C C

B A A B

IM IM

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 573

A Technique to Identify and Reconstruct

the Cementoenamel Junction Level
Using Combined Periodontal and
Restorative Treatment of Gingival
Recession. A Prospective Clinical Study

Francesco Cairo* Gingival recession is defined as the

Giovan Paolo Pini-Prato** location of the gingival margin api-
cal to the cementoenamel junction
(CEJ).1 The treatment of gingival
recession is an ever more frequent
query of patients with high standards
of oral hygiene.2 The ultimate goal
of any root coverage procedure is
Gingival recession is often associated with abrasion in the cervical area with an the location of the gingival margin
unidentifiable cementoenamel junction (CEJ). This condition complicates the
coronal to the CEJ (complete root
diagnosis and treatment of gingival recession. The aim of this study was to
coverage), with minimal probing
propose a technique to identify the CEJ level for planning periodontal and
depth and a pleasant soft tissue inte-
restorative treatment of the recession. The CEJ of a contralateral homologous
gration with the adjacent teeth. A
tooth or adjacent teeth was used to replicate the lost CEJ at the treated tooth.
Reconstruction of the CEJ using composite resin and a coronally advanced flap, recent systematic review showed
with or without a connective tissue graft, was performed for 25 recessions in that a coronally advanced flap is a
12 patients. After 2 years, 20 defects (80%) showed complete root coverage safe and predictable approach for
with a significant recession reduction (2.4 mm, P < .0001). (Int J Periodontics root coverage, and it is often asso-
Restorative Dent 2010;30:573–581.) ciated with the complete coverage
of the exposed root surface. A con-
nective tissue graft or enamel matrix
proteins, in conjunction with a coro-
nally advanced flap, enhances the
probability of obtaining complete
root coverage and improving reces-
sion reduction in Miller Class I or II
single gingival recessions.3
The successful outcome of a root
*Research Associate, Department of Periodontology, University of Florence, Florence, Italy. coverage procedure is based on a sta-
**Dean, Dental School, University of Florence, Florence, Italy.
ble gingival margin coronal to the CEJ
Correspondence to: Dr Francesco Cairo, Via Giotto 44, 50100 Florence, Italy; fax: 055 after healing.4 The CEJ is the major
2638437; email: cairofrancesco@virgilio.it. reference point used to establish a

