Effects of non-surgical rapid maxillary expansion on nasal structures and breathing: A systematic review

Effects of non-surgical rapid maxillary expansion on nasal structures and breathing: A systematic review

To cite this article: Alyessary AS, et al. Effects of non-surgical rapid maxillary expansion on nasal structures and breathing: A systematic review. I...

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To cite this article: Alyessary AS, et al. Effects of non-surgical rapid maxillary expansion on nasal structures and breathing: A systematic review. International Orthodontics (2019), https://doi.org/10.1016/j.ortho.2019.01.001 International Orthodontics 2019; //: ///

Effects of non-surgical rapid maxillary expansion on nasal structures and breathing: A systematic review

A Review of the Literature

Websites: www.em-consulte.com www.sciencedirect.com

Akram S. Alyessary 1,2, Siti A. Othman 1, Adrian U.J. Yap 3,4, Zamri Radzi 1, Mohammad T. Rahman 1

Available online:

1. University of Malaya, Faculty of Dentistry, Department of Paediatric Dentistry and Orthodontics, Kuala Lumpur, Malaysia 2. Karbala University, College of dentistry, Department of Orthodontics, Karbala, Iraq 3. National University Health System, Ng Teng Fong General Hospital, Department of Dentistry, Singapore, Singapore 4. University of Malaya, Faculty of Dentistry, Department of Restorative Dentistry, Kuala Lumpur, Malaysia

Correspondence: Akram S. Alyessary, University of Malaya, Faculty of Dentistry, Department of Paediatric Dentistry and Orthodontics, 50603 Kuala Lumpur, Malaysia. [email protected]

Keywords Orthodontics Maxillary expansion Nasal airway obstruction Breathing

Mots clés Orthodontie Expansion maxillaire Obstruction des voies respiratoires nasales Ventilation

Summary Objective > This systematic review aims to determine the effects of non-surgical rapid maxillary expansion (RME) on breathing and upper airway structures. Materials and methods > An electronic search of the scientific literature from January 2005 to June 2016 was done using Web of Science, Dentistry & Oral Sciences Source and PubMed databases. A combination of search terms "rapid maxillary expansion'', "nasal'', "airway'' and "breathing'' were used. Studies that involved surgical or combined RME-surgical treatments and patients with craniofacial anomalies were excluded. Results > The initial screening yielded a total of 183 articles. After evaluation of the titles, abstracts and accessing the full text, a total of 20 articles fulfilled both inclusion/exclusion criteria and possessed adequate evidence to be incorporated into this review. Conclusions > Non-surgical RME was found to improve breathing, increase nasal cavity geometry and decrease nasal airway resistance in children and adolescents.

Résumé Effets de la disjonction non chirurgicale sur les structures nasales et la ventilation : étude systématique Objectif > Cette revue systématique vise à déterminer les effets de la disjonction (rapid maxillary expansion) non chirurgicale sur les structures respiratoires et les voies aériennes supérieures. Matériels et méthodes > Une recherche électronique dans la littérature scientifique de janvier 2005 à juin 2016 a été effectuée à l'aide des bases de données Web of Science, Dentistry & Oral Sciences Source et PubMed. Une combinaison des termes de recherche « expansion maxillaire

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tome xx > 000 > xx 2019 https://doi.org/10.1016/j.ortho.2019.01.001 © 2019 CEO. Published by Elsevier Masson SAS. All rights reserved.

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To cite this article: Alyessary AS, et al. Effects of non-surgical rapid maxillary expansion on nasal structures and breathing: A systematic review. International Orthodontics (2019), https://doi.org/10.1016/j.ortho.2019.01.001

A Review of the Literature

A.S. Alyessary, S.A. Othman, AUJ. Yap, Z. Radzi, M.T. Rahman

rapide », « nasal », « voies respiratoires » et « ventilation » a été utilisée. Les études portant sur des traitements chirurgicaux ou des traitements chirurgicaux combinés à la disjonction et sur des patients présentant des anomalies crânio-faciales ont été exclues. Résultats > Le tri initial a permis de sélectionner 183 articles au total. Après évaluation des titres, résumés et textes intégraux, 20 articles au total ont répondu à la fois aux critères d'inclusion/non inclusion et ont comporté les éléments de preuve nécessaires pour être incorporés dans cette revue systématique. Conclusions > La disjonction maxillaire non chirurgicale améliore la ventilation, augmente la géométrie des fosses nasales et diminue la résistance des voies aériennes nasales chez les enfants et les adolescents.

