International Journal of Current Research and Review
ISSN: 2231-2196 (Print)ISSN: 0975-5241 (Online)
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IJCRR - 13(2), January, 2021

Pages: 09-12

Date of Publication: 16-Jan-2021


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RATIONALE OF BONE GRAFTS FOLLOWING PERIAPICAL SURGERY: A REVIEW

Author: HARKANWAL PREET SINGH

Category: Healthcare

Abstract:Following periapical surgery, restoration of the destroyed bony architecture is a pre-requisite. Previous studies had shown that supplementing with artificial bone substitutes, growth factors or barrier membranes in the osseous defects is essential in influencing the healing following surgical intervention. This review is intended to focus on whether tissue regeneration with the aid of bone grafts coupled with a membrane barrier will suffice or is there a need for recruiting progenitor/stem cells. A literature search was conducted on several medical databases. All studies that used bone graft following periapical surgery were included Around 38 relevant articles were selected for this review. Literature shows that the mere use of a membrane barrier and/or bone graft following surgery would not yield the desired outcome. Previous studies show that some substitutes are capable of generating progenitor/stem cells and induce the undifferentiated mesenchymal cells to differentiate. Bone augmentation with the aid of bone graft materials along with biologically active molecules in addition to a mechanical barrier in the form of a membrane would enhance the healing of periapical tissues following periapical surgery. Better bone fill, gain in clinical attachment level is achieved with the use of various grafts as compared to non grafted sites.

Keywords: periapical surgery, allogenous bone grafts, PRF, Guided tissue regeneration

Full Text:

Introduction

A periapical pathology inevitably results in the presence of a nonvital tooth which is left unattended. This ultimately will result in osseous destruction in the periapical area. It is also a familiar observation that despite an accurately accomplished endodontic treatment failure can be encountered due to microbial infection. This can lead to the formation of a periapical lesion as a result of an inflammatory response to bacterial infection within the root canal.1 An important goal in periapical surgery is to enrich healing along with removing the unhealthy tissues.2

Periapical surgery not only eliminates the unhealthy tissues in the periapical region but also cleanses the root surface along with contouring the surrounding bone. However, few studies have suggested that the healing of the tissues by the newly formed tissue generally fails to fully restore the architecture of the pre-existent bone.3,4 The concept of tissue regeneration has been introduced to improve the quality of healing. The kind of cells that repopulates the wound initially determines the quality of healing.5

Literature shows that the use of either bone graft materials or incorporation of biologically active molecules in addition to the placement of a mechanical barrier following periapical surgery enhances tissue regeneration in the periapical tissues.

Bone grafts

It is a well-known fact that periapical lesions that are relatively small in size would heal satisfactorily with the aid wound healing but larger lesions would require recruitment of stem cells and their differentiation. In huge osseous defects, insufficient osseous regeneration occurs.6

Numerous studies in the past have demonstrated a better outcome with regards to tissue healing following periapical surgery with the aid of regenerative technique using bone graft compared to the same lesions without regenerative techniques.7,8 It is believed that a simple enucleation of the periapical cyst usually leaves a bony defect. Because the maxilla demonstrates a relatively high regenerative capacity, optimal obliteration of this osseous defect in presence of a background of an inflammatory reaction may be hindered.9 Inadequate or less optimal bone healing results when the regenerative technique is not employed due to the invagination of overlying tissue into the osseous defect, preventing osteogenesis.10 According to Jansson et al., the survival rates of periapical surgery was found to be 68% in molars and 77% in single-rooted teeth over 10 years.11 This highlights the fact that augmentation with the aid of bone grafts is essential to facilitate optimal tissue healing in the periapical region following periapical surgery.

