This chapter reviews a classification for diagnosis and treatment planning for patients who are partially or completely edentulous and require implant prostheses. Only gold members can continue reading. By using this classification, which the author first presented in 1985, the doctor is able to convey the dimensions of the bone available in the edentulous area and also indicate the strategic position of the segment to be restored.15. This article discusses psychologic characteristics of edentulous patients who seek restorative: dental services. Wed. 25 Nov. 2020 5:00 PM CET (Berlin) Speaker: Dr. Martin Schimmel Screw versus cemented implant supported restorations 10. In Class I patients, distal edentulous segments are bilateral and natural anterior teeth are present. Recommended. By using this classification, which the author first presented in 1985, the doctor is able to convey the dimensions of the bone available in the edentulous area and also indicate the strategic position of the segment to be restored. A sinus graft is usually performed before implant placement. Treatment plan for implant-supported restorations for the edentulous patient. The implant dentistry bone volume classification developed by Misch and Judy in 1985 may be used to build on the four classes of partial edentulism described in the Kennedy-Applegate system. In addition, in order to define the most suitable treatment plan, there must be a dental specialist team working synchronically for defining the most suitable treatment plan to accomplish stable occlusion and facial harmony. This can be accomplished with the use of a papillameter, Alma Gauge, and wax rim. The fourth treatment option in the mandible is nerve repositioning and endosteal implants in Class I patients who are poor candidates for bone augmentation or subperiosteal implants. 480 20 Treatment Plans for Partially and Completely Edentulous Arches in Implant Dentistry CARL E. MISCH † AND RANDOLPH R. RESNIK Partially Edentulous Arches A classi cation of patient conditions is necessary to organize treat- ment plans in a consistent approach. Impressions techniques for implant dentistry 9. The patients’ quality of life and individual situation is always in focus. Each choice of prosthesis has advantages and disadvantages, and final selection should be made based on the oral health issues with which the patient presents, the recommended treatment plan, and the materials selected for treatment. Class I, Division D ridges are rarely found in the mandibular partially edentulous patient. The Kennedy classification is difficult to use in many situations without certain qualifying rules. Available bone height is restricted by the mandibular canal or maxillary sinus. Treatment planning of the edentulous maxilla 7. Figure 19-1 In Class I, Division C, options include small-dimension implants such as disc implants, which can be placed in minimal heights of bone above the mandibular canal. Cummer,1 Kennedy,2 and Bailyn3 originally proposed the classifications of partially edentulous arches that are most familiar to the profession. – The sequence of procedures planned for the treatment of a patient after diagnosis. Treatment planning of the edentulous mandible 8. Implants may be placed after the graft has created a Division A ridge, and the treatment plan follows the options previously addressed. Therefore independent restorations are indicated. The occlusal plane and tipped or extruded teeth should be closely evaluated and restored as indicated to provide a favorable environment in terms of occlusion and forces distribution. Flexure of the mandible during opening may cause a rigid splint to exert lateral forces on the posterior implants. Kennedy-Applegate Class II partially edentulous patients are missing teeth in one posterior segment (see Box 19-1). To organize treatment plans in a consistent approach, a classification of patient conditions is necessary. Copyright © 2020 Elsevier B.V. or its licensors or contributors. Improving oral hygiene for edentulous bedridden patients ... Clinicians typically use the tool to detect problems in performing activities of daily living and to plan care accordingly. Four Division B root forms may be the foundation of an independent fixed partial denture (FPD) in the mandible, depending on the other stress factors. The RPDs, which place more force on the abutment teeth (e.g., precision partial dentures), will place less force on the bone. In addition, the occlusal scheme must accommodate the specific conditions of mobile anterior teeth. Today, primary factors to consider in treatment planning edentulous arches are not only bone quantity but also quality of bone density, which can be improved using regeneration methods. Figure 1 – Treatment options for the edentulous patient Treatment planning Meticulous diagnosis and treatment planning is critically important to obtaining a predictable outcome. The eight Applegate rules are used to help clarify the system. should provide disclusion of the posterior implants during all excursions when opposing natural teeth or a fixed prosthesis. Molar endosteal implants should not be rigidly cross-splinted to each other in the Class I patient. Chapter 7. According to GPT- 8th ed. Log In or, Click to share on Twitter (Opens in new window), Click to share on Facebook (Opens in new window), Click to share on Google+ (Opens in new window), on 19: Treatment Plans for Partially and Completely Edentulous Arches in Implant Dentistry. The clasp design, which places less force on the tooth (e.g., bar clasp including t, y rpi), will place more force on the bone. Edentulous areas have severely resorbed ridges, involving a portion of the basal or cortical supporting bone. The implant dentistry bone volume classification developed by Misch and Judy in 1985 may be used to build on the four classes of partial edentulism described in the Kennedy-Applegate system.15,16 This facilitates communication of teeth positions and the primary edentulous sites among the large segment of practitioners already familiar with this classification, and it enables the use of common treatment methods and principles established for each class. Because more than 65,000 possible combinations of teeth and edentulous spaces exist in a single arch, no universal agreement exists regarding the use of any one classification system. The posterior soft tissue–supported Class I partial dentures are designed to either primary load the edentulous regions or the natural anterior teeth. The second rule is that the most posterior edentulous area always determines the classification. Diagnosis and treatment planning for oral rehabilitation of partially edentulous mouths must take into consideration the following: control of caries and periodontal disease, restoration of individual teeth, provision of harmonious occlusal relationships, and the replacement of missing teeth by fixed (using natural teeth and/or implants) or removable prostheses. The extent of the modification is not considered. Their use allows the profession to visualize and communicate the relationship of hard and soft structures. However, dentures further the tooth bone loss. Class I, Division B patients have narrow bone in posterior edentulous spaces and anterior natural teeth. Satisfieddenturepatient Thesatisfieddenturepatientgoes infrequentlyfor treatment and typically uses a denture for many years. In addition, a partial denture that is not well designed or maintained distributes additional loads to abutment teeth and may even contribute to poor periodontal health. When patients are placed in a Class I, Division A category, an independent implant-supported fixed prosthesis is usually indicated. Molar endosteal implants should not be rigidly cross-splinted to each other in the Class I patient. They are tissue-supported, which may lead to frequent occurrence of sore spots and complaints associated with nerve impingement. examination suggest the best possible treatment plan compatible with the age, physical, mental financial status of the patient; 72 Any Question 73. Augmentation is used most often in the Class I maxilla, where sinus grafts with a combination of allografts and autogenous bone are a predictable modality. This modality entails placement of more implants (six to eight) to provide multiple implant bridges per arch. If stress factors are too great (as a result of parafunction) or bone density is poor (as in the maxilla), then the Division B bone should be augmented to Division A before larger-diameter implant insertion. However, many of these mandibular Class I patients oppose a maxillary denture, in which case bilateral balance is more appropriate. These classifications were developed to organize removable partial denture (RPD) designs and concepts. The anterior teeth in Class I patients. Takanashi Y, P enrod J R, Lund J P, Feine JS. Reports in the literature concern dysesthesia and fracture of the severely atrophic mandible.21,22 In addition, the gain of height in the C–h mandible may only permit the placement of implants 10 mm high, still insufficient to compensate for the increased crown height and resultant unfavorable crown/implant ratio. Several factors play a role in treatment selection such as anatomy, phonetics, esthetics, available interocclusal space, neuromuscular func- tion, cost, and patient compliance (i.e., oral hygiene). With topics ranging from treatment modalities to tooth-supported prostheses to both immediate and complete dentures, this valuable resource gives the basic information necessary to treat the edentulous patient. In either case, the removable prosthesis often accelerates the posterior bone loss. The evaluation of the edentulous patient is performed by taking the patient’s medical history, evaluating the existing denture, and examining the intraoral and extraoral structures, using special examination methods. Copyright © 1991 Published by Mosby, Inc. https://doi.org/10.1016/0022-3913(91)90421-R. Successful oral rehabilitation of edentulous patients with removable prostheses demands careful adherence to a clinical protocol. The implant dentistry classification for partially edentulous patients by Misch and Judy also includes the same four available bone volume divisions previously presented for edentulous areas. If the intent of the bone graft is to change a Division C to a Division A or B for endosteal implants, then at least some autogenous bone is indicated. Edentulous areas have abundant bone width (>6 mm), height (>12 mm), and length (>7 mm) for endosteal implant(s). Surgical options usually require augmentation before implants can be inserted. Surgical options for C–w include osteoplasty or augmentation; for C–h, options include subperiosteal or