Introduction

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Transverse maxillary deficiency (TMD) is a common craniofacial skeletal problem. It is often associated with antero-posterior and/or vertical skeletal incongruities and presents in both syndromic and non-syndromic patients [1]. The aetiology of TMD is complex and multi-factorial, encompassing congenital, genetic, developmental, traumatic and/or iatrogenic causes [2–5]. Contributing factors include a variety of craniofacial syndromes, thumb/finger-sucking habits and mouth breathing during facial growth as well as trauma or surgical complications during cleft palate repair. The reported incidence of TMD ranges from 8.5 to 22% in children and adolescents [6]. The wide range can be attributed to a lack of universally accepted classification, diagnostic criteria and methods for scoring inadequacies of dental and skeletal components [6–8]. Incidence does not appear to be influenced by gender or ethnicity [9] and prevalence in the adult population is not known. The most frequently reported clinical manifestations of TMD are uni- or bilateral posterior crossbites, palatal inclination of teeth, crowding of teeth, high palatal arches, narrow/tapering arch forms and problems related to nasal respiration [9]. Unlike vertical or sagittal discrepancies, TMD is hard to diagnose extra-orally. The extra-oral expressions are often discrete and confined to contracted alar bases, paranasal excavations and deep nasolabial grooves. They are commonly masked by concomitant vertical and sagittal anomalies. Correction of TMD usually requires expansion of the palate by a combination of orthopaedic and orthodontic tooth movements. Three expansion modalities are employed nowadays. They are rapid maxillary expansion (RME), slow maxillary expansion (SME) and surgically assisted rapid maxillary expansion (SARME). Disagreements exist pertaining to their indications due to their comparative advantages and disadvantages [10]. RME is probably the most popular modality among the three. Haas first proposed the use of fixed palatal expanders to rapidly correct TMD in children and adolescents in the 1960's [3,11]. Fixed palatal expanders were found to unstable and ineffective in mature patients [12]. Complications of non-surgical RME in adults have been described and includes expansion relapse,

molar tipping, opening rotation of the mandible, gingival recession, bone loss, root resorption, pain and swelling [13,14]. The midpalatal suture begins to fuse by the late teens and becomes relatively rigid in adults [15,16]. Surgical interventions are therefore indicated in mature, non-growing patients. Many studies have reported the success of surgically assisted rapid maxillary expansion (SARME) for separating the midpalatal suture and widening of the maxillary arch [13,17–19]. A systematic review on the effect of SARME on upper airway volume was recently published [20]. The authors concluded that SARME produced a substantial short-term increase in nasal volumes but had no effect on oropharyngeal volumes in nongrowing patients. Effect of volume changes on respiratory function could not be determined. The last systematic review on RME on airway dimensions and breathing was conducted about 5 years ago [21]. The authors concluded that RME in growing children improved nasal breathing and results are stable up to 11 months after therapy. In view of the advances in RME appliances and protocols as well as supplementary clinical trials over the past few years, an update on this subject matter is required. This systematic review aims to re-appraise the available literature on the effects of non-surgical RME on breathing and upper airway structures. It was hypothesized that nonsurgical RME decreases nasal airway resistance, increases nasal cavity dimensions and nasal volume in children and adolescents.