Augmented bone graft plays a key role by acting as a template for osteogenesis and slowly resorb to permit replacement by new bone.10Bone grafts have either osteogenic, osteoinductive or osteoconductive properties. 12 Hydroxyapatite can be considered to be a very effective alloplastic material particularly in large bone destruction caused by periradicular lesion where it can facilitate effective bone replacement in the later stages as well as provide functional support to the tooth in the initial stages.10 A recent study evaluated bone regeneration in the periapical region using Platelet-rich fibrin(PRF) and nanocrystalline hydroxyapatite with collagen in combination with PRF and their effects on healing and concluded that the combination of PRF and nanocrystalline hydroxyapatite with collagen produced a significantly faster bone regeneration and that conventional technique and PRF were less predictable with its healing response.13,14

Biologically active molecules

            PRP play a critical role in enhancing wound healing due to the discharge of some growth factors via α granules.12,14 These growth factors generally act both locally and systemically.15 It increases early wound strength by enhancing collagen synthesis and angiogenesis.

Few studies suggested that the use of a triple antibiotic paste for canal disinfection along with PRF strengthens the effectiveness of sterilization in carious teeth, infected dentin, periapical lesions and necrotic pulp.16 Huang et al. in his study concluded that PRF can multiply pulp cells in addition to enhancing the expression of osteoprotegerin and Alkaline phosphatase activity.17

In vitro studies have demonstrated that PRF has shown no cytotoxicity toward many normal cells present in the periapical region.18 A recent study showed that the PRF membrane has a slow sustained release of growth factors for 7-28 days.19

A recent study used PRF with tricalcium phosphate (TCP) bone graft for treating a periapical cyst and advocated that usage of PRF and TCP together would yield enhanced results than the usage of biomaterials alone.20 Study done by Keswani et al on the revascularization of immature pulp apices concluded that PRF acts as a biological connector for neoangiogenesis and vascularization.21 This highlights the fact that augmentation with the aid of bone grafts coupled with biologically active molecules is essential to facilitate optimal tissue healing in the periapical region following periapical surgery.

Barrier membranes

To prevent invading of the overlying soft tissue into the osseous defect, it is advisable to use a mechanical barrier on top of the defect. This would create an environment for the cells to repopulate into the defect.22 Resorbable membranes are available alternatives to non-resorbable membranes.23 They are resorbed by proteolytic enzymes and excreted via kidney.24 An in vitro study advocated that resorbable membranes stimulate cellular proliferation more than non-resorbable membranes.25

Literature shows that collagen membrane coupled with a bone graft significantly enhances the preservation of alveolar bone.26 Membranes containing greater than 5% metronidazole show antibacterial activity deprived of any cytotoxic effects.27

Amnion membrane is derived from the human placenta. It incorporates growth factors presenting anti-inflammatory and antimicrobial properties.28 The thickness of the amnion membrane is lesser than collagen membranes which assist a proper adaption over the osseous defect.29,30 Amnion membrane facilitate the proliferation of endothelial cells and angiogenesis in addition to recruitment of mesenchymal progenitor cells assisting accelerated wound healing.31,32

Inference

The application of graft materials in the form of hydroxyapatite, tricalcium phosphate or xenograft alone would lead to the formation of fibrous encapsulation of the graft material and thereby interfere with the ideal healing in the periapical tissues following surgical intervention.32 It is believed that a blood clot plays a key role in stabilizes the wound matrix in the event of wound healing. Platelet alpha granules of PRP act as a source of growth factors that facilitate cellular proliferation and bone formation.33 PRF facilitates the preservation of the integrity of the bone graft material by revascularizing the bone graft particles through neo-angiogenesis.2,34 Once PRF starts resorbing slowly it releases growth factors that maintain a viable field to enhance healing.35,36 In addition to this placement of a barrier membrane would avoid the invagination of soft tissue into the osseous defect thereby enhancing the wound healing.

