Farid Akhlaghi
Clinical relevance: Based on the reviewed literature, crown margins should preferably be
placed in a supragingival position in order to favour maintenance of periodontal health.
Key words; crowns; gingivitis; alveolar bone loss; periodontal attachment loss;
periodontium; prosthodontics; systematic review.
1.Introduction:
The goal of all prosthetic treatment is to obtain a satisfying functional and esthetical oral
status. Successful treatment outcome following prosthetic treatment relies on healthy hard
tissues but also on healthy soft tissues. Side effects as a result of the treatment may arise
during the prosthetic rehabilitation, for example because of the preparation and its location[2].
Preparation types may differ in a number of ways, due to factors related to type of tooth,
clinical crown height and position, tooth vitality, the degree of remaining tooth substance and
specific aesthetic needs. Positioning of restorative margins, with relation to both the gingival
and the osseous tissues, has long been a source of controversy in periodontics, and in dentistry
as a whole. Two different principles have been discussed in the literature. The first one
recommended that the preparation should be placed subgingivally [3], and the second one
proposed location of the preparation at or above the gingival crest[4]. G.V.Black [3]
advocated a scientific approach regarding cavity preparation and design. The concept of
"extention for prevention" was one of the principles recommended. As long ago as 1930 this
concept was attacked by Gottlieb & Orban[4]. They argued that the concept of "extention for
prevention" was harmful to the periodontal tissues. This argument was further investigated by
Le et al[2], who also stated that "the concept of extention for prevention" was wrong and
outdated. In recent years the biological aspects of fixed reconstructions have received a lot of
attention. The concept of biological width was first put forward by Ingber et al.[5], who
defined it as the minimum width at the gingival sulcus required to maintain a normal gingival
attachment. This definition was based on Garguilos study [6] of post-mortem specimens.
Their research documented that there is a proportional dimensional relationship within a small
range, 0.5 mm, between the dentogingival junction and the other supporting tissues of the
tooth; namely, between the crest of the alveolar bone, the connective tissue attachment, the
junctional epithelium, and sulcus depth. In their study, a total of 325 measurements were
taken from clinically normal specimens. The authors noted a great consistency in the
dimensions of the various components: (1) the sulcus depth was 0.69 mm, (2) the junctional
epithelium was 0.97 mm, and (3) the connective tissue attachment averaged 1.07 mm. The
combined dimension of the connective tissue attachment and the junctional epithelium,
therefore, averages 2.04 mm and has been considered as the biological width. These two
zones form a biologic seal around the neck of the tooth, that acts as a barrier to help prevent
migration of microorganisms and their products into the underlying gingival connective tissue
and supporting alveolar bone. Eissman et al. [7] recommended that restorations should not be
placed at or near the alveolar crest and that there must be 2 mm of root surface between the
alveolar crest and the restoration to provide for the biologic width. Wilson and Maynard [8]
stated that some distance of unprepared tooth structure should remain between the finish
line of the prepared tooth and the junctional epithelium .. this distance ideally should be 0.5
mm. .
It has been suggested that extension of tooth preparation apical to the base of the histological
crevice will violate the biologic width, and will disrupt the biologic seal. This extension might
allow bacteria and their products to penetrate the underlying connective tissue and alveolar
bone. The purpose of this systematic review was to study the effect of crown margin
positioning on surrounding periodontal tissues. In addition, some clinical cases illustrating the
issues discussed are presented.
"Crowns"[MeSH] AND "Alveolar Bone Loss"[MeSH], 161 articles, (151 articles were in
English, none were in Swedish).
The Cochrane Central Register was searched, using the following combinations: crowns and
periodontal attachment loss, crowns and gingivitis, crowns and bone loss, periodontal
and prosthetic, periodontium and crowns, (34 articles were found, all in English).
Figure 1 describes the process of identifying the included studies from an initial yield of 392
titles. Titles and abstracts were independently screened by two reviewers (Farid Akhlaghi &
Jan Derks) to identify publications that met the inclusion criteria. A total of 45 articles were
identified. Kappa score on agreement was 77.8%. All disagreements were resolved by
consensus discussion after examining the abstracts. The final sample included 38 articles
which were evaluated in full text by one reviewer (FA). Additional searches of reference lists
resulted in 14 articles. These articles were also ordered in full text and were studied, rendering
a total of 52 articles, from which 21 articles were included in the study.