Materials and methods An electronic search of the scientific literature from January 2005 to June 2016 was done using Web of Science, Dentistry & Oral Sciences Source and PubMed databases. A combination of search terms "rapid maxillary expansion'', "nasal'', "airway'' and "breathing'' were used. Inclusion criteria for the review included: clinical (randomized controlled, retrospective and prospective cohort) studies that used one or more of the following investigations: rhinomanometry (RMN), cone-beam computed tomography (CBCT), conventional tomography and radiography for measuring of RME effects. Reviews, clinical case reports, case series and opinion papers were excluded as were studies

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To cite this article: Alyessary AS, et al. Effects of non-surgical rapid maxillary expansion on nasal structures and breathing: A systematic review. International Orthodontics (2019), https://doi.org/10.1016/j.ortho.2019.01.001

A Review of the Literature

Effects of non-surgical rapid maxillary expansion on nasal structures and breathing: A systematic review

Figure 1 PRISMA flow diagram of the search results from the databases

Results A total 183 titles were ascertained for the period of January 2005 to June 2016 (figure 1). Duplicate records appearing in more than one database were discarded. From the titles, only 52 abstracts were relevant to this review. Of these abstracts, only 20 publications fulfilled both inclusion/exclusion criteria and possessed satisfactory evidence to be appraised. For discussion purposes, the articles were grouped into those concerning breathing and those related to airway structures.

Discussion Effects of non-surgical RME on airway structures (table I) Changes at the nasal floor adjacent to the midpalatal suture following non-surgical RME had been reported [11,22]. The transverse skeletal maxillary thickness and nasal cavity widths were found to be significantly increased post-RME [23,24] leading to decreased airway resistance [25–27]. A few authors investigated the association between RME and nasal airway

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resistance (NAR) [26–28]. Collectively these studies indicated that RME reforms the nasal valves of patients and decreases NAR during breathing. There were, however, subjective variations in treatment planning and expansion appliances used in these studies. In addition, the stability of airway structures with RME over time and its effect on NAR was unclear [26,29]. Studies assessing the effects of RME on NAR and dimensions are summarized in table I. From these studies, it is evident that nonsurgical RME increases nasal geometry and the increase in transversal nasal measurements ranged from 2 to 4 mm. Enoki et al. [30] and Compadretti et al. [31] estimated the changes in the cross-sectional area of the nasal cavities in children with mixed dentition. Enoki et al. [30] found no difference in the cross-sectional area at the level of the valve and inferior nasal turbinate despite a statistical reduction in NAR after expansion. Compadretti et al. [31] reported a decrease in NAR. They, however, related a significant increase in cross-sectional area, total nasal volume, nasal cavity width and inter-zygomatic distance after RME treatment using rhinomanometry, acoustic rhinometry and postero-anterior radiographs. In 2007, Doruk et al. [32] assessed the effects of RME on nasal volume with computed tomography (CT) and acoustic rhinometry (AR) at the start of and 6 months after expansion. Both methods showed significantly increased nasal volume and correlation analysis showed no difference in volume using either of the two methods. In the same year, Palaisa et al. [33] examined the nasal cavity area and volume using CT in 19 cases of RME. Significant increases in the anterior nasal cavity area from pre-to post-

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involving surgical or combined RME-surgical treatment pre-, during and/or post-expansion, syndromic subjects with craniofacial anomalies. Titles and abstracts of potentially relevant articles were screened and evaluated according to the inclusion and exclusion criteria. The identified publications were then secured and appraised. Electronic search was complemented by manual-search in the reference list of the selected publications where applicable.

To cite this article: Alyessary AS, et al. Effects of non-surgical rapid maxillary expansion on nasal structures and breathing: A systematic review. International Orthodontics (2019), https://doi.org/10.1016/j.ortho.2019.01.001

A Review of the Literature

A.S. Alyessary, S.A. Othman, AUJ. Yap, Z. Radzi, M.T. Rahman

TABLE I Studies estimating effects of non-surgical RME on airway structures. Study/year

Number of cases

Parameters

Effects of RME

Compadretti et al. [31]/2006

27 cases with a mean age 8–20 years

NAR and cross-sectional area

Decreased nasal airway resistance and increased total minimal cross-sectional-area

Yes

Enoki et al. [30]/ 2006

29 cases between 7 and 10 years old

NAR and cross-sectional area

Decreased nasal airway resistance but no significant change in minimal cross-sectionalarea