Recent advances

Conventional periapical surgical generally results in a big osseous defect. With the aid of the 3D printed template, the osseous defect resulted in surgical intervention is limited to 3–4 mm. This confines injury to osseous tissues resulting in less bleeding, less postoperative complications, shorter healing time and better prognosis.37

A recent study employed Cone Beam Computed Tomography(CBCT) imaging, 3D printing technology and a 3D surgical guide designed with computer-aided software. A hollow trephine bur was used to perform the osteotomy, resection of the root, and enucleation of the lesion. The intact cortical plate was salvaged and used as a graft along with plasma-rich fibrin acquired preoperatively from the patient's blood. The positioning guide allowed the clinicians to precisely achieve targeted tissues and shorten the procedure time. Modified soft tissue management helped achieve a small surgical wound for uneventful healing.38

Conclusion

Guided tissue regeneration acts as an adjunct to surgical intervention that can employ an extensive range of biomaterials. Augmentation with the aid of bone graft materials along with biologically active molecules in addition to a mechanical barrier in the form of a membrane would enhance the healing of peripheral tissues following periapical surgery. We conclude that that better bone fill, gain in clinical attachment level are achieved with the use of various grafts as compared to non grafted sites.

Acknowledgment: Authors acknowledge the enormous help received from the authors whose articles are cited and included in references to this manuscript. The authors are also grateful to authors/editors/publishers of all those articles, journals and books from where the literature for this article has been reviewed and discussed.

Conflict of Interest: Nil

Source of Funding: Nil

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One article from every issue is selected for the ‘Best Article Award’. Authors of selected ‘Best Article’ are rewarded with a certificate. IJCRR Editorial Board members select one ‘Best Article’ from the published issue based on originality, novelty, social usefulness of the work. The corresponding author of selected ‘Best Article Award’ is communicated and information of award is displayed on IJCRR’s website. Drop a mail to editor@ijcrr.com for more details.

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This award is instituted to encourage women researchers to publish her work in IJCRR. Women researcher, who intends to publish her research work in IJCRR as the first author is eligible to apply for this award. Editorial Board members decide on the selection of women researchers based on the originality, novelty, and social contribution of the research work. The corresponding author of the selected manuscript is communicated and information is displayed on IJCRR’s website. Under this award selected women, the author is eligible for publication incentives. Drop a mail to editor@ijcrr.com for more details.