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574
correct diagnosis and to plan the
proper treatment of a gingival reces-
sion. However, gingival recession is
often associated with tooth abrasion
in the cervical area, leading to a total
or partial disappearance of the CEJ,
and sometimes to a deep enamel/
root discrepancy.5 If the CEJ is not
identifiable, it is difficult to assess the
true depth of the real gingival reces-
sion, and therefore, the diagnosis is
not accurate. Other problems may
arise during surgery; in fact, an
unidentifiable CEJ does not allow for
the precise location of the gingival
margin of a flap during suturing. In
addition, a deep enamel/root dis-
crepancy resulting from severe tooth
abrasion shows sharp edges often
associated with dental hypersensitiv-
ity. The presence of such defects may
complicate the proper adaptation of
the flap on the tooth, leading to soft
tissue collapse and poor stabilization
of the graft over the exposed root.
The absence of an identifiable CEJ
does not allow for an accurate assess-
ment of the clinical outcomes follow-
ing root coverage procedures, and
therefore it is impossible to establish
if complete root coverage really has
been achieved. In this case, even if
complete root coverage occurs, the
final esthetic result may be poor
because the profile of the gingival
margin tends to be flat, parallel to
the abrasion edge.4 Finally, the loss of
an identifiable CEJ makes the inter-
view with the patient regarding the
choice of treatment and its prognosis
difficult. The patient might expect
that the entire dental lesion (root and
crown abrasion) will be covered com-
pletely by gingival tissue after the
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procedure. Since the original gingival
margin covered the CEJ, the margin
level after the procedure cannot be
located coronally on the lost enamel
but apically at the level of the previ-
ous CEJ; the periodontist has to
explain to the patient the expected
location of the gingival margin after
treatment.
Restoration of a missing CEJ
before the root coverage procedure
has been suggested.6 Various dental
materials and surgical approaches
have been used to manage gingival
recessions associated with tooth abra-
sion in the area of the CEJ.7,8 The aim
of this clinical study was to propose a
technique for the identification and
reconstruction of the CEJ using com-
bined periodontal and restorative
treatment of a gingival recession.
Method and materials
Study population
A total of 12 patients with esthetic
requests or dental hypersensitivity
were selected consecutively from a
private periodontal practice and
enrolled in this study. All patients were
older than 18 years of age and with no
systemic disease. Periodontal entry
criteria were: the presence of single or
multiple Miller Class I or II recession
defects,9 a partially or totally uniden-
tifiable CEJ in the recession area, the
absence of periodontal disease, full-
mouth plaque and bleeding scores <
10% (four sites), and the presence of
a contralateral homologous tooth or
adjacent teeth. Periodontal exclusion
criteria included the presence of tooth
rotation, extrusion, or significant
occlusal abrasion at the involved
teeth.
Before any procedure, each par-
ticipant signed an informed consent
form in accordance with the Helsinki
Declaration of 1975, as revisited in
2000. Professional oral hygiene pro-
cedures were performed for each
patient. All patients received oral
hygiene instructions (roll technique)
to eliminate the habits related to the
etiology of the recession/tooth abra-
sion at least 3 months prior to surgery.
Identification of CEJ level
A contralateral homologous tooth or
adjacent teeth were used to identify
the level of lost CEJ, the crown
length, and the shape of the gingival
margin at each tooth with gingival
recession.
Contralateral homologous tooth
with gingival recession and a
completely identifiable CEJ
When using the contralateral homol-
ogous tooth with gingival recession,
two PCP UNC-15 periodontal probes
(Hu-Friedy) were used to identify the
reference points. The first periodon-
tal probe was positioned horizontal-
ly over the CEJ at the base of the
interdental papillae, and the second
periodontal probe was positioned
vertically, parallel to the tooth axis at
the center of the tooth (Fig 1). By
crossing the two probes, the follow-
ing points were identified: the most
mesial coronal point of the inter-
proximal CEJ (A), the most distal
coronal point of the interproximal

C
B A
IM
Fig 1 Identification of the CEJ position at
the contralateral homologous tooth by
using two periodontal probes before treat-
ment. The horizontal probe identifies points
A and B while the vertical probe identifies
points C and IM.
CEJ (B), the intersection point
between the CEJ and the vertical
probe at the center of the tooth (C),
and the incisal margin at center of
the tooth (IM).
After identification of the refer-
ence points, the following measure-
ments were assessed: the incisal
margin to the CEJ at the center of the
tooth (length of the anatomical
crown; IM–C) and the mesiodistal
width of the anatomical crown at the
base of interdental papillae (A–B).
Once the reference points and
measurements were obtained, these
were transferred to the involved
tooth. The vertical probe was posi-
tioned at the center of the tooth, and
the distance IM-C served to identify
the most apical point of the lost CEJ.
The horizontal probe was positioned
at the base of the interdental papillae,
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575
C
C
A B
B A
IM IM
Fig 2 Identification of the CEJ at (left) the contralateral homologous tooth without gingival
recession and (right) the affected tooth. The yellow line simulates the horizontal probe
(points A and B); the blue line simulates the vertical probe (points IM and C).
identifying points A and B. The ref-
erence points (A, B, C) were con-
nected, simulating a scalloped line
similar to that of the contralateral
homologous tooth.
Homologous tooth without
gingival recession
In patients with a homologous tooth
without gingival recession, since the
CEJ was covered by the gingival mar-
gin, the length of the anatomical
crown was obtained by placing the
vertical probe at the center of the
tooth and adding the correspond-
ing probing depth (PD), thus identi-
fying the point CPD (IM–C + PD).
There fore, the distance IM–C PD
showed the location of the most api-
cal point of the CEJ. The horizontal
probe identified points A and B, as
referenced previously (Fig 2).
Volume 30, Number 6, 2010
576

C GM0
C
CEJL
A B A B

IM
IM IM

Fig 3 Identification of the CEJ using the adjacent teeth. The refer- Fig 4 Measurements before treatment.
ence tooth is the canine while the involved tooth is the first premolar. The dotted line simulates the CEJ level
In this case, the level of the CEJ at the canine is apical to that at the (CEJL). The distance between the CEJ level
first premolar. and GM0 corresponded to REC0 (area of
root coverage).