disc implants or augmentation. Because the patient is less likely to wear the RPD, the opposing natural teeth have often extruded into the posterior edentulous region. However, in the long term, this treatment option may prove a disservice to the patient. The Kennedy classification is difficult to use in many situations without certain qualifying rules. Through an understanding of patient motives and expectations, the most appropriate treatment can be selected. Direction of load is within 30 degrees of implant body axis. When inadequate bone exists in height, width, length, or angulation, or if crown/implant ratios are equal to or greater than 1, the practitioner must consider several options. Historically, available bone was the primary factor used to develop a treatment plan for the completely edentulous patient. Webinar: Removable dentures, a viable treatment option for edentulous patients. How an educator uses Prezi Video to approach adult learning theory; Nov. 11, 2020. Flexure of the mandible during opening may cause a rigid splint to exert lateral forces on the posterior implants. Root forms may be considered with augmentation and/or nerve repositioning. In the mandible, the third option for the Class I, Division C patient is to place unilateral subperiosteal implants or disc implants above the canal (Figure 19-1). The primary reason could be ascribed to the insufficient initial assessment and a treatment plan inconvenient for the clinic. ScienceDirect ® is a registered trademark of Elsevier B.V. ScienceDirect ® is a registered trademark of Elsevier B.V. Numerous classifications have been proposed for partially edentulous arches. If many years pass before implants are to be inserted in the lesser available bone, then continued resorption may require augmentation before reconstruction. Nowadays the use of implants has a great im- pact on the prosthodontic treatment of the edentu- lous patient. The patient missing molars and both premolars requires additional implant support. After the graft is mature and the available bone improved, the patient is evaluated and treated in a manner similar to other patients with favorable bone volume. In Class I patients, distal edentulous segments are bilateral and natural anterior teeth are present. We’ve created this e-book so you can find out whether the All-on-4® treatment concept is right for your practice. When one is planning treatment for the edentulous pa- tient,two categories must be considered-thesatisfied denture patient and the dissatisfied denture patient. A cost comparison . The first step in treatment planning the maxillary edentulous arch is to determine the facial and incisal edge position of the maxillary anterior teeth. Two independent fixed prostheses are supported by implants. This requires increased implant support in the posterior segments when compared with most Class II or III patients, as well as greater attention and frequency for occlusal adjustments. The Class I patient is more likely to wear a RPD than Class II or III patients because mastication and/or support of an opposing removable prosthesis is more difficult when not wearing a mandibular prosthesis. Understand restorative protocols of edentulous therapy including immediate temporization. Financial concerns may require the staging of treatment over years. Risks of long-term paresthesia exist that may include hyperesthesia and pain. The third principle is that edentulous areas, other than those determining the classification, are referred to as modifications and are designated only by their number. Some simplified protocols have been successfully introduced. References ; Complete Denture Prosthodontics, 1st Edition, 2006 by John Joy Manappallil, Chapter 2. CLASSIFICATION OF PARTIALLY EDENTULOUS ARCHES. Treatment planning for the edentulous patient. Zarb. In addition, a partial denture that is not well designed or maintained distributes additional loads to abutment teeth and may even contribute to poor periodontal health. Recognizing psychologic factors that contribute to dissatisfaction with dental treatment will permit the dentist to match patient needs with suggested treatment. 11 Treatment plan :- According to SHELDON WINKLER Treatment planning means developing a course of action that encompasses the ramifications and sequelae of treatment to serve the patient’s needs. We use cookies to help provide and enhance our service and tailor content and ads. 6. The first principle is that the classification should include only natural teeth involved in the final prosthesis and follow rather than precede any extractions of teeth that might alter the original classification. Clinical objectives are met by using a routine clinical protocol that includes most or all of the following steps: Restoration of soft tissue health. Edentulous areas have inadequate available bone for endosteal implant (or implants) with a predictable result, because of too little bone width (C–w), length, height (C–h), or angulation of load. Especially in edentulous cases where often clinical limitations are given, options to meet the individual context are needed because the dental team is confronted with a patient whose dental issue needs to be solved in the most accurate and professional way. The RPDs, which place more force on the abutment teeth (e.g., precision partial dentures), will place less force on the bone. Most often, treatment plans for completely edentulous patients consist of a maxillary denture and a mandibular overdenture with two implants. Advancements in computer-assisted design/computer assisted manufacture (CAD/CAM) technology have enabled dentists to provide their patients with maximal functional and esthetic results, while reducing both the time and cost of treatment. Their use allows the profession to visualize and communicate the relationship of hard and soft structures. 