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How to Extract the Money Tooth & Create a Great Implant Site
Foreword
Dr. Ziv Simon is a Rock Star in dentistry!
He is teaching dentists how to become better, faster, and more efficient surgeons
through his legendary SurgicalMaster.
Run, and dont walk, to anywhere he is teaching.
Howard Farran, DDS, MBA
Founder and publisher of Dentaltown
How to Extract the Money Tooth & Create a Great Implant Site
for YOU
Dear enthusiastic doctor,
Of all interesting and sophisticated topics, why write a book about the extraction of
a lower molar?
Because you asked for it.
For many years, I have been seeing comments, questions, heated discussions,
controversies, and online engagement with my videos and teachings on this very
topic.
This is such a common procedure and in this book Im going to share my way of
extracting the Money Tooth (lower first molar).
It is seemingly easy to write about a procedure that I perform almost every day.
Wellnot quite!
When it comes to describing accurate details, there is just too much information
about a relatively simple procedure.
Imagine you had to describe in writing all the details about the process of driving
from home to work, step-by-step, minute-by-minute. You would have to write dozens
of detailed pages. It wont be conducive to learning.
I considered the large amount of details involved with tooth extraction and concluded
it would be too much to include it all. There is a fine balance between being informative
and having information overload that can ruin your learning experience.
So I literally had to cut into the flesh and break the process down to a bare minimum
core while knowingly omitting certain details. I look forward to sharing all the rest
with you in future training programs. I feel that this way you can go through this
book with very little pain and learn more without getting confused or frustrated.
How to Extract the Money Tooth & Create a Great Implant Site
My team tells me that I say the word Perfect! a lot. I actually do.
The process Im describing is not perfect. Perfection is the ultimate goal but not easy
to achieve. There is going to be some variability in your outcomes, but if you follow a
sound protocol, your results will be excellent.
I always consider myself work in progress. Knowing this keeps me fresh, humble
and open to new ideas and influence from other great masters.
I believe that I can confidently convey this process to you. I had great success with it
for many years. It is predictable in my hands and I ENJOY performing it.
Im also passionate about sharing this knowledge with you. I have no secrets and
there will many more exciting procedures to share with you in the future.
By now many dentists have read this book and provided feedback. I constantly
update this book and newest version can be found at www.moneytoothbook. Head
over there to download the newest version (whats a 1MB or 2 between friends?).
If you feel frustrated with your results extracting lower molars, I know how you feel
because I also had challenges at the beginning. You came to this world crying at the
beginning of your lifes journey.
All beginnings are rough. Welcome to yours!
I found that with education, persistence and constant
improvements and adjustments you can be great at
surgery.
To your surgical success with the Money Tooth!
How to Extract the Money Tooth & Create a Great Implant Site
In this eBook
YOU will:
Learn how to extract a lower molar
step-by-step,
with less stress,
with less complications,
& Faster
to help create a Beautiful Implant Site
Every dentist knows the Money Tooth. It is the lower 1st molar.
You have treated it and you have extracted it. If its in your mouth, it probably has
some type of restoration (is it missing or replaced?).
How to Extract the Money Tooth & Create a Great Implant Site
Crowns and root canal treatments need to be sometimes re-done. Thankfully apical
surgery is rare. The next caries lesion or crack is a death sentence for the tooth.
Extraction and replacement are next.
FASTER
I have extracted a few thousand Money Teeth so far.
Like you, I have been in the trenches as a full time clinician in private practice. Ive
done just as many difficult extractions as simple ones. Ive seen the different levels of
infection, bone destruction, abnormal anatomy and other challenges.
How to Extract the Money Tooth & Create a Great Implant Site
By now, I have very predictable protocols that allow me to extract lower molars of all
shapes and conditions and manage extraction sockets of all shapes and conditions.
Sounds interesting?
The doctors Ive worked with and taught over the years and who use the protocols in
this book get more bone and better bone for their implants, FASTER.
The protocol forces you to assess the lower molar before you even touch it. You will
be able to predict challenges and choose the best course of action for the challenge.
The protocol has a plan A, B, C, D and E.
That doesnt mean its necessarily easy. There are problems and complications that
happen even under the best circumstances.
