CHROME Webinar Series: Nano-Ceramic Prosthetic & RAPID Appliance

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Rewritten Transcript

Hello everyone. We’re going to begin the chrome guided systems educational event. Today we’re going to talk about the nano ceramic provisional, the rapid appliance, and then we’ll have a couple of slides on the backup denture. A there, there’s some key features about it’s use and, and the ordering because they’re, they’re not all the same.

Okay.

Sorry about that set of topics. We’re going to cover our smile design for the Nano for the nano ceramic prosthetic and how the smile design works with the Nano to design it, which leads into the second part, which is the setup, the digital setup and that how and how that is designed from the smile from the smile simulation and then many slides on a tips and do’s and don’ts. And then we’ll, we’ll go into some detail about the rapid appliance and its use. And then finally the backup denture milled versus printed. Um, that’s the main, that’s the main issue around the backup dentures.

Okay.

So what’s unique about the nano ceramic provisional? Every other system on the market, and they’re not comparable of course to chrome, but every, every system on the market for full arch reconstruction is essentially a copycat of the all on four protocol to denture. That’s that just kind of picked up in place and then realigned. And it’s, it’s a free handed system. The implants the bone reduction, the prosthetic, everything’s free handed. So this isn’t a big news flash, but, but the significance of this slide is that every other system out there works with a denture or processed acrylic with denture teeth. And the, the key component, one of the key components to chrome is that, that the prosthetic is delivered on the guy that it’s integrated in the guide and it’s, it’s a repeatable position, which is why the, the, the nano ceramic and then the, the nano ceramic provisional and the rapid appliance works so well together because of this repeatable position of the implants and the teeth and so forth.

And what makes it a, just a simplified process to the final restoration. And often that’s the key feature with either the restorative doctor involved in these cases as far as getting the team together with a surgeon and the restorative doctor. but it’s also key feature in, in any doctor who’s going to see this case all the way through or is going to try to sell. Um the fact that it’s perhaps it costs a little bit more, but the package, the package deal is it can be a very profitable a product compared to other systems on the market such as these others on the screen here. And so just real quickly, if you think about the, the other process, if you want to compare chrome to other processes, the other process often requires the doctor to go through all these stages.

Custom trays is one appointment and you can just see all the other appointments above my level. Impressions by block, screwed on setup seven appointments over two and a half, three months or more. Um, it’s a very expensive chair time procedure for the doctor, for the staff. but if you have an anode ceramic and you have a, a rapid appliance, you know, or the IG or printed trying, which we’re gonna talk about in subsequent meetings the process to final is so simple and the fact that the, that the nano ceramic, that the prosthetic is very carefully planned and, and the laboratories involved in this know this, it’s so carefully planned because the goal is for the patient to wear a prosthetic for the healing time that is a prototype for the final. It’s not just an immediate denture that’s been converted. there is, there is science and there is technology and there is laboratory experience that goes into every one of these cases and how these teeth are arranged.

And this all starts with the photograph almost every one of these cases. And we, if the patient has an upper denture and it’s perfect, then that’s, that’s the the tooth position. if it’s a lower than a, than a smile stimulation really isn’t necessary. But for all these cases where there’s uppers, where there’s pathology, where there’s Malocclusion, where it’s just not a good smile. That is, that is how we, that is how we produce the nano ceramic. That’s the beginning part of the science of it. And so they all start with photographs, full face, full smile. And I highly suggest taking these pictures with an SLR camera. putting the camera lens right in the middle, pointing at the nose, have the patient stand up in a full exaggerated smile. We wanted the exaggerated because we don’t want to have to make them, we don’t want to make a mistake on the transition line.

and we want a nice camera so that we have light in the mouth so we have depth of field and take a great photograph. And so that’s what we can use for these smiles simulations. Um, you know, chrome uses preview and we suggest as this company to any doctor out there involved in this, that they either purchase a software themselves and learn how to do these smiles simulations and 10 minutes, eight minutes really quickly, I’m sure maybe to convince the patient to do dentistry. but the, the, the teeth that are in these smiles directly correlate with what is set up at the laboratory. The digital setup with these teeth that directly correlates with these smiles simulations, chrome, a chrome hired preview to do something very special. And that is to take essentially human teeth smiles of, of, of beautiful smiles at patients and take those natural teeth and warp them, change them and shape into the size of the STL files that we use for setups.