9. In this manner, implants of greater size and surface area can resist the unilateral posterior forces while the patient awaits future treatment. Root form implants and independent prostheses often are indicated. If both posterior segments require bone grafting, the patient is encouraged to have both posterior segments augmented at the same time. Implant Treatment Planning For The Edentulous Patient implant treatment planning for the edentulous patient pageburst retail bedrossian edmond isbn 9780323095464 kostenloser versand fur alle bucher mit versand und verkauf duch amazon Treatment Planning Uidelines And Prosthetic Options For the consequences of complete edentulism impact areas such as anatomical esthetic nutritional self … The majority of these arches are only missing molars, and almost all have retained at least the anterior incisors and canines.17 Therefore, once restored to proper occlusal vertical dimension, the natural anterior teeth contribute to the distribution of forces throughout the mouth in centric relation occlusion. The anterior teeth in Class I patients should provide disclusion of the posterior implants during all excursions when opposing natural teeth or a fixed prosthesis. Other classifications have also been proposed4–14 (including one by the American College of Prosthodontists), none of which has been universally accepted. More importantly, when opposing natural teeth or in fixed implant prosthesis, they also permit excursions during mandibular movement to disclude the posterior implant-supported prostheses and protect them from lateral forces. This concept, for example, considers whether second or third molars are to be replaced in the final restoration. These patients are often able to function without a removable restoration and are less likely to tolerate or overcome the minor complications of wearing the prosthesis. Because more than 65,000 possible combinations of teeth and edentulous […] Surgical options include osteoplasty, small-diameter implants, and/or augmentation. Egon Euwe: The esthetic upgrade for the edentulous patient The lecture reviews the treatment plan and workflow for fixed prosthetic restorations of edentulous arches. These patients are often able to function without a removable restoration and are less likely to tolerate or overcome the minor complications of wearing the prosthesis. The clasp design, which places less force on the tooth (e.g., bar clasp including t, y rpi), will place more force on the bone. The diagnostic planning before the implant surgery can be tested e.g. In the mandible, the third option for the Class I, Division C patient is to place unilateral subperiosteal implants or disc implants above the canal (. By continuing you agree to the use of cookies. Four … Reports in the literature concern dysesthesia and fracture of the severely atrophic mandible. The available bone is therefore often adequate for endosteal implants, even when long-term edentulism has been present. These patients often need autogenous bone onlay grafts to improve implant success and prevent pathologic fracture before prosthodontic reconstruction. A fixed prosthesis is also indicated in these categories. The greater the number of teeth missing, the larger the size and/or number of implants required. Nov. 11, 2020. The loss of all of the teeth is a life-changing event that brings functional challenges. In either case, the removable prosthesis often accelerates the posterior bone loss. 3 The position of the maxillary anterior teeth determines the anterior arch form for the final restoration. If stress factors are too great (as a result of parafunction) or bone density is poor (as in the maxilla), then the Division B bone should be augmented to Division A before larger-diameter implant insertion. If narrow-diameter root forms are used, then a greater number than for the Division A ridge is indicated, and the use of one implant for every missing tooth root with no cantilever is recommended. Clients are scored yes/no for independence in each of the six functions. Treatment Planning: Class II Kennedy-Applegate Class II partially edentulous patients are missing teeth in one posterior segment (see Box 19-1). The Kennedy classification, however, has been taught in most American dental schools. In this way, the autologous portion of the graft may be harvested and distributed to both posterior regions, decreasing the number of surgical episodes for the patient. The first treatment option is to not use implant support, but rather to orient the patient toward a conventional removable partial prosthesis. and soon-to-be edentulous patients. Numerous classifications have been proposed for partially edentulous arches. Two independent fixed prostheses are supported by implants. Class I patients often have mobile anterior teeth, because long-term lack of bilateral posterior support caused by