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Best Article Award

A study by Dorothy Ebere Adimora et al. entitled \"Remediation for Effects of Domestic Violence on Psychological well-being, Depression and Suicide among Women During COVID-19 Pandemic: A Cross-cultural Study of Nigeria and Spain\" is awarded Best Article of Vol 14 issue 23
A study by Muhas C. et al. entitled \"Study on Knowledge & Awareness About Pharmacovigilance Among Pharmacists in South India\" is awarded Best article for Vol 14 issue 22
A study by Saurabh Suvidha entitled \"A Case of Mucoid Degeneration of Uterine Fibroid with Hydrosalphinx and Ovarian Cyst\" is awarded Best article of Vol 14 issue 21
A study by Alice Alice entitled \"Strengthening of Human Milk Banking across South Asian Countries: A Next Step Forward\" is awarded Best article of Vol 14 issue 20
A study by Sathyanarayanan AR et al. entitled \"The on-task Attention of Individuals with Autism Spectrum Disorder-An Eye Tracker Study Using Auticare\" is awarded Best article of Vol 14 issue 19
A study by Gupta P. et al. entitled \"A Short Review on \"A Novel Approach in Fast Dissolving Film & their Evaluation Studies\" is awarded Best Article of Vol 14 issue 18.
A study by Shafaque M. et al. entitled \"A Case-Control Study Performed in Karachi on Inflammatory Markers by Ciprofloxacin and CoAmoxicillin in Patients with Chronic Suppurative Otitis Media\" is awarded Best Article of Vol 14 issue 17
A study by Ali Nawaz et al. entitled \"A Comparative Study of Tubeless versus Standard Percutaneous Nephrolithotomy (PCNL) \? A Randomized Controlled Study\" is awarded Best Article for Vol 14 issue 16.
A study by Singh R. et al. entitled \"A Prospective Study to Find the Association of Astigmatism in Patients of Vernal Keratoconjunctivitis (VKC) in a Tertiary Health Care Centre in India (Vindhya Region MP)\" is awarded Best Article for Vol 14 issue 15
A Study by Humaira Tahir et al. entitled "Comparison of First Analgesic Demand after Major Surgeries of Obstetrics and Gynecology between Pre-Emptive Versus Intra-Operative Groups by Using Intravenous Paracetamol: A Cross-Sectional Study" is awarded Best Article for Vol 14 issue 14
A Study by Monica K. entitled "Risk Predictors for Lymphoma Development in Sjogren Syndrome - A Systematic Review" is awarded Best Article for Vol 14 issue 13
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A Study by Pandya S. et al. entitled "Acute and 28-Day Repeated Dose Subacute Toxicological Evaluation of Coroprotect Tablet in Rodents" is awarded Best Article for Vol 14 issue 10
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A Study by Vinita S & Ayushi S entitled "Role of Colour Doppler and Transvaginal Sonography for diagnosis of endometrial pathology in women presenting with Abnormal Uterine Bleeding" is awarded Best Article for Vol 14 issue 08
A Study by Prabhu A et al. entitled "Awareness of Common Eye Conditions among the ASHA (Accredited Social Health Activist) Workers in the Rural Communities of Udupi District- A Pilot Study" is awarded Best Article for Vol 14 issue 07
A Study by Divya MP et al. entitled "Non-Echoplanar Diffusion-Weighted Imaging and 3D Fiesta Magnetic Resonance Imaging Sequences with High Resolution Computed Tomography Temporal Bone in Assessment and Predicting the Outcome of Chronic Suppurative Otitis Media with Cholesteatoma" is awarded Best Article for Vol 14 issue 06
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A Study by Mbungu Mulaila AP et al. entitled "Ovarian Pregnancy in Kindu City, D.R. Congo - A Case Report" is awarded Best Article for Vol 14 issue 03
A Study by Maryam MJ et al. entitled "Evaluation Serum Chemerin and Visfatin Levels with Rheumatoid Arthritis: Possible Diagnostic Biomarkers" is awarded Best Article for Vol 14 issue 02
A Study by Shanthan KR et al. entitled "Comparison of Ultrasound Guided Versus Nerve Stimulator Guided Technique of Supraclavicular Brachial Plexus Block in Patients Undergoing Upper Limb Surgeries" is awarded Best Article for Vol 14 issue 01
A Study by Amol Sanap et al. entitled "The Outcome of Coxofemoral Bypass Using Cemented Bipolar Hemiarthroplasty in the Treatment of Unstable Intertrochanteric Fracture of Femur in a Rural Setup" is awarded Best Article Award of Vol 13 issue 24
A Study by Manoj KP et al. entitled "A Randomized Comparative Clinical Trial to Know the Efficacy of Ultrasound-Guided Transversus Abdominis Plane Block Against Multimodal Analgesia for Postoperative Analgesia Following Caesarean Section" is awarded Best Article Award of Vol 13 issue 23