Yes

Doruk et al. [32]/ 2007

10 cases between 12 and 14 years old

Nasal volume

Increased nasal volume

Yes

Palaisa et al. [33]/ 2007

19 cases between 8 and 15 years old

Nasal volume and nasal area

10% increase in nasal area and nasal volume

Yes

Oliveira et al. [36]/ 2008

38 cases with a mean age 13 years old

Nasal cavity dimensions, and nasal airway resistance

A mean reduction of nasal airway resistance; and mean increases in total nasal volume and nasal valve area

Yes

Haralambidis et al. [35]/2009

24 cases with mean age, 14.5 years old

Nasal cavity volume

A significant average increase of 11.3% in nasal volume Sex, growth, and skeletal relationship did not influence measurements or response to treatment

NM

Matsumoto et al. [38]/2010

27 cases with age 7– 10 years of old

Evaluation the nasal cavity by acoustic rhinometry and computed rhinomanometry

RME significantly increased nasal and maxillary width, but the nasal mucosal effects were subtler and not stable

No

Görgülü et al. [34]/ 2011

15 cases with a mean age, 13.86 years old

Nasal cavity volume

A 20% average increase was found at the coronal level, and a 12.1% increase was measured in nasal cavity volume

NM

Langer et al. [39]/ 2011

25 cases with age 7– 10 years old

Dimension of the nasopharyngeal space

RME does not influence on nasopharyngeal area or nasal airway resistance in long-term evaluation

NM

Cordasco et al. [41]/ 2012

8 cases with a mean age of 9.7 years

Skeletal nasal cavity size

Significant enlarge the dimension of nasal cavity and the increment is bigger in the lower part of the nose and equally distributed between the anterior and the posterior part of the nasal cavity

NM

20 cases between 8 and 15 years old

Nasal cavity volume and nasopharynx volume

Significant increases in nasal cavity volume and nasopharynx volume

NM

Itikawa et al. [37]/ 2012

29 cases with age 7– 10 years old

Facial morphology and nasal cavity dimensions of mouth breathing children

No effect on nasal resistance since the nasal bony expansion is followed by a mucosal compensation

NM

Chang et al. [42]/ 2013

14 cases with a mean age, 12.9 years; range, 9.7–16 years

Dimensional changes of the upper airway

Only the cross-sectional area of the upper airway at the posterior nasal spine to basion level significantly gains a moderate increase after RME

NM

Smith et al. [40]/ 2012

Are results stable?

RME: rapid maxillary expansion; NM: not mentioned.

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expansion (11.7%), from post-expansion to post-retention (22.2%) and from pre-expansion to post-retention (35.7%) were found. In addition, they discovered similar increases of 10% and 15% in middle and posterior nasal cavity volumes during post-expansion and post-retention, respectively. These alterations were mainly stable at different retention periods.

Furthermore, Görgülü et al. [34] and Haralambidis et al. [35] evaluated the results of RME on nasal cavity volume by utilizing modelling applications and 3-dimensional simulation. Görgülü et al. [34] substantiated that expansion within the anterior element of the maxillary bone was higher than the posterior component, and expansion was greatest at the coronal level and

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To cite this article: Alyessary AS, et al. Effects of non-surgical rapid maxillary expansion on nasal structures and breathing: A systematic review. International Orthodontics (2019), https://doi.org/10.1016/j.ortho.2019.01.001

lower towards the cranial level for all the parameters measured. Haralambidis et al. [35] also observed a significant increase (11.3%) in the nasal volume. Oliveira et al. [36] found that RME involved the separation of the maxillary bones in a pyramidal shape, where the highest enlargement is at the level of the incisors, slightly below the nasal valves. Additionally, palatal disjunction may cause a total volume increase within the nasal cavity as the lateral partitions are moved far apart. In contrast, Itikawa et al. [37] and Matsumoto et al. [38] assessed the effects of RME on facial morphology and nasal cavity dimensions of young children and observed a significant increase in nasal and maxillary transversal bony width. No difference in nasal volume was, however, detected as mucosal changes were slighter greater than bony ones when RME was employed. More studies are thus warranted to confirm the outcomes of non-surgical RME on dimensional changes of upper airway structures and breathing with special emphasis on nasal mucosal changes in order to determine the long-term stability of RME. Furthermore, Langer et al. [39] concluded that