Electronic search
392 articles with titles and abstracts
Further handsearching,
14 articles
31 articles excluded
(Table 3)
Moderate value:
A study was considered to have a moderate value if it did not meet all the requirements for a
study of high value but neither had the characteristics of studies with low value.
Low value:
The intervention and control group were not comparable.
Lack of adequate analysis in regard to study aim.
The population was not well defined.
Large number of, or unexplained drop outs.
Further important confounders, other than those reported, were suspected.
Systematic distortion of the results could be suspected.
10
3- Results:
3.1. Subgingival crown margins increase gingival inflammation (Evidence grade 3).
The literature search resulted in 19 selected studies in which increased gingival inflammation
could be related to the subgingival placement of the crown margin. Four studies were
considered to be of moderate value [9-12] (Table 1) and fifteen studies of low value [13-27]
(Table 2). Sixteen studies showed that there was a greater degree of inflammation around
crowns with subgingival margins [9-12, 14-18, 20-25, 27]. Two studies of low value did not
demonstrate any clear relationship between subgingival placement of the crown margin and
the degree of inflammation [19, 26]. In the first of these two [26] (Table 2), the relationship
between the location of crown margins and gingival inflammation was examined on 12
molars with one half of the facial margin being supragingival and the other half subgingival.
No difference in gingival health was found using Les Gingival Index to assess gingival
tissue reaction. The authors reported no differences in terms of sulcus depth, gingival contour,
or plaque accumulation. It was concluded that fit and finish of full crown restorations may be
more important to gingival health than the location of the finish line. However, the
intracrevicular depth of the preparation was not reported in this study. In the second article of
the two mentioned above [19] (Table 2), forty-six full crown restorations in 28 patients were
evaluated according to gingival margin placement, to determine if there was a difference in
gingival inflammation. In this study, highly motivated patients from a private practice were
selected and the results did not show any difference between supragingival and subgingival
crown margins. Furthermore, in an additional study of low value, crown margins located just
at the gingiva had more inflammation compared to both supra- and subgingival crown
margins [13] (Table 2).
11
The scientific evidence grade 3 for the statement Subgingival crown margins increase
gingival inflammation is based on four studies of moderate value, according to the previous
description. A short summary of these four studies is as follows:
12
even more pronounced around crowns with subgingival placement. Valderhaug [28, 29]
reported similar results in previous studies from 1976 and 1980.
3.2. The scientific evidence is insufficient to support the statement the deeper the
placement of the crown margin, the higher the degree of inflammation.
Three studies were identified that addressed the question of whether the depth of subgingival
margin placement relates to the degree of gingival inflammation. One study was of moderate
value [11] (Table 1) and two of low value [14, 17] (Table 2). All these three studies indicated
that the deeper the placement of the crown margin, the higher the degree of inflammation.
The only study that could be considered for evidence assessment was an investigation by
Gunay [11]. It was a prospective 2-year clinical trial, in which PBI (Papillary Bleeding Index)
was analyzed before, and 3, 6, 12 and 24 months after crown therapy on 116 teeth. After
preparation, the distance between the restoration margins and the alveolar crest was
registered. Teeth were divided into 3 groups: Group 1, less than 1 mm between crown margin
and alveolar bone, Group 2, 1-2 mm and Group 3, more than 2 mm. The highest PBI increase
was noted in Group 1. The most significant increase in Group 1 was observed between 3 to 6
months after preparation.
The scientific evidence for the statement The deeper the placement of the crown margin, the
higher the degree of inflammation is therefore graded as insufficient, because no more than
one study with moderate value was identified.
13
3.3. The scientific evidence of the effect of crown margin placement on periodontal
attachment and bone levels is insufficient for any conclusion.
Five studies were identified that described the relationship between crown margin location
and changes in attachment level. Two of these studies were of moderate value [11, 30] (Table
1) and three of low value [21, 25, 31] (Table 2). In one study of moderate value [11] (Table 1)
marked loss of attachment did not occur during a 2-year examination period. A second study
of moderate value [30] (Table 1) showed that intracrevicular crown placement resulted in
attachment loss despite careful supportive therapy. In this study, crowned teeth had an
average of 0.71 mm more attachment loss than control teeth during a 12-month period.