Adjacent tooth/teeth with an
unidentifiable CEJ at a
contralateral homologous tooth
If the CEJ of the contralateral homol-
ogous tooth was not identifiable, the
levels of the CEJ of the adjacent
tooth or teeth were used as refer-
ence. If recession was evident at the
adjacent tooth, the identification of
points A and B and the correspond-
ing distance was similar to that using
a contralateral homologous tooth
with an identifiable CEJ. The posi-
tion of the vertical probe to identify
point C was also similar, even if the
final location of the most apical point
of the CEJ (point C) was different.
Since the length of the anatomical
crown10 and periodontal biotype11
are different, the location of point C
varies accordingly. If treatment is
received at a first premolar (Fig 3),
the reference is the adjacent canine,
and therefore the obtained vertical
length must be reduced.
If the adjacent tooth or teeth were
without recession, the identification
of the CEJ was assessed in the same
manner as that of a homologous tooth
without gingival recession.
CEJ reconstruction
Following the positioning of rubber
dam, the reconstruction of the CEJ
profile or lost enamel was performed
before the surgical procedure. In
patients with an unidentifiable CEJ
resulting from superficial abrasion
without surface discrepancy, follow-
ing the identification of reference
points, the CEJ profile was restored
with a composite resin dental mate-
rial (Enamel Plus HFO, Micerium),
thus creating a smooth surface. In
patients with a deep abrasion (steep)
involving the root and crown, the
lost enamel and CEJ were restored,
paying close attention to creating a
smooth finishing line between the
dental material and root and avoid-
ing filling the root abrasion with
composite resin. The residual root
defect then underwent periodontal
treatment (flap with or without graft).
Measurements at the involved
tooth
After completion of the restorative
procedures, the following dental and
periodontal measurements were
assessed before the surgical proce-
dure (Fig 4): the distance between
the incisal margin and gingival margin
(IM–GM0), the distance between the
most apical point of the reconstruct-
ed CEJ and the gingival margin
(CEJL–GM0) corresponding to the
baseline gingival recession (REC0),
the distance between the most apical
point of the reconstructed CEJ and
the incisal margin (CEJL–IM), probing
depth (PD), and the presence of
bleeding on probing.