RME did not influence nasal resistance or nasopharyngeal area in their long-term evaluation. They explained that the improvements in nasal airway could have occurred due to craniofacial growth, rather than RME action itself. This study was limited as only rhinomanometry was used to assess differences in the nasopharyngeal area and NAR after RME. Smith et al. [40] assessed the airway volume, soft-palate area, and soft-tissue thickness changes before and after RME in adolescents using 3-dimensional computed tomography. They observed sizeable increases in nasal cavity volume, nasopharynx quantity, anterior and posterior facial heights, and palatal and mandibular planes. Cordasco et al. [41] evaluated the effects of RME on skeletal nasal cavity size in growing subjects and found that RME produced significant skeletal transverse increases in the nasal and palatal regions. The increases were bigger within the lower part of the nasal cavities. In addition, RME is capable of increasing the skeletal nasal cavity volume by about 0.08 to 0.10% of the pre-expansion volume. The increasing dimension is equally allotted between the anterior and the posterior parts of

A Review of the Literature

Effects of non-surgical rapid maxillary expansion on nasal structures and breathing: A systematic review

TABLE II Studies estimating effects of non-surgical RME on breathing. Study/year

Number of cases

Parameters

Effects of RME

Are results stable?

Monini et al. [46]/ 2009

65 cases younger than 12 years

Assessment of nasal flow in young children

There was an improvement of nasal respiration in children via a widening effect on the nasopharyngeal cavity

NM

Aloufi et al. [50]/ 2012

30 cases with a mean age of 14.2 years

Upper and lower pharyngeal airway spaces

Positive effect on the upper pharyngeal airway. RME did not significantly improve the mode of breathing

NM

Iwasaki et al. [47]/ 2012

23 cases with mean age 10.2 years

Use computational fluid dynamics to estimate the effect of rapid maxillary expansion on nasal ventilation

Improvement of nasal airway ventilation by rapid maxillary expansion was detected by computational fluid dynamics

NM

Iwasaki et al. [48]/ 2014

25 cases with a mean age 9.7 years

Evaluate changes in ventilation conditions using computational fluid dynamics

The nasal airway ventilation conditions was improved and constriction of the pharyngeal airway less likely after RME

NM

Caprioglio et al. [49]/ 2014

14 cases with a mean age 7.1  0.6 years

Airway volume

Increases of total airway volume

NM

Fastuca et al. [51]/ 2015

15 cases with a mean age 7.5  0.3 years

Airway volume and oxygen saturation

The upper, middle, and lower airway volumes were significantly increased and oxygen saturation was increased

NM

Izuka et al. [53]/ 2015

25 cases with a mean age of 10.5 years

Upper airway dimensions

Significant increase in airway volume of the nasopharynx and nasal cavities as well in anterior and posterior widths of the nasal floor

NM

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RME: rapid maxillary expansion; NM: not mentioned.

To cite this article: Alyessary AS, et al. Effects of non-surgical rapid maxillary expansion on nasal structures and breathing: A systematic review. International Orthodontics (2019), https://doi.org/10.1016/j.ortho.2019.01.001

A Review of the Literature

A.S. Alyessary, S.A. Othman, AUJ. Yap, Z. Radzi, M.T. Rahman

the nasal cavity. Furthermore, in 2013. Chang et al. [42] used CBCT to determine the dimensional changes of the upper airway in 14 orthodontic patients (mean age 12.9 years) with maxillary constriction treated by RME. They confirmed that only the transverse width of the upper airway from the posterior nasal spine to the basion area had a moderate increase after RME. The increases were approximately 0.50 to 0.60 of the pre-expansion of that area, while changes to the mid-sagittal areas and volumes of the oropharyngeal airway and its corresponding segments were insignificant. The sample sizes of the cited studies were small and retention period was short.