Is it a one-to-one? No, it’s not, but it’s very close. And so the smile that you see on the full screen here is what we are going to deliver at surgery. and we’re going to get a, an a and a minus. It’s not going to be 100%. Um, does not have to be 100%, but it has to be very close. And any other smiles simulation software that’s been used on the market, it doesn’t, does not hold a candle to preview. There is nothing like it. And a lot of this, we’ll start with the smile library. the, the smile Sim Library from preview is accessible on the, on the chrome guided systems website. And it can be shared with patients. They can thumb through it, they can pick a smile, they can pick ovoid triangular, rectangular square. We might develop some more smiles in the future.

but if, you know, I’m a dental technician who picks a denture teeth every day, they pick about six different molds. They don’t use the entire living mold chart, living mold guide to pick smiles. It’s just not something they do. They just pick about the same six. So we picked a chrome pick these four and it’s very effective. And so those four smiles, those four teeth there were all changed into the shape of calls or teeth. And it’s just working wonderfully. So what the patient sees is what they get. And I, that was one of the, one of the statements, you know from the, from the founder of chrome that is see your smile before a surgery using smile technology. I mean it’s just a very, very effective tool for communication with the patient, communication between the doctor and the laboratory. and then communication just here within the laboratory for how we’re going to design these cases.

This is a case that patient agreed to you know, to show her, to show her face. she’s on Youtube. She is, couldn’t be more proud of the technology that the doctor shared with, with her. Um, it’s funny because you know, a lot of smiles just the, the, the patients in a testimonial that he just loved their smile and it’s wonderful and they’ve, they’ve been through so much in their lives and those stories are wonderful at this lady. If you ever see her on Youtube, she really into the detail about the science that the doctor shared with her about, about the smile, about the teeth. So you see this beautiful smile simulation and then you see her smile, right? That’s, that’s her in the day of surgery. And the closeup, I mean, it was very, very close to what we, what, what chrome promise, what previous ma promised in this smile. And as you might know, we take that smile simulation, we superimpose it in a software and we perform a digital setup and we, we perform a, a set up with the teeth behind the lips, behind the soft tissue so that we can specifically design the architecture of the teeth and of the gums and the ginger will areas that ginger will zenith. I mean, it’s really some brilliant technology that goes into fabrication.

So the digital setup is all completed. And then of course there’s a number of tasks that go into fabrication. But then, you know, here we are at a, at fabrication is produced directly from those smiles simulations. So that’s the workup to, to achieving an a on Nano. And a rapid appliance for Abbott appliance is really just a duplicate of the nano. And so now we’re gonna move into these key points. She really liked to like to have for each one of these sessions, the key points of all the components of chromes. We’ll cover that and then we’ll get into some do’s and don’ts and tips. Um, you know, in the, in the previous in the previous meetings we talked a lot about the carrier guide and we talked about how it works with the fixation base. but it also works with the Nano.

It supports the nano. It is, it is basically what makes the nano float above the bone. The Pin Guide I’m sorry, the carrier guide is the spacer. It’s the gap between the intaglio of the nano prosthetic and the bone, a three millimeter gap because that’s kind of the average a tissue thickness. So prosthetics sits on the on the carrier guide and it, and it works with these two male components. It’s on the inside of the Nano, there’s a female. And on the carrier guy there was a male. And, and some of these key points is be careful with how the prosthetic is fitting on this carrier guide. You don’t want to force the prostetic down and you may find that the, that the prosthetic fits, but maybe the maybe the rapid appliance is a little bit tight. So the, the trick there is to adjust the inside of the prosthetic, open the hole up on the prosthetic.