the wearing of a poorly fitting RPD, or none at all, has resulted in an overload to the remaining dentition. Class II: Partially Edentulous Arch with Unilateral Edentulous Area Posterior to Remaining Teeth, Class III: Partially Edentulous Arch with Unilateral Edentulous Area with Natural Teeth Remaining Anterior and Posterior, Class IV: Partially Edentulous Arch with Edentulous Area Anterior to Remaining Natural Teeth and Crossing the Midline. Treatment of an Edentulous Patient with CAD/CAM Technology: A Clinical Report Abstract. Implant Dentistry Classification of Partially Edentulous Arches, Class I: Partially Edentulous Arch with Bilateral Edentulous Areas Posterior to Remaining Natural Teeth. As a treatment option, traditional dentures are time tested, least costly, and the quickest noninvasive option available for rehabilitating an edentulous patient. Note: If the bilateral edentulous areas are not within the same division, then the right side is described first (e.g., Class I, Division A, B). The treatment plan must consider the factors of force previously identified and relate them to the existing bilateral edentulous condition. A thorough pre-treatment evaluation of edentulous patients or patients with failing/terminal dentition is necessary to establish a predictable treatment outcome. Therefore osteoplasty to increase bone width has limited applications. Chapter 19 Treatment Plans for Partially and Completely Edentulous Arches in Implant Dentistry, To organize treatment plans in a consistent approach, a classification of patient conditions is necessary. When observed, the most common causes are from trauma or surgical excision of neoplasms. The second option is to use bone augmentation procedures. The lack of posterior implant support in the mandible will allow posterior bone loss to continue. Therefore these patients often require a posterior implant prosthesis to be independent from the mobile natural teeth. Connecting implants to teeth 12. Box 19-1 Implant Dentistry Classification of Partially Edentulous Arches. When treating edentulous patients, an alternative to a hybrid prosthesis is the use of implant supported fixed prosthesis (i.e., implant bridges). However, if the modification segment is also included in the treatment plan, then it is listed, followed by the available bone division it characterizes (Box 19-1). Blog. It is not unusual to require extraction of the second molar, endodontics, crown lengthening and a crown of the first molar, and enameloplasty for the second premolar. The combinations of these conditions lead to bone loss in the edentulous regions and poorer adjacent natural abutments.18–20 As a result, it is this author’s observation that long-term Class I patients who have been wearing an RPD often exhibit Division C ridges and mobile abutment teeth. The majority of these arches are only missing molars, and almost all have retained at least the anterior incisors and canines. Adequate alveolar bone height and width are essential for implant placement. Statement of problem: Edentulous patients who require implant-supported prostheses have diverse jaw anatomy and functional, esthetic, and economic concerns. However, although this condition is easiest to treat with a traditional soft tissue–borne restoration, bone loss will continue and can eventually compromise any restorative modality. The treatment options for edentulous patients range from conventional complete dentures to fixed implant-supported restorations of varying complexities. However, the local bone density may be decreased. Endosteal implants with minimum osteoplasty are a common modality in these patients, who are more often Class II, Division A or B types.23,24. A variety of prosthetic designs associ- ated with implant prostheses can be observed, and some new designs have emerged in response to the specific … Edentulous areas have moderate available bone width (2.5 to 6 mm) and at least adequate bone height (>12 mm) and length (> 6 mm). Understand how the use of a two-piece restorative concept in combination with angled implants can contribute to effective care of fully edentulous patients. with provisional diagnostic dentures. Therefore independent restorations are indicated. Other intradental edentulous regions that are not responsible for the Kennedy-Applegate class determination are not specified within the available bone section, should implants not be considered in the modification region. Prosthodontic Treatment for Edentulous Patients Complete Dentures and Implant-Supported Prostheses. The combinations of these conditions lead to bone loss in the edentulous regions and poorer adjacent natural abutments. The Kennedy classification divides partially edentulous arches into four classes. 