A Study by Karimova II et al. entitled "Changes in the Activity of Intestinal Carbohydrases in Alloxan-Induced Diabetic Rats and Their Correction with Prenalon" is awarded Best Article of Vol 13 issue 22
A Study by Ashish B Roge et al. entitled "Development, Validation of RP-HPLC Method and GC MS Analysis of Desloratadine HCL and It’s Degradation Products" is awarded Best Article of Vol 13 issue 21
A Study by Isha Gaurav et al. entitled "Association of ABO Blood Group with Oral Cancer and Precancer – A Case-control Study" is awarded Best Article for Vol 13 issue 20
A Study by Amr Y. Zakaria et al. entitled "Single Nucleotide Polymorphisms of ATP-Binding Cassette Gene(ABCC3 rs4793665) affect High Dose Methotrexate-Induced Nephrotoxicity in Children with Osteosarcoma" is awarded Best Article for Vol 13 issue 19
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A Study by Bhat Asifa et al. entitled "Efficacy of Modified Carbapenem Inactivation Method for Carbapenemase Detection and Comparative Evaluation with Polymerase Chain Reaction for the Identification of Carbapenemase Producing Klebsiella pneumonia Isolates" is awarded Best Article for Vol 13 issue 17
A Study by Gupta R. et al. entitled "A Clinical Study of Paediatric Tracheostomy: Our Experience in a Tertiary Care Hospital in North India" is awarded Best Article for Vol 13 issue 16
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A Study by Mona Isam Eldin Osman et al. entitled "Psychological Impact and Risk Factors of Sexual Abuse on Sudanese Children in Khartoum State" is awarded Best Article for Vol 13 issue 12
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A Study by Purushottam S. G. et al. entitled "Development of Fenofibrate Solid Dispersions for the Plausible Aqueous Solubility Augmentation of this BCS Class-II Drug" is awarded Best article for Vol 13 issue 10
A Study by Kumar S. et al. entitled "A Study on Clinical Spectrum, Laboratory Profile, Complications and Outcome of Pediatric Scrub Typhus Patients Admitted to an Intensive Care Unit from a Tertiary Care Hospital from Eastern India" is awarded Best Article for Vol 13 issue 09
A Study by Mardhiah Kamaruddin et al. entitled "The Pattern of Creatinine Clearance in Gestational and Chronic Hypertension Women from the Third Trimester to 12 Weeks Postpartum" is awarded Best Article for Vol 13 issue 08
A Study by Sarmila G. B. et al. entitled "Study to Compare the Efficacy of Orally Administered Melatonin and Clonidine for Attenuation of Hemodynamic Response During Laryngoscopy and Endotracheal Intubation in Gastrointestinal Surgeries" is awarded Best Article for Vol 13 issue 07
A Study by M. Muthu Uma Maheswari et al. entitled "A Study on C-reactive Protein and Liver Function Tests in Laboratory RT-PCR Positive Covid-19 Patients in a Tertiary Care Centre – A Retrospective Study" is awarded Best Article of Vol 13 issue 06 Special issue Modern approaches for diagnosis of COVID-19 and current status of awareness
A Study by Gainneos PD et al. entitled "A Comparative Evaluation of the Levels of Salivary IgA in HIV Affected Children and the Children of the General Population within the Age Group of 9 – 12 Years – A Cross-Sectional Study" is awarded Best Article of Vol 13 issue 05 Special issue on Recent Advances in Dentistry for better Oral Health
A Study by Alkhansa Mahmoud et al. entitled "mRNA Expression of Somatostatin Receptors (1-5) in MCF7 and MDA-MB231 Breast Cancer Cells" is awarded Best Article of Vol 13 issue 06
A Study by Chen YY and Ghazali SRB entitled "Lifetime Trauma, posttraumatic stress disorder Symptoms and Early Adolescence Risk Factors for Poor Physical Health Outcome Among Malaysian Adolescents" is awarded Best Article of Vol 13 issue 04 Special issue on Current Updates in Plant Biology to Medicine to Healthcare Awareness in Malaysia
A Study by Kumari PM et al. entitled "Study to Evaluate the Adverse Drug Reactions in a Tertiary Care Teaching Hospital in Tamilnadu - A Cross-Sectional Study" is awarded Best Article for Vol 13 issue 05
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A Study by Sharipov R. Kh. et al. entitled "Interaction of Correction of Lipid Peroxidation Disorders with Oxibral" is awarded Best Article of Vol 13 issue 03
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A Study by Sonali Banerjee and Mary Mathews N. entitled "Exploring Quality of Life and Perceived Experiences Among Couples Undergoing Fertility Treatment in Western India: A Mixed Methodology" is awarded Best Article for Vol 12 issue 18