However, the author pointed out that the observed attachment loss at crowned teeth was
probably not of clinical relevance.
In a 26-year longitudinal study by Schatzle [32], the relationship between dental restorations
and periodontal health was investigated in 160 patients. This study suggested that the
increased loss of attachment found in teeth with subgingival restorations started slowly, and
could be detected clinically 1 to 3 years after the fabrication and placement of the restorations.
Since this study included only fillings and not crowns, it was excluded, and could not be
considered for evidence assessment.
Attachment loss in connection with subgingival crown margins was also reported in two
studies by Valderhaug [28, 29]. Both of these studies showed slightly higher attachment loss
around subgingival crown margins after five and ten years when compared to teeth with
margins at or above the gingival crest. Mean differences in clinical attachment levels were
found to be 0.7 mm after ten years [29]. However, the author did not provide significance
testing. In a 15-year follow-up of the same material [10] (Table 1), no analysis was found
regarding changes in attachment level. Because of the inadequate analysis, the studies [28, 29]
14
were excluded and could not be considered for evidence assessment of attachment level
changes.
When evaluating changes in bone level, three studies were identified which discussed the
relationship between subgingival crown margins and bone loss [10, 11, 31]. Two studies were
found to be of moderate value [10, 11] (Table 1) and one of low value [31] (Table 2). Based
on histological observations, Tarnow et al. [31] (Table 2) showed a correlation between
subgingival crown margins and bone loss. The two remaining studies failed to show any
relationship using intraoral radiographs [10, 11]. One of them was a 15-year longitudinal
study by Valderhaug [10] (Table 1), in which the bone loss could not be related to the location
of the crown margin at the time of placement. In another study by Gunay [11] (Table 1), no
alterations of bone levels could be diagnosed on radiographs during the 2 years of
investigation. It is important to note that standardized techniques are necessary to guarantee
comparable radiographs, and due to the fact that these studies had different designs, it was
impossible to draw any conclusions regarding the changes in bone level.
15
4- Discussion:
The limited number of studies in the analysis, and the diversity of the approach in determining
the influence of crown margins on periodontal tissue health, have made meaningful synthesis
of the evidence difficult. No study of high value could be found. Only a few studies of
moderate value were identified and most studies that could be related to the issue were of low
value (Table 1 and 2). However, several of the selected studies concluded that subgingival
crown margin could contribute to gingival inflammation [9-12, 14-18, 20-25, 27]. Statistically
significant differences in regard to mean Le and Silness Gingival Index (GI) values between
crowned and control teeth were observed in several patient populations. It is important to note
that GI values are an ordinal value, which means that a greater index value is correlated with
increased inflammation. Since the data is not continuous, a score of 2 does not mean that the
periodontal tissue was twice as inflamed as a score of 1. This must be taken into account in
order to reduce the risk of "bias". In a 15-year longitudinal study by Valderhaug et al. [10]
(Table 1), the authors described the relationship between gingival inflammation and the crown
margin placement by reporting the results in terms of frequencies of index score, and thus
reduced the risk of "bias".
Another consideration is that the term subgingival refers to the placement of a restoration
margin between the free gingival margin and the alveolar crest. Wilson and Maynard [8]
created the term intracrevicular restorative dentistry. It is defined as placement of
restorative margins within the gingival sulcus and above the junctional epithelium or
epithelial attachment. Because the term subgingival often refers to margins extending
beyond the gingival crevice, the term intracrevicular is more suitable to use. However, in
most studies factors such as intracrevicular depth of crown margins were frequently not
reported. Only three studies could be identified that investigated the effect of crown margin
depth on periodontal health [11, 14, 17]. In a study by Newcomb [17], 59 patients with 66
16
anterior veneer crowns, with subgingival labial margins, were examined. The results from this
study showed that the degree of inflammation was related to the location of the crown margin.
There was a clear negative correlation between gingival inflammation and the distance of the
crown margin from the base of the crevice, and a strong positive correlation between gingival
inflammation and the distance of the crown margin below the gingival crest. Deeper
placement of the crown margin resulted in more gingival inflammation. Since this study was
cross-sectional, it was excluded, and could not be considered for evidence assessment.