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Surgical procedures
With the aid of a surgical microscope
or operative loops in patients with
single or multiple recessions, a coro-
nally advanced flap, with or without a
connective tissue graft, was per-
formed.12–14 Split full-thickness flaps
were raised to the mucogingival junc-
tion with or without the use of verti-
cal releasing incisions. The flaps were
mobilized with a sharp horizontal inci-
sion in the vestibular mucosa to elim-
inate muscle tension and obtain
adequate coronal displacement of
the gingival margin. If necessary,
additional finishing of the restoration
margin was then accomplished using
a diamond bur and rubber cup. The
exposed root surface apical to the
restoration was treated carefully with
root planing. When a smooth root
surface was obtained underneath the
restored CEJL, a coronally advanced
flap alone was performed. If a root
discrepancy resituated apical to the
restoration, this was filled using a con-
nective tissue graft harvested from
the palate and secured in the area of
the bony dehiscence by means of
resorbable sutures. The coronal level
of the graft ended at the apical level
of the reconstruction. The anatomical
interdental papillae were then care-
fully deepithelialized and the flap was
sutured coronally using sling or inter-
rupted sutures, thus covering the api-
cal limit of the restoration.
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Postsurgical protocol
Patients were instructed to avoid any
mechanical trauma at the surgical
area and to avoid brushing their
teeth. A chlorhexidine rinse was pre-
scribed twice daily for 1 minute. Ten
days after surgery, sutures were
removed and prophylaxis with pol-
ishing was performed. Approximately
3 weeks after surgery, patients were
instructed to perform a mechanical
tooth cleaning with a toothbrush.
Patients were recalled 3, 6, 9, and
12 months after surgery for profes-
sional oral hygiene procedures until
the 1-year follow-up. Patients were
also recalled 18 months and 2 years
after surgery for follow-up.
Final measurements at the
2-year follow-up
At the final follow-up (2 years post-
surgery), the distance between the
incisal margin and the new gingival
margin (IM–GM1) was assessed. The
amount of root coverage was evalu-
ated by the difference between the
original gingival margin position and
the new one (IM–GM0 – IM–GM1),
which corresponded to the recession
reduction (Rec Red). When Rec Red
was equal to or greater than
CEJL–GM0, complete root coverage
was determined. If Rec Red was less
than CEJL–GM0, the amount of resid-
ual recession (Rec1) was assessed. In
addition, PD, bleeding on probing,
complications, and patient discom-
fort were also registered in the
patients’ clinical charts.
577
Statistical analysis
Statistical analysis was performed
using JMP (version 7.0, SAS Institute)
and MLwiN (version 2.02; CMM,
University of Bristol) software.
Descriptive statistics were presented
as mean ± standard deviation for
quantitative variables. Since some
patients presented more than one
treated site, analyses were performed
on three levels: (1) patient, (2) tooth,
and (3) observation. Models were
adjusted considering baseline reces-
sion depth (Rec0). The outcome vari-
able of the models was Rec Red at the
2-year follow-up examination.
Results
According to the protocol, 12 patients
(8 women, 4 men) with a total of 25
gingival recessions were treated by
the same operator (FC). The mean
age was 42.6 ± 10.7 years. The mean
PD at baseline was 1.2 ± 0.4 mm.
Considering the CEJL position at the
involved teeth, the mean baseline
recession (Rec0) was 2.6 ± 1.3 mm.
Nine of 12 patients showed multiple
gingival recessions, while the residual
3 patients were treated for single gin-
gival recessions.
Before the surgical procedure, the
lost enamel or CEJ area was restored
by means of a composite resin dental
material. Of the nine patients showing
multiple gingival recessions, four were
treated by means of a coronally
advanced flap with a connective tissue
graft and five with a coronally
advanced flap alone. Of the three
patients showing single recessions,
Volume 30, Number 6, 2010
578

Table 1 Descriptive statistics of treated patients

Patient no. Age (y) Sex Tooth no.* Surgical procedure
1 36 M 14, 13, 12 CAF
2 48 M 14 CAF
3 51 F 25 CAF
4 56 F 33, 34 CAF + CTG
5 54 F 15, 14, 13 CAF
6 51 F 23, 24, 25 CAF
7 49 M 24, 25 CAF
8 38 F 14, 13 CAF + CTG
9 29 F 44, 45 CAF
10 33 M 24 CAF + CTG
11 28 F 14, 13 CAF + CTG
12 32 F 23, 24, 25 CAF + CTG
M = male; F = female; CAF = coronally advanced flap; CTG = connective tissue graft.
*FDI tooth-numbering system.

Table 2 Clinical parameters at the baseline and 2-year

follow-up (mean ± standard deviation)
Rec0 (mm) Rec1 (mm) IM–GM0 (mm) IM–GM1 (mm)
2.6 ± 1.3 0.2 ± 0.5 12.4 ± 2.0 10.0 ± 1.3
REC0 = gingival recession at baseline; REC1 = gingival recession at 2-year follow-up;
IM–GM0 = distance between incisal margin and gingival margin at baseline;
IM–GM1 = distance between incisal margin and gingival margin at 2-year follow-up.