A Study by Jabbar Desai et al. entitled "Prevalence of Obstructive Airway Disease in Patients with Ischemic Heart Disease and Hypertension" is awarded Best Article for Vol 12 issue 17
A Study by Juna Byun et al. entitled "Study on Difference in Coronavirus-19 Related Anxiety between Face-to-face and Non-face-to-face Classes among University Students in South Korea" is awarded Best Article for Vol 12 issue 16
A Study by Sudha Ramachandra & Vinay Chavan entitled "Enhanced-Hybrid-Age Layered Population Structure (E-Hybrid-ALPS): A Genetic Algorithm with Adaptive Crossover for Molecular Docking Studies of Drug Discovery Process" is awarded Best article for Vol 12 issue 15
A Study by Varsha M. Shindhe et al. entitled "A Study on Effect of Smokeless Tobacco on Pulmonary Function Tests in Class IV Workers of USM-KLE (Universiti Sains Malaysia-Karnataka Lingayat Education Society) International Medical Programme, Belagavi" is awarded Best article of Vol 12 issue 14, July 2020
A study by Amruta Choudhary et al. entitled "Family Planning Knowledge, Attitude and Practice Among Women of Reproductive Age from Rural Area of Central India" is awarded Best Article for special issue "Modern Therapeutics Applications"
A study by Raunak Das entitled "Study of Cardiovascular Dysfunctions in Interstitial Lung Diseas epatients by Correlating the Levels of Serum NT PRO BNP and Microalbuminuria (Biomarkers of Cardiovascular Dysfunction) with Echocardiographic, Bronchoscopic and HighResolution Computed Tomography Findings of These ILD Patients" is awarded Best Article of Vol 12 issue 13 
A Study by Kannamani Ramasamy et al. entitled "COVID-19 Situation at Chennai City – Forecasting for the Better Pandemic Management" is awarded best article for  Vol 12 issue 12
A Study by Muhammet Lutfi SELCUK and Fatma entitled "Distinction of Gray and White Matter for Some Histological Staining Methods in New Zealand Rabbit's Brain" is awarded best article for  Vol 12 issue 11
A Study by Anamul Haq et al. entitled "Etiology of Abnormal Uterine Bleeding in Adolescents – Emphasis Upon Polycystic Ovarian Syndrome" is awarded best article for  Vol 12 issue 10
A Study by entitled "Estimation of Reference Interval of Serum Progesterone During Three Trimesters of Normal Pregnancy in a Tertiary Care Hospital of Kolkata" is awarded best article for  Vol 12 issue 09
A Study by Ilona Gracie De Souza & Pavan Kumar G. entitled "Effect of Releasing Myofascial Chain in Patients with Patellofemoral Pain Syndrome - A Randomized Clinical Trial" is awarded best article for  Vol 12 issue 08
A Study by Virendra Atam et. al. entitled "Clinical Profile and Short - Term Mortality Predictors in Acute Stroke with Emphasis on Stress Hyperglycemia and THRIVE Score : An Observational Study" is awarded best article for  Vol 12 issue 07
A Study by K. Krupashree et. al. entitled "Protective Effects of Picrorhizakurroa Against Fumonisin B1 Induced Hepatotoxicity in Mice" is awarded best article for issue Vol 10 issue 20
A study by Mithun K.P. et al "Larvicidal Activity of Crude Solanum Nigrum Leaf and Berries Extract Against Dengue Vector-Aedesaegypti" is awarded Best Article for Vol 10 issue 14 of IJCRR
A study by Asha Menon "Women in Child Care and Early Education: Truly Nontraditional Work" is awarded Best Article for Vol 10 issue 13
A study by Deep J. M. "Prevalence of Molar-Incisor Hypomineralization in 7-13 Years Old Children of Biratnagar, Nepal: A Cross Sectional Study" is awarded Best Article for Vol 10 issue 11 of IJCRR
A review by Chitra et al to analyse relation between Obesity and Type 2 diabetes is awarded 'Best Article' for Vol 10 issue 10 by IJCRR. 
A study by Karanpreet et al "Pregnancy Induced Hypertension: A Study on Its Multisystem Involvement" is given Best Paper Award for Vol 10 issue 09

List of Awardees

A Study by Ese Anibor et al. "Evaluation of Temporomandibular Joint Disorders Among Delta State University Students in Abraka, Nigeria" from Vol 13 issue 16 received Emerging Researcher Award


A Study by Alkhansa Mahmoud et al. entitled "mRNA Expression of Somatostatin Receptors (1-5) in MCF7 and MDA-MB231 Breast Cancer Cells" from Vol 13 issue 06 received Emerging Researcher Award


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International Journal of Current Research and Review (IJCRR) provides platform for researchers to publish and discuss their original research and review work. IJCRR can not be held responsible for views, opinions and written statements of researchers published in this journal

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