When evaluating gingival inflammation and changes in attachment and bone levels, variables
such as initial health of the periodontium, intracrevicular depth of the restoration and
adaptation of the restoration margin are important factors for accurate assessment of the
outcome. Frequently, studies failed to report the exact techniques how these were assessed. In
addition, side effects of the prosthetic treatment per se might have significant influence.
Periodontal tissues may be affected by the preparation of the tooth, impressions,
provisionalization and cementation. It is also important to note that teeth generally have
received extensive direct restorative therapy that may have included intracrevicular
restorations before crown therapy. It is therefore suggested that future clinical investigations
document the tooths restorative history and initial periodontal status, so that each crowned
tooth serves as its own control. A further consideration is that a small but statistically
significant difference in terms of clinical attachment and bone levels may be of minor or no
clinical relevance. Some studies [10, 11] have evaluated bone levels based on radiographic
findings. Standardized radiographic methods are a prerequisite to properly assess these, but
were not always used. This may question the validity of the reported results.
The aim of the present study was to evaluate the effect of crown margin positioning on
surrounding periodontal tissues. The situation around implants might be considered as
somewhat similar to crowned teeth. The dimension of the peri-implant mucosa has been
17
demonstrated to resemble that of the gingiva around teeth and includes a junctional epithelium
and a connective tissue compartment [33, 34] In so-called 2-part implants, the
abutment/fixture borderline is located in the connective tissue portion, and several studies
have shown that the gap between the intraosseous and transmucosal components have a
detrimental effect on the surrounding connective tissue and marginal bone level [35-39]. The
smaller the gap, the closer the position of the marginal bone to the abutment-implant
interface[40-43]. This condition does not exist around natural teeth and therefore a
comparison is not possible from this point of view between teeth and implants. The conditions
around subgingival crown margins are more comparable to submucosally placed implant
crown margins, because most likely both interface the epithelium. Little is known about the
effect of implant crown margin positioning on surrounding peri-implant tissues. Some studies
have shown that in patients with appropriate oral hygiene, the intracrevicular position of the
restoration margin did not appear to adversely affect peri-implant health [44, 45], while SBI
score (sulcus bleeding index) decreased as the location of a crown margin went from sub- to
supragingival position [46]. In addition, cement-retained crowns revealed a consistently
higher degree of sulcus bleeding than screw-retained crowns [46]. Further research is
necessary to understand the effect of implant crown margins on peri-implant tissues.
18
5- Conclusion:
The scientific evidence is insufficient to support the statement the deeper the placement of
the crown margin, the higher the degree of inflammation.
The scientific evidence of the effect of crown margin placement on periodontal attachment
and bone levels is insufficient for any conclusion.
19
Authors
Type,
Year
Duration
Flores-de-
Prospective
Jacoby et
1-year clinical
al.[9]
study
Sample
Outcome
Results
Evidence
variables
19 pat.
693 teeth
PI
Moderate
scores of GI.
GI
PD
margin> supragingivally
PI
1989
Valderhaug
et al.[10]
Longitudinal
study, 15 years
102 pat.
108 bridges
1993
GI
PD
subgingivally.
No statistical differences in bone loss between
control and crowned teeth.
Bone level
Moderate
Changes in
attachment levels
reported in previous
studies in 1976 and
1980.
Gunay
et al.[11]
2000
Prospective
41 pat.
2-year clinical
116 prepared
study
teeth
HI
Moderate
PBI
PD
PAL
Bone level
Reitemeier
et al.[12]
RCT,
1 year
240 pat.
480 metal ceramic
PI
Moderate
SBI
crowns
2002
Koke
Prospective
11 pat.
CAL
et al.[30]
1-year clinical
44 teeth,
Ging.
study
Uncrowned
recession
2003
controls
Moderate
( PI= Plaque Index, HI=Hygiene Index, GI= Gingival Index, PD= Probing Depth, CAL= Clinical Attachment Level, PBI= Papillary
Bleeding Index, GCF= Gingival Crevicular Fluid)
20
Type,
Sample
Duration
Larato[27]
Cross-sectional
1969
Marcum
Outcome
Results
Evidence
variables
Gingivitis
Low
66 gold crowns in
Gingival
Low
6 dogs
inflammation
(Different
histological
crest.
268 pat.