Effects of non-surgical RME on breathing (table II) Maxillary enlargement is a well-known and advocated therapy in dealing with constricted maxillary arches in developing patients. Considering the fact that the maxillary bones form half of the nasal cavity's anatomic construction, it has been assumed that midpalatal disjunction would influence the anatomy and the physiology of the breathing structures [43,44]. Despite the increase in both nasal and pharyngeal airway dimensions, the actual mechanism for improved breathing remains speculative [45]. Several studies had investigated the association between RME and breathing (table II). Monini et al. [46] evaluated the shortand long-term effects of RME on nasal flow in young children. The authors stated that in cases of maxillary constriction and nasal airway obstruction, RME proved to be an efficient method for improving nasal respiration/breathing in children via a widening effect on the nasopharyngeal cavity. Furthermore, in 2012 and 2014, Iwasaki et al. [47,48] used computational fluid dynamics to estimate the effect of RME on breathing. They found that the nasal airway ventilation conditions were improved and constriction of the pharyngeal airway less likely after RME. As computational fluid dynamics can evaluate airflow in the nasal cavity alone, it might give a more accurate evaluation of the effect of RME than conventional methods. Furthermore, Caprioglio et al. [49] investigated the effects of RME on the airway and correlated CBCT computed volumes to polysomnography evaluation of oxygen saturation and apnoea/hypopnea index. They proved that at the examined time points, the relation between the total airway volume, oxygen saturation, and apnoea/hypopnea index changes were not correlated. The increases of total airway

volume, oxygen saturation and apnoea/hypopnea index were, however, statistically significant. In contrast, Aloufi et al. [50] assessed mode of breathing and pharyngeal airway after RME. They reported that maxillary expansion during orthodontic treatment could have a positive effect on the upper pharyngeal airway, but had no significant effect on the lower airway and mode of breathing. The authors, however, utilized lateral cephalometric radiography and not 3D imaging. More recently, Fastuca et al. [51] evaluated the alterations in airway volumes and respiratory performance in patients treated with RME using CBCT scans. They found that RME treatment caused significant increases in upper, middle, and lower airway compartment volumes, and also confirmed that the lower baseline airway volumes of the middle and lower compartments were associated with greater increases in SpO2. According to the results of this study, the bony expansion seemed to induce a good response in the respiratory mucosal tissue, even though this remained questionable [52] in the anterior and posterior widths of the nasal floor. It was also found to significantly improve the quality of life of mouth-breathing patients [53]. Although past studies suggest a positive effect of RME on breathing in children/adolescents, more studies employing computational fluid dynamics and longer retention periods are warranted before a definitive conclusion can be derived.

Conclusion Based on the reviewed literature, RME appears to improve breathing, increase nasal cavity geometry and decrease nasal airway resistance in children and adolescents. As the sample sizes of most previous studies were small, future studies should incorporate more subjects and longer retention/observation periods. In addition to rhinometry, the use of computational fluid dynamics should be considered to give more accurate evaluations of the effect of RME. Acknowledgement: This research is supported by High Impact Research MoE Grant UM.C/625/1/HIR/MOHE/DENT/21 from the Ministry of Education Malaysia. Disclosure of interest: the authors declare that they have no competing interest.

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A Review of the Literature

Effects of non-surgical rapid maxillary expansion on nasal structures and breathing: A systematic review

To cite this article: Alyessary AS, et al. Effects of non-surgical rapid maxillary expansion on nasal structures and breathing: A systematic review. International Orthodontics (2019), https://doi.org/10.1016/j.ortho.2019.01.001

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A Review of the Literature

A.S. Alyessary, S.A. Othman, AUJ. Yap, Z. Radzi, M.T. Rahman

[51] Fastuca R, Perinetti G, Zecca PA, Nucera R, Caprioglio A. Airway compartments volume and oxygen saturation changes after rapid maxillary expansion: a longitudinal correlation study. Angle Orthod 2015;85:955–61.

[52] Yilmaz BS, Kucukkeles N. Skeletal, soft tissue, and airway changes following the alternate maxillary expansions and constrictions protocol. Angle Orthod 2015;84 (5):868–77.

[53] Izuka EN, Feres MFN, Pignatari SSN. Immediate impact of rapid maxillary expansion on upper airway dimensions and on the quality of life of mouth breathers. Dental Press J Orthod 2015;20:43–9.

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