two were treated with a coronally
advanced flap alone, while one was
treated with a coronally advanced flap
and a connective tissue graft.
Descriptive statistics of the treated
patients are presented in Table 1.
The amount of root coverage
was evaluated by the difference
between the original and final gingi-
val margin levels (IM–GM0 – IM–GM1)
and corresponded to the recession
reduction (Rec Red). When Rec Red
was equal to or greater than
CEJL–GM0, complete root coverage
was determined. When Rec Red was
less than CEJL–GM0, the amount of
residual recession (Rec 1 ) was
assessed. At the 2-year follow-up, the
final residual recession (Rec1) was
0.2 ± 0.5 mm (91% mean root cover-
age). The corresponding mean Rec
Red was 2.4 ± 1.5 mm (P < .0001).
Twenty defects (80%) showed com-
plete root coverage. No major com-
plication was observed and no
residual dental hypersensitivity was
reported. All treated sites showed
PD ≤ 3 mm (mean PD, 1.5 ± 0.6 mm),
with no bleeding on probing. All
restorations were retained at the last
follow-up and no marginal discrep-
ancy was detected at the clinical
examination. All patients were satis-
fied with their treatment.
Clinical parameters from the
baseline and 2-year follow-up exam-
inations are reported in Table 2.
Figures 5 and 6 show the complete
restorations of two patients (patients
1 and 4).

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 579

Fig 5 Patient 1.

Fig 5a (left) Gingival recessions were

evident at the maxillary right first premolar,
canine, and lateral incisor with abrasion in the
area of the CEJ. Note the planned CEJ level
at the canine (dotted line).

Fig 5b (right) Flap elevation was complet-

ed for multiple recessions after enamel/CEJ
restoration.

Fig 5c (left) The flap was sutured coronally

to the restored CEJ level.

Fig 5d (right) Complete root coverage

was achieved by the 2-year follow-up.

Fig 6 Patient 4.

Fig 6a (left) Deep abrasion and gingival

recession was seen at the mandibular left
first premolar.

Fig 6b (right) CEJ reconstruction was

accomplished before flap elevation (arrow).

Fig 6c Flap elevation. Fig 6d (above) A connective tissue graft

was placed beyond the apical limit of the
restoration (arrow).

Fig 6e (right) Complete root coverage

was noted at the 2-year follow-up.

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580
Discussion
The CEJ serves as the reference point
for the definition, diagnosis, and
treatment of gingival recessions.
However, gingival recessions are
often associated with tooth abrasion
in the cervical area with a total or par-
tial disappearance of the CEJ, some-
times with deep enamel/root
discrepancies. The absence of the
CEJ associated with dental surface
discrepancies determines several
problems during preoperative diag-
nosis, soft tissue management, the
final assessment of the outcomes.
The absence of an identifiable CEJ
and the presence of enamel abrasion
might create misleading treatment
expectations, since patients may
expect that the entire dental lesion
will be covered completely by soft
tissue following therapy. In patients
with partial or total CEJ abrasions,
the use of homologous or adjacent
teeth is of paramount importance to
make the patient aware of the limit of
the root coverage procedure.
Patients should be alerted that a suc-
cessful outcome is the final location of
the gingival margin at the same CEJ
level as the corresponding tooth; an
enamel lesion, if any, cannot be cov-
ered by the gingival tissue.
In the periodontal literature, dif-
ferent approaches have been pro-
posed to manage deep hard tissue
discrepancies. Grinding the abrasion
to eliminate the sharp edges was
suggested to improve flap/graft posi-
tion and stabilization.15 However, if
root coverage is incomplete, this pro-
cedure can lead to increased post-
surgical hypersensitivity and should
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be considered critically if patients do
not complain of dental hypersensi-
tivity before treatment. The use of a
bilaminar technique to improve soft
tissue adaptation for an enamel/root
discrepancy has been suggested in
the past couple of years,16,17 even if
this procedure could result in a flat
gingival margin parallel to the abra-
sion edge.
In light of these considerations,
the identification and reconstruction
of the CEJ level and lost enamel is
decisive to manage the gingival
recession associated with CEJ abra-
sion. In this study, 25 recessions asso-
ciated with dental abrasions were
treated in 12 patients using the
described technique. All treated
patients showed homologous or
adjacent teeth with identifiable CEJ.
By intersecting two periodontal
probes, detected reference points
and measurements were reported at
the treated tooth, allowing for the
identification of lost enamel, the root
surface, and the CEJ level in the area
of abrasion. This technique allowed
both clinicians and patients to iden-
tify the correct line of root coverage.
This method is also useful to identify
the CEJ level of a given tooth when
the contralateral/adjacent teeth do
not show a recession. In fact, when
the CEJ is covered by the gingival
margin, the length of the anatomical
crown of the reference tooth is mea-
sured by adding the length of the
clinical crown to the corresponding
probing depth.
All restorations were retained at
the last follow-up, and no marginal
discrepancy was detected at the clin-
ical examination. All treated sites
showed no presence of bleeding on
probing at the last follow-up, even if
the apical limit of the restoration was
covered by the gingival margin. The
combined restorative and perio -
dontal approach allowed for careful
finishing of the restoration margin
after flap elevation using a magnifi-
cation system. This may have facili-
tated proper soft tissue healing over
the apical aspect to the restoration
margin. These findings corroborate
the observation that minimal inflam-
mation is observed following root
coverage and CEJ reconstruction
when a proper finishing of the den-
tal material is accomplished.8,18–21
In this study, two different surgi-
cal procedures were used. A coro-
nally advanced flap was used for
smooth root surfaces apical to the
restored CEJ. A coronally advanced
flap with a connective tissue graft
was used for a deep root abrasion
apical to the restored CEJ to mini-
mize a possible soft tissue collapse
into the root abrasion. These results
support studies showing that root
coverage is feasible irrespective of
the type of dental material used for
the restoration or the type of surgical
approach applied.7,8,18–21
All treated defects showed
PD ≤ 3 mm at the last follow-up, thus
supporting a previous investigation
reporting no detrimental effects for
deep periodontal tissue using resin
restorations in conjunction with flap
surgery. 22 In addition, epithelial/
connective tissue attachment to
resin material may also be observed
after restorative procedures of sub-
gingival lesions.23
 581