546 teeth
Histological
[13]
animal study,
1967
3 months
parameters)
Karlsen
Histological
[14]
animal study,
1970
2-12 months
2 dogs and
Gingival
3 monkeys
inflammation
placement.
Low
Silness[15]
Cross-sectional
1970
385 teeth/
contralateral
PI
GI
Low
subgingival margins.
PD
Bergman
Longitudinal
et al.[16]
2-year clinical
1971
trial.
Richter &
Prospective
30 pat.
PI
61 crowns
GI
subgingival.
Low
PD
12 crowns
PI
Ueno[26]
study,
GI
1973
3 years
PD
Low
Newcomb
Cross-sectional
[17]
59 pat.
66 crowns with
PI
of 8,23 months/
Low
GI
average age
1974
PD
Uncrowned
inflammation.
controls
Janenko &
Smales[18]
1979
Cross-sectional
126 pat.
101 PJC crown
88 PBM crown
PI
GI
Low
marginal placement.
( PI= Plaque Index, HI=Hygiene Index, GI= Gingival Index, PD= Probing Depth, CAL= Clinical Attachment Level, PBI= Papillary
Bleeding Index, GCF= Gingival Crevicular Fluid)
21
Table 2 continued
Authors
Type,
Sample
Duration
Koth[19]
Cross-sectional
1982
Outcome
Results
Evidence
variables
A-38 full crown
Crevicular
restorations in 26
Fluid,
patients.
Gingival
inflammation
placement.
PI
Low
only highly
motivated patients
Grasso
Cross-sectional
291 pat.
et al[20]
GI
1985
Muller[21]
Cross-sectional
1986
Tarnow
et al.[31]
Low
5 pat.
79 teeth
Histological
examination.
2 pat.
13 teeth
1986
PD
placement of a crown.
PI
GI
PD
CAL
Histological
observations,
changes in
bone and
attachment
level.
Low
No subgingivally
located margins
Low
Orkin
Cross-sectional
PI
355 subgingival
et al.[22]
1987
Bader
423 pat.
Cross-sectional
68 supragingival
GI
Untreated controls
Gingival
recession
PI
831 pat.
Low
Low
crown margins.
et al.[23]
GI
1991
PD
( PI= Plaque Index, HI=Hygiene Index, GI= Gingival Index, PD= Probing Depth, CAL= Clinical Attachment Level, PBI= Papillary
Bleeding Index, GCF= Gingival Crevicular Fluid)
22
Table 2 continued
Authors
Type,
Sample
Duration
Pippin
Cross-sectional
60 pat.
GI
Evidence
PFMs.
Low
GCF
60 veneers and 60
1995
Results
variables
120 restorations
et al.[24]
Outcome
PD
Giollo
et al.[25]
2007
Retrospective
40 pat.
clinical trial,
40 ceramic
3-5 years
crowns
Uncrowned
controls
PI
Low
BI
PPD
CAL
subgingival crowns.
( PI= Plaque Index, HI=Hygiene Index, GI= Gingival Index, PD= Probing Depth, CAL= Clinical Attachment Level, PBI= Papillary
Bleeding Index, GCF= Gingival Crevicular Fluid)
23
Authors
Year
Reason
Silness[47, 48]
1970
1972
Only fillings.
Renggli[50]
1974
Only fillings.
Bellos[51]
1974
Silness[52]
1974
Observations on pontics.
1976
1977
Valderhaug[29]
1980
Romanelli[54]
1980
Silness[55]
1980
Jenkins[56]
1981
1981
1982
Rohner et al.[59]
1983
[28]
1983
Behrend[61]
1984
1984
Lesan[63]
1987
Brandau et al.[64]
1988
Bader et al.[65]
1991
Tiwarri et al.[66]
1992
Wang et al.[67]
1993
Sherif et al.[68]
1993
Shavell[69]
1994
24
Table 3 continued
Authors
Year
Reason
Mojon et al.[70]
1995
Kois[71]
1996
General aspects.
Swartz et al[72]
1996
Schatzle et al.[32]
2001
Only fillings.
Broadbent et al.[73]
2006
De Backer et al.[74]
2007
25
Case 1:
The patient is practising good oral hygiene but still the gingiva around the subgingivally placed crown
on 11 shows gingivitis. Soft tissues around the non-treated tooth 21 are perfectly healthy. It is a quite
common clinical finding that soft tissues around subgingivally placed crowns show more gingivitis
than around non-prepared teeth under the same oral hygiene conditions.