The good news: it is all part of the protocol and the decision-making process.
At this point I am very familiar with this process. I have already predicted most of
the problems associated with their case and I can give a very accurate run-down of
the procedure from A to Z. I can even predict the shape of the ridge at the end of the
healing period and if additional grafting will be needed.
You too will be able to create an accurate roadmap to follow and achieve success. This
well-planned and predictable approach doesnt only create calmness and confidence
within you. Your patients will also be more calm, trusting and confident in you as
their surgeon.
How to Extract the Money Tooth & Create a Great Implant Site
Sounds familiar?
There are more:
o The buccal plate is missing or breaks during the extraction.
o Your patient is still feeling the procedure even after you had given a
block multiple times.
o The soft tissue is poor and keeps tearing.
o Hard to fit and stabilize a membrane and its not clear which one to use.
o The bone graft particles keep coming out.
o Socket is full of pus and youre hesitating to graft.
o Healing is compromised and implant site is poor.
If this sounds familiar, you are not alone. These are true problems experienced by
hundreds of thousands of dentists. You are in a good group.
When a procedure doesnt go well. Patients can tell everyone about the nightmare
of tooth extraction they had with you. That then, unfortunately, becomes your
nightmare.
The issue of patient perception is very important to me.
A good patient experience and your perception as a great surgeon is part of your
success. I always recommend learning about patient communication and management
skills in addition to learning techniques. You will be perceived based on how you
represent yourself.
How to Extract the Money Tooth & Create a Great Implant Site
A good attitude doesnt make up for a bad performance and the other way around:
Great technique doesnt make up for poor bedside manner.
So be great in both aspects.
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10
3 months later
It turned out to be a very compromised implant site. It had horizontal and vertical
deficiencies with poor tissue quality.
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When I look back, it was obvious I had no defined extraction protocol (plan A) or
alternatives (plans B and C), a defined armamentarium and a step-by-step-sequence.
I used the instruments handed to me by my assistant without too much thought.
There was no plan, no attention to extraction mechanics, identifying complicating
factors and biologic principles that are critical in bone grafting.
The results were accordingly. Poor.
One more negative thing. I didnt enjoy performing this procedure. It was a painful
process not just for the patient but also for me.
There was something fundamentally wrong with the approach I took and if things
kept going this way I would have lost my confidence and retired from exodontia.
It was clear that keeping doing the same and expecting different results is not going
to work.
A Periapical radiograph
More specifically: a proper evaluation of a PA before the procedure.
You may be thinking: Are you kidding? Isnt that obvious? You obviously need to
look at a radiograph before a procedure
Yes. You need to look but looking is not enough.
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I adapted methods that were relatively simple to execute. The less steps, the less time,
the less trauma, the less swelling, the less pain the better the outcomes.
I didnt make this up:
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I learned how to use bone grafts, membranes and biologics to preserve the alveolar
ridge.
I kept documenting and analyzing my results. Wherever needed, I made necessary
adjustments and the results kept improving.
Its very similar to any other craft not related to dentistry, may it be in the sports or
music world. The more your practice, the better you perform.
This process never ends.
You may hit some plateaus but there are always new things to learn. The process of
learning and getting better NEVER EVER stops.
I refer to this process as Perfectionization (not an English word)
Its the continues effort to achieve ultimate perfection. Its never ending and you
actually never reach it. Dont get discouraged. You will get quite close.
Following the protocol allows you to create a beautiful implant site
= A site with good bone quantity and quality and as early as 8 weeks after the
extraction. All of this with less stress and a great patient experience.
This eBooks focus is on the extraction process and in the next one Ill describe
bone grafting.
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Im going to start going over some details now. Have patience as I walk you through
the process (dont skip to the photo of forceps!). Every step builds on the previous one.
Every detail matters.
You may think some points are obvious so bare with me. Im tackling this topic from
angles you were probably not aware of. Besides, this book is meant for thousands of
doctors at different levels of experience and expertise. We all need to be on the same page.
Im starting with the most basic thing:
this one?
This is a must-know answer.
You have to have a diagnosis that leads to a recommendation for an extraction and
replacement.
The tooth needed an extraction is not a diagnosis.