12. Risks of long-term paresthesia exist that may include hyperesthesia and pain. Two or more endosteal root form implants are required to replace molars with independent prostheses. Written by Dr. Edmond Bedrossian, one of only a few specialists doing zygoma implants, Treatment Planning for the Fully Endentulous Patient: A Graftless Approach to Immediate Loading covers the latest advances in implants, products, and techniques. The eight Applegate rules are used to help clarify the system.11 They may be summarized in three general principles. Class I, Division D usually occurs most often in the long-term edentulous maxilla. Endosteal small-diameter root form implants may be placed in the mandibular posterior Division B edentulous ridge. Stay on the cutting edge of implant dentistry for the edentulous patient! evaluation of implant treatment in edentulous patients-preliminary results. It offers unique advantages over traditional treatment options for both patient and clinician. The Index ranks adequacy of performance in the six functions of bathing, dressing, toileting, transferring, continence, and feeding. The disc implants support independent posterior fixed prostheses bilaterally. The Kennedy classification divides partially edentulous arches into four classes.2 Class I has bilateral posterior edentulous spaces, Class II has a unilateral posterior edentulous space, Class III has an intradental edentulous area, and Class IV has an anterior edentulous area that crosses the midline. implant treatment planning for the edentulous patient Sep 14, 2020 Posted By Sidney Sheldon Media TEXT ID 4530356d Online PDF Ebook Epub Library rochester minnesota usa with the introduction of osseointegration the use of dental implants to support and retain dental prostheses had become predictable and offers the As a result, they are not as likely to wear a removable restoration. implant treatment planning for the edentulous patient a graftless approach to immediate loading amazonde edmond bedrossian dds facd facoms fremdsprachige bucher Implant Treatment Planning For The Edentulous Patient A these lead the reader through treatment planning for the edentulous maxilla and mandible including initial assessment to study models radiographs and ct scanning this planning … Int J Prosthodont 2005; 18: 20-27. The posterior soft tissue–supported Class I partial dentures are designed to either primary load the edentulous regions or the natural anterior teeth. The aim of this guide is to assist clinicians in following suggestions in a systematic format and protocol, allowing for the formulation of a comprehensive treatment plan. Prosthodontic Treatment for Edentulous Patients, 12th edition. Because more than 65,000 possible combinations of teeth and edentulous spaces exist in a single arch, no universal agreement exists regarding the use of any one classification system. Augmentation procedures are often required to improve posterior bone volume, increase the implant surface area, and permit the fabrication of an independent implant restoration. Kennedy-Applegate Class II partially edentulous patients are missing teeth in one posterior segment (see, 10: Available Bone and Dental Implant Treatment Plans, 8: Treatment Plans Related to Key Implant Positions and Implant Number, 11: Scientific Rationale for Dental Implant Design, 17: Maxillary Arch Implant Considerations: Fixed and Overdenture Prostheses, 19 Treatment Plans for Partially and Completely Edentulous Arches in Implant Dentistry, 15: The Completely Edentulous Mandible: Treatment Plans for Fixed Restorations, 18: Treatment Planning for the Edentulous Posterior Maxilla. The first premolar-positioned implants must avoid encroachment on the apex of the canine root and yet avoid the anterior loop of the mandibular canal or maxillary sinus. Osteoplasty cannot be as aggressive in the Class I patient to increase bone width, compared with the Class IV or fully edentulous patient with implants primarily in the anterior regions, because of the opposing anatomical landmarks (maxillary sinus or mandibular canal). Restorative treatment options range from conventional dentures to implant-supported fixed partial dentures. About PowerShow.com. The patient missing molars and both premolars requires additional implant support. This chapter reviews a classification for diagnosis and treatment planning for patients who are partially or completely edentulous and require implant prostheses. 6 essential time management skills and techniques Four Division B root forms may be the foundation of an independent fixed partial denture (FPD) in the mandible, depending on the other stress factors. Treatment Option 1: The Brånemark Approach • Treatment option 1 places four to six implants between the mental foramina, and bilateral distal cantilevers replace the mandibular teeth • As a general rule, when five to six anterior implants are placed in the anterior mandible between the foramina to support a fixed prosthesis, the cantilever should not exceed 2 times the A-P spread, with all other stress factors being … The posterior region with the greatest volume of bone usually is restored first, if no bone grafting is required. The Class I patient is more likely to wear a RPD than Class II or III patients because mastication and/or support of an opposing removable prosthesis is more difficult when not wearing a mandibular prosthesis. Posterior available bone is limited in height by the mandibular canal in the mandible or the maxillary sinus in the maxilla. In Class I, Division C, options include small-dimension implants such as disc implants, which can be placed in minimal heights of bone above the mandibular canal. The fourth treatment option in the mandible is nerve repositioning and endosteal implants in Class I patients who are poor candidates for bone augmentation or subperiosteal implants. Designing abutments for cement retained implant supported restorations 11.
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