Do not adjust the male. This is the delicate part of that, of that marriage between the two materials. Don’t adjust this cause you could break it off. You don’t want to violate the integrity of it. but you’ll find that when you’re testing, you want to make sure that the, that the nanostream mic is seated all the way down to the carrier guide, that it’s a perfect marriage between the two. The holes on the carrier match the holes in the prosthetic. It’s a software that pushes a hole through both. So there’ll be the exact same size. If you find you need to adjust a cure, you, you probably have to adjust the nano. Um, hopefully the surgery is precise enough that that doesn’t have to happen. Um, and [inaudible] yes. So that’s that. On that slide it’s really very important to what we call, what I call is protect the prosthetic and protect the prosthetic means ensuring that there is no possible way that it gets locked in the mouth.

we’ve had those phone calls and those phone calls are the prosthetic is locked. Either either material flowed underneath the carrier guide or the material flowed down inside of these temporary cylinders, and that’s a disaster. So if you’ve ever been involved in, in that, or an all enforced surgery where the denture is locked in or out, or an impression it’s just a disaster because then it’s cutting and removing prosthetics from the mouth and destroying them. So use the green gaskets for block-out there. They’re even less than paper thin. They’re extremely thin. They won’t lift the prostetic up and be sure to use some type of block out. These blue plugs work well but you can use a gauze sticks. you can use birch shanks. You can use um cotton number of things, number of different materials that you can use. So just be sure to protect the prosthetic.

So one of the tips with adjusting a prosthetic it’s, it’s best if you don’t have to adjust a prosthetic. It’s best if the, if the whole system was was utilized exactly as it was designed, but sometimes an implant moved while the implants going in because it was not a fully guided kit. It was just a a guided kit. And so free handing the implant into the osteotomy will create movement. Um, you also might find that there was a site that did not have the right Torque or it was a spinner quote unquote that implant might’ve had been moved to a different site and therefore there has to be some adjustment to a prosthetic. we’ve seen a lot of cases where the rotation of the angled implant is not perfect and instead of disassembling the temporary cylinder and abutment and rotating the implant, the prosthetic was sacrificed.

You can see in this image here on the right hand side that the, that the lingual section of that was adjusted and opened up and, and even the distal part of it did a total disaster. Um, probably not, but just remembered that the trajectory or that temporary cylinder, the trajectory of that abutment is never going to change because if it’s off by five degrees, there was no changing that. If it’s off by 15 degrees or 45 degrees, you can just use a different abutment. but if you’re off by five and you’re now violating an embrasure or the lingual of a, of a, of a prosthetic or the, you know, or, or labial or buccal that’s the way it’s going to be and it’s going to be some creativeness to have to fix that later. So you’re always better off rotating an implant or, or adjusting position instead of adjusting prosthetic longterm.

but the tip on this screen is, you know, use a sharpie and Ben in surgeries where it just grab a sharpie out of the pile, out of the pocket of surgical sharpie and make the marks and then do all the adjustment outside of the mouth. You don’t want to do adjustments inside the mouth. You don’t want debris you know, you know, falling into the site on the outside of the mouth and then, and then cleaned of course. Uh but the most important part, and this is this is these next slides are that that adjustment sometimes has to be needed at the carrier guide level or at the intaglio and have some subsequent slides about that. But on this slide, a must add sufficient material, seen a lot of cases. Um, sometimes it’s the rapid appliance where there just needs to be a snap quick pickup, but it was not efficient sufficient enough to you know, to, to marry the temporary cylinder to the prosthetic.

and then they come out and then you’ve lost the indexing. So it’s just very important to backfill that void between the temporary cylinder and the prosthetic and really try to load up that entire void and fill it up. You can see on this top right, this is just completely deficient on about 70% of that temporary cylinder is essentially tacked in a cannot have any movement. Um, and, and you don’t want this to come out back in the lab while you’re finishing up the prosthetic. And then under magnification, try to reset this back into place. This has to go back in the mouth. It has to be clean. It has to be cleaned out. You have to use some more adhesive and start all over again. So very important to use enough material and it’s also very important to use the materials appropriately that we have two different materials in this in this demonstration.

there are others on the market. we recommend really to one that comes with the kit, which is Voco a actually stellar can also be an option in the kit too. But with Voco from quick up, a quick up from Voco, sorry, you must use a bonding agent cases without bonding agent fail. It’s this, this, then it becomes 100% of mechanical retention. It has to be a chemical, a chemical bond for a hundred percent retention. So use the materials as um, as needed. We’ll get a little bit more in the materials later. Um, so in the, in the series of tips, one of the tips is is shimming and we really haven’t talked about this technique very much. Um but this is a very effective technique. If the bite, if the bite is off either posterior, early contact and your early contact, usually it’s not left and right.