Conclusion 8. Lucchesi JA, Santos VR, Amaral CM, 19. Santamaria MP, Suaid FF, Casati MZ, Nociti
Peruzzo DC, Duarte PM. Coronally posi- FH, Sallum AW, Sallum EA. Coronally posi-
tioned flap for treatment of restored root tioned flap plus resin-modified glass
This technique is useful in identifying surfaces: A 6-month clinical evaluation. ionomer restoration for the treatment of
the level of lost CEJ at teeth with J Periodontol 2007;78:615–623. gingival recession associated with non-
gingival recessions associated with 9. Miller PD Jr. A classification of marginal tis- carious cervical lesions: A randomized con-
tooth abrasion. Clinical outcomes sue recession. Int J Periodontics Restorative trolled clinical trial. J Periodontol 2008;79:
Dent 1985;5:8–13. 621–628.
obtained with combined restora-
10. Magne P, Belser U. Bonded Porcelain 20. Santamaria MP, da Silva Feitosa D, Nociti
tive/periodontal treatment may be
Restorations in the Anterior Dentition. A FH Jr, Casati MZ, Sallum AW, Sallum EA.
maintained at the 2-year follow-up, Cervical restoration and the amount of soft
Biomimetic Approach. Chicago: Quintes -
with good esthetic results and min- sence, 2002. tissue coverage achieved by coronally
imal signs of inflammation. advanced flap: A 2-year follow-up ran-
11. Olsson M, Lindhe J, Marinello CP. On the domized-controlled clinical trial. J Clin
relationship between crown form and clin- Periodontol 2009;36:434–441.
ical features of the gingiva in adolescents.
J Clin Periodontol 1993;20:570–577. 21. Santamaria MP, Ambrosano GM, Casati
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12. Pini Prato G, Pagliaro U, Baldi C, et al. EA. Connective tissue graft plus resin-mod-
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1. Consensus report. Mucogingival therapy.
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2. Zaher CA, Hachem J, Puhan MA, Mombelli ical study. J Periodontol 2000;71:188–201. controlled clinical trial. J Clin Periodontol
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recession. J Clin Periodontol 2005;32:
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Volume 30, Number 6, 2010

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