Before probing.
Note the colour on 11 cervically.
26
Case 2:
Inadequate oral hygiene in combination with bad
fit and deep subgingival placement of the
finishing line results in pronounced gingivitis.
Case 3:
neighbouring
teeth
27
Case 4:
The originally cemented crown was placed subgingivally showing the typical inflammation of
subgingival margin. After an esthetic gingivectomy had been performed a bonded crown was placed
with the finishing line at the gingival level. Healthy gingiva and better esthetics are the result.
Dr. S. Toreskog
Case 5:
The cemented crown 11, where the gingiva has
receeded, illustrates the darkening effect of the root
surface by the crowns blocking of incident light. This
also affects the colour of the gingiva since light is not
transmitted through the crown. As a result, the gingiva
looks slightly inflamed. Note that tooth 11 is vital.
This crown was cemented with phosphate cement and the cement has now been washed away in the
margin with a more pronounced plaque accumulation as a result.
28
Case 6:
28-year
old
woman
with
Previous treatment: 11 and 21 were treated with composite. 31 and 41 were treated with metal-ceramic
crowns. The sole reason for crown therapy on 31 and 41 was the discolouration of these teeth. The
patient was not satisfied with the esthetical result and wanted new restorations. She has a very good
oral hygiene. Visually, the gingiva seems healthy but examination by probing revealed gingivitis
around 31 and 41.
This case illustrates that the gingiva around subgingivally placed cemented crowns may look
acceptable but there might still be signs of inflammation when the pockets are probed. However, the
bonded porcelain veneers placed deep subgingivally showed no signs of gingivitis after probing.
29
Case 7:
Teased at school because of the yellow colour of 21, which is
seriously affected by 'enamel hypoplasia'. 22, which has been treated
with composite, has also been affected, but not as much.
Note the inflamed gingiva caused by the absence of glossy enamel
and the accumulation of plaque at the rough dentine surface.
Dr. S. Toreskog
Dr. S. Toreskog
Dr. S. Toreskog
This case shows that a rough tooth surface often will result in more plaque accumulation than a
smooth ceramic surface and will thus cause more inflammation. When the surface is restored with
bonded veneers, even though they might be subgingivally placed, the inflammation will recede. This
case also illustrates beautifully that the right anatomy of the buccal veneer will reposition the marginal
gingival to its right place.
30
Case 8:
An interesting aesthetic case, from the standpoint
that the patient lost her centrals when she was 10
years old and the entire quadrant 1 and 2 was moved
orthodontically one step forward.
Dr. S. Toreskog
Before treatment.
After treatment.
Dr. S. Toreskog
31
Acknowledgement
I would like to thank Dr. Jan Derks for the assistance regarding the database screening and Dr. Sverker
Toreskog for the clinical pictures.
32
Titel:
Tidskrift:
r/volym/sidor
Beskrivning av studien:
Typ av studie/studiedesign:
parodontit
protetik
Material
Estetik
Annat (namnge)
Vrdmilj
Typ av vrdgivare
Land/vrldsdel
Kommentarer
Patientkarakteristiska:
-
Kontrollgrupp
Kommentarer
33
Allmn hlsa
Tobaksbruk
vrigt, Kommentarer
Uppfljningstid:
Intervention;
Frbehandling/typ:
Material/ typ:
Kommentarer:
Effektmtt;
Frndringar i plackfrekomst
Gingival inflammation
Frndring i fickdjup
Frndring i fsteniv
34
Frndring av benvvnad
Tandmobilitet
Frlust av tnder
Inklusionskriterier:
Exklusionskriterier:
Skstrategi, skord:
35
Sammanfattande bevisvrde:
Hgt
Medelhgt
Lgt
Sammanfattande kvalitetsomdme:
Ytterligare kommentarer:
Granskare:
Datum:
36
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[2]
[3]
[4]
[5]
[6]
[7]
[8]
[9]
[10]
[11]
[12]
[13]
[14]
[15]
[16]
[17]
[18]
[19]
[20]
[21]
37
[22]
[23]
[24]
[25]
[26]
[27]
[28]
[29]
[30]
[31]
[32]
[33]
[34]
[35]
[36]
[37]
[38]
[39]
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