It’s usually anterior posterior only. Um, you can shim and there is a technique to it. one of the, one of the important things is that the, the male on the carrier guide should be adjusted down to about one third the height. So don’t leave the entire the, the entire pin because then it’s too hard to rotate and Shim the prosthetic. So you cut it down, both of them. And then Shem in this case to post area was shimmed. Um, I, I believe the doctor I don’t have a very good picture of it. I think the doctor used a little bit of bite material and had the patient bite into place and then shimmed it not in that order. put the patient in the bite, opened it up and shimmed it and backfill it with some bite material. And that’s what held it open.

And then the, the prosthetic was connected to the temporary cylinders. So the shimming technique is not if the case is off you know, for some reason the patients open, you know, five millimeters in the anterior, or if it’s a significant opening, then it may be a better idea to meet it halfway. In other words, equilibrate to a certain point until maybe you’re halfway between the a know perfect occlusion and it, and the open and then Shem, the rest because you don’t want to Shem five millimeters and then open the patient up you want to do those kinds of adjusted gross adjustments later. So this was this shimmed case. Um, you can see some more material was added you know, back here in the post area.

So Nice tick, nice, nice to a nice tip. Um, and here’s the little Shim, you know, in, in this case the shimming one wasn’t completed. And so that means the adjustment had to be made you know, later during your collaboration. So shimming probably could have fixed that that, that case probably about a hundred percent. And another very important tip is to it actually, this is a must and that is to adjust a prosthetic to remove the, the, the the distal extension off of the Nano. You don’t have to do it on the rapid because the rapid appliance is going to be more of a guide towards the final. But on the prosthetic, this must be removed five millimeters to to the terminal implant. Just cut it off if it’s halfway between a molar Soviet, but rounded up. You can see on that bottom left picture this, the, the implant, the last implant is here at the second buy, but the molar is in full contact with this posterior tooth, which means this patient is going to enjoy eating in a couple of weeks and they’re going to enjoy eating something that is going to crack this nano product right here.

And we’re going to get a phone call. And this was a recent case that was completed and that was a criticism of a case when great. But that’s the criticism leaving, leaving an extension. [inaudible] no, same thing in this case on the, on the left lower. This is a patient who, this is how the patient presented. The patient didn’t have posterior you know, really any posterior occlusion. And so the prosthetic had surgery sent the patient home in the same condition and that’s OK. okay. But I guarantee that if we send the patient back with, with um, 10, 12, 15 millimeter distal free end extensions, it’s going to break. And then it’s a real problem.

Every chrome case has a heads up bite that’s included. It’s called the a, the surgical bite. And this is simply made from from the, from the lab opening the articulator and from installing the installing the bite and then closing the patient and the, and then creating it and using it as an open bite. Um, the seating Jig essentially. So this is more common in tough bites. usually if the teeth come together really well, then, then that’s, then that’s how you’ll, you know, that’s how you’ll cure the cure, the prosthetic in the mouth. But sometimes just to make sure that it’s aligned properly, you can use the, the surgical bite, the silicone bite. definitely an important don’t, is I’m putting too much material around the temp around the temporary cylinders. these cylinders are supposed to protrude a couple of millimeters from the prosthetic so that they can engage so that they can engage the multiunit abutment.

If they have a bulk of material around them, then they are, then the prosthetic is forced to displace the tissue that will be, that will cause discomfort. It puts pressure on on the tissue, on the stitches. If there’s bone grafting material, it puts pressure on everything. So both of these pictures just show really the, the incorrect way you know, to finish a, to finish a prosthetic I’m going to show, I think some, a later that are, that are just right, that are just ideal. Um, don’t allow, this is another tip. Don’t allow the Nano prosthetic to contact the temporary cylinders. This is a real problem because this means that either the prosthetic is moving or the temporary cylinders moving or that there’s pressure. So now there’s a, there’s an off angle torque on this implant. So these things must be relieved.

Now perhaps this was a multiunit abutment with a high collar height, and so it pushed that temporary cylinder up into the prosthetic. Maybe the abutment could be changed. Maybe a lower collar height could be used. Perhaps the implant was placed a little too shallow. You never know. but in the end the prosthetic just cannot touch cannot touch a metal part has to be passive. So you’ll see that in all of these, in all of these actually this, this circle really should be around this this implant here. but you can see this, for instance, this temporary cylinder was, was moved far away from the original hole. The prosthetic was really adjusted. Um, but I guess I’m hoping that this is all passive underneath there. You can see that the temporary cylinder here is contacting the carrier guide. It’s off angle. That’s an angulation problem. Probably an implant rotation problem. Um, but cannot touch the carrier guide, cannot touch the prosthetic.

