional. Taking into account theseissues, in conjunction with additional con-founding factors, it implies that the out-come of any particular procedure is not100% clear or has unclear risk. This meansthat it is best to consider the above men-tioned factors prior to extrapolating any
clinical
outcomes.
In
order
to
evaluate
thevalues of the flapless approach correctly,the researcher would require more studiesof comparable loading procedures thatfairly relate conventional approach tothe flapless technique.In conclusion, the current data obtained
from posterior maxilla areas showed thatflapless surgery could be a viable andpredictable treatment method for implantplacement, indicating efficacy and clinicaleffectiveness. The available short-termand long-term results reported in thisreview illustrate that the flapless approach,initially endorsed for inexperienced clin-icians, requires extra skill andpre-surgicalpreparation than initially thought. Theflapless approach requires greater knowl-edge and skill than the conventional sur-gical techniques. In the light of modernadvancements in digital imaging and com-puter guided surgery, the above require-ment is no longer mandatory. Cautionshould be exercised in using flapless sur-gery to minimize complications and mis-haps. This implies that the implantpractitioners must be willing to learnand adapt to new technology.
Being diligent and cautious with newtechnique and technology aremeasures thatcould help to safeguard against unwantedcomplications in flapless implant surgery,including those implantsplaced in thepos-terior maxilla. The application of flaplessimplant surgical technique in everyday pro-cedure should be limited to experienced
surgeons, and it is not endorsed for inex-perienced clinicians.
Funding
ITI Foundation for the dental implantproject.
Competing interests
There is no conflict of interest. Theprojectis purely scientific and there is no com-mercial interest.
Ethical approval
Human Ethical Committee, QueenslandUniversity of Technology and FujianMedical University
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Address:Yin XiaoInstitute ofHealth andBiomedicalInnovationQueensland University of TechnologyKelvin Grove CampusBrisbaneQld 4059AustraliaTel: +61 7 3138 6240; Fax: +61 7 3138 6030E-mail: yin.xiao@qut.edu.au
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