Very, very important. Um, and then, and then here, this is another part that was picked up. You know, it’s not a not a temporary season. it is a temporary cylinder but it’s definitely contacting the prosthetic. So beat a dead horse, but really critical. Oh, this is going back to an earlier slide. Um, we’re where you have to be careful about adding material on the temporary cylinders. Now this, this case, um this particular tech I believe was somehow instructed to add a flange to the nano ceramic to, to fill a gap in the maxilla. Um, should not be doing that. Um, you know, perhaps a little bit of lip if, if there’s some exposure but don’t add a flange to the prosthetic. This causes all kinds of problems, especially with seating it against the tissue. You can see what I’m you can see the result of this. I mean, any, any any violation like this is going to manifest itself in some real problems later. Um, so it’s okay to have a gap. It’s okay to see a stitch and sometimes it’s even okay to see a multiunit abutments or that, that junction of temporary cylinders it’s certainly better than having a a flange built into it after surgery.

If for some reason you’re not using the green gaskets, be very careful about adding too much block-out material around these temporary cylinders, this kind of material. You can see this um, these, these kinds of kind of blobs here. These are going to raise the prosthetic up, they’re going to lift it up. And so this definitely has to be flat. This material can be expressed around each of the cylinders real quickly, and then the prosthetic can be seated while it before it has, um cured and compress it flat. Um, so those are kind of the do’s and don’ts with prosthetics. I, I, we’re not finished with the meeting yet, but if you have other tips or any questions about the, about the prosthetic, that’s just a, just such an important part of the whole the chrome and the whole conversion. Please please stay on afterwards and bring up any points of interest.

I, I’d love to hear some feedback about it. So we’re going to talk about the rapid appliance and the rapid appliance is you know, it’s optional and, and there are doctors that, that, that um, that chrome works with that they don’t use the rapid. They, they do the IGETC only and they, and then they do a printer trying to go to final. And that is a wonderful tactic. We support that. Of course, 100%. It’s a, it’s a great tool to go to a final. The rapid appliance can also be used. I mean, sure, it can be used to go to final. there are some philosophical reasons why not to do it. Some occlusal reasons. there’s, there’s a whole discussion there about whether to, or to not use the rapid appliance as a means to go to the final, but if you did a rapid ed surgery, if you did the second pickup and completed it and you held on if the doctor holds onto the rapid appliance and there are any problems with the nano ceramic during healing, you have a perfect mechanism for sending those records to the laboratory for the laboratory to receive them.

Think of it, all you have to do, hopefully the implants have integrated, is remove the prosthetic screw in the rapid appliance. Pick up any temporary cylinders that weren’t picked up at surgery. We’ll talk about that in just a minute. And then equilibrate so that the bites the same as the, the, the prosthetic the patient’s been wearing. Take a bite, take an opposing, send it to the laboratory and have another prosthetic made and send it back for the remainder of the healing process. Because if you don’t have the rapid, if the rapid appliance was not taken, then the toils of going from a broken prosthetic in the mouth to a new prosthetic are, I mean, they’re, they’re, they’re quite monumental really, that the patient doesn’t want to send their prosthetic in. certainly the, the lab may have to go cheer aside and help with records. Um, there are techniques to flagging and making models and so forth, but really there’s no good solution to go from a broken prosthetic to a new, to a new to, to a new longterm temper or final.

So these are just some images of of some rapid appliances that were picked up. This is one that has pink, sometimes they have pink on them. It’s a little different on request. Um, but rapid appliances that have already been mounted with with relined impressions and they’re essentially ready to go to either make finals or to make ’em, you know, to make more longterm temporaries. [inaudible] pardon me. Just a very simple process. Nope, a rapid appliance. So there are some tips and tricks with rapid appliances. Um, don’t cut off the distal extension. It can be added later digitally, you know, in the IJ or the printed tryin. It can be added. But the rapid appliance is sent a with a full Flange, I’m sorry, the full distal extension. And, and I, and I, the, the, the text in here is wrong. It doesn’t mean leave distal flange. It means leave that, the whole distal extension on there because you can do a Relynn impression underneath it to capture the ridge. Um, but it’s much harder to add teeth to it distally. So lead the extension.

One of the neat tricks with with the rapid is to only pick up a few implants. Don’t pick up every one. You don’t necessarily have to. Now the recommendation is to pick up all this is a six unit implant case. That means when you order, when the doctor orders their implant parts have them order double six for the Nano and then six for um, for the rapid. But sometimes surgeries go on a little bit long. Sometimes there is anesthesia, sometimes the patient’s waking up. Sometimes it’s just a feeling that it’s time to wrap things up. Well, you can just put three temporary cylinders in an index that all you need to do is tripod it one, two, three removed from the mouth. It probably takes a after you’ve already been through the process with the, with, with the Nano, this probably takes about 15 minutes to do a second pickup.

But think of how far along you are. If you have a problem, you have an index prosthetic and then, and then you can just pick up the other four of the other three sites down the road. If it’s a question of time. So the nano and the, the prosthetic, they’re just a, they’re mirrors of each other. They’re made from the same file. They’re, they’re made the same. Same type of purpose to um, to capture the tooth position, implant position. I mean that’s the brilliance of the rapid appliance. It gives you everything. Implant position, bite tooth position, smile, vertical, everything to go right to the articulator. highly advised to take the rapid before I mentioned. Um, no your materials, that’s key. So these two materials work completely differently. They’re both recommended but they’re different. Voco the Voco that comes in chrome or that, that you, that you supply with chrome is a self cure.

It’s a self cure only 120 seconds. You have to use the adhesive. It comes with the HASIP, the bonding agent. If you don’t use a bonding agent, the material will fail. It is not designed to stick to PMH designed to stick to the bonding agents. So very, very important that you use both. Don’t take our store. Cut On that. Stellar is a dual care. Now the manufacturer will say that you can use a that you can use it as just a self cure. Um, my recommendation is don’t use that as like your, anytime you can use a light, use a light, it will cure it faster and it’ll cure it harder, faster. So if those are the two materials that you’re using or one of those two, then just follow the instructions. I mean, you can use GC pattern, resin a, you can use acrylic, you can use era pickup you can use [inaudible] [inaudible] probably the stronger of those last four mentioned. Um, I would not cut corners on the expense of the pickup material. I would use one of these two. It’s proven over and over and over again that it works for the long term.

and then just a simple procedure. Just make sure you use a bonding agent, make sure it’s clean, make sure it’s dry. And then and then just you know, take the time to make sure that the metal is reduced down, that it’s smooth, that it’s been polished and and deliver. So the last item on the, on the agenda is the backup dentures. And this part is critical. Just just kind of fundamentally understanding when printed is used and when milled is used. If it’s a double arch case chrome recommends ordering, milled or a little more expensive. Um, but if you, if you have a, a double arch and one arch does not go, but the other arch does, you don’t want to have a printed denture against a nano ceramic, a converted prosthetic. They’re completely different. in aesthetics you can see left to right.

I mean the, the right sides of printed the left side, some [inaudible], they’re not even close. I’ll show you again on the next on the next slide. if it’s a single arch, then pick printed less expensive works wonderfully. It’s beautiful. Um, terrific. So single versus double. And here’s just an example. Um, the, the lower printed really is is an earlier version. It’s an earlier printed denture material. We have different even laboratories have different materials that they’re printing now that look more lifelike and this less red than this. But no matter what, no matter what you do, printed versus mill, this going to have like just a completely different look for the patient when they wake up.

Okay.

That is our program for the day. I am, I’m, as always, I’m happy to take questions. Um, we can talk about any of these topics or previous topics. If there’s something you have for our previous meeting you want to bring up. Let me just mention that on Monday. I’ll say that he’s a, a special guest at noon on Monday. I recommend definitely tuning in and, and let me suggest this, that it does not just have to be people at the laboratory who are associated with chrome. Um Ms Joe is a a veteran 40 years working with, um with in dental technology, but especially focused on full arch reconstruction. And his entire presentation is going to be on analyzing and working with a full arch, single, large double arch cases, analyzing the models, analyzing the patients and it will be a wealth of knowledge for anyone involved in full arch chrome or not chrome.

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