Poor prognosis is also not a diagnosis (its a prognosis!).
The tooth needs a diagnosis and then a reason for extraction side by side.
The combination of the two needs to be such that extraction would be the best
solution for the tooth.
Also, both have to be discussed with the patient and documented in the chart. You
need hard proof to support it and make a case for extraction.
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Diagnosis examples:
o Tooth #30 vertical root fracture, hopeless prognosis.
o Tooth #19 severe chronic periodontitis, hopeless prognosis.
o Tooth #30 combined perio-endo infection, poor prognosis.
1ST STEP:
Prepare your patient.
Reach a diagnosis; discuss the need for extraction and type of replacement you
recommend. Its good to discuss different treatment options and their advantages
and disadvantages. Let your patient know about the consequences of no-treatment
(for example: if the tooth is not extracted, infection will persist, get larger and affect
the adjacent teeth).
2ND STEP:
Prepare yourself for the procedure.
Study the pre-operative radiograph. Dont be fast to
refer for a 3D scan. 95% of your preparation comes from
evaluating a recent diagnostic periapical radiograph.
Most of the small and important details are just in front
of your eyes. The saying the devil is in the details is
so true. Attention to all the small details will make a
HUGE difference in achieving a success.
Which is more difficult to extract? A or B?
Answer: Money Teeth A and B have
different types of challenges so there
is really no right or wrong answer.
Understand the difficulties by studying
the Extraction Enemies next.
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o Shape of roots
o Root proximity
o Adjacent
restorations
o Caries &
resorption
o Dense bone
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How to Extract the Money Tooth & Create a Great Implant Site
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20
10
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Forceps
3 types are usually needed: Universal,
specialized and root forceps. The universal
is able to grab relatively intact tooth
structure, specialized is for compromised
tooth structure and the purpose of the root
forceps is obvious. Follow the protocol
to know when to use each one. Logically,
assess the remaining tooth structure and
type of restoration and determine what
forceps would be the most appropriate.
Burs
Burs will be needed to split the coronal part of the tooth
and between the roots. For that purpose we use two
type of long straight carbide burs. One is thin (#700XL)
and one is thick (#702L). Additionally, if a restoration
needs to be cut off initially, use a combination of
diamond and carbide burs that you would normally use
in restorative dentistry.
Straight elevators
Straight elevators create a lever effect on the tooth or
root tip. Placement is in between the tooth structure
and bone, which is the fulcrum. Most commonly I
use a medium size and am always careful. Damage to
adjacent tooth, restoration and even bone is possible.
The can be wedged between the roots of the Money
Tooth after they were split.
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No, its not time to send your kids to their room as punishment
(if youre a parent, you know what Im talking about).
Its the time to STOP and make sure everything has been
done correctly so far and also going forward. The Time
out principle comes from the medical world. It is meant to
confirm that that the whole team is on the same page and
also to prevent medical errors. For example, in orthopedic
surgery the hip requiring surgery will be visibly marked and
sometimes by the patient as well (Its ok to mark the tooth).
So just before you are ready to make some irreversible changes, Stop. Its time for
time out!.
Make sure you have the right patient, the right tooth, consent obtained and signed
and the medical history was reviewed and that there are no contraindications. The
purpose of this step is to prevent mishaps like anesthetizing the wrong side, proceeding
without permission and even extraction of the wrong tooth (it still happens in this
day and age and you need to make sure it never happens to you).
I do a few things as part of my time out!. I look at the chart and confirm the patients
name. I then match it with the consent form and look at the radiograph of the tooth. I
then ask the patient if they are clear about what we are doing today. I even ask them
to point to the tooth needing extraction or the area of the extraction.
I state out loud: tooth #30, lower right (for example). I involve my assistant in
the Time out! process. My assistant will also confirm the tooth to be extracted.
During the procedure, I would say something like Im placing it on tooth #30 (as
an example) for my assistant to confirm. Thats another safety step.
Patients will sometimes joke with you, saying Doc, dont pull the wrong tooth.
Although its a silly joke, what they are really expressing is some sort of concern or
anxiety because everybody heard about medical errors.. Tell your patient about your
Time out! protocol. They will appreciate your care and focus on safety and harm
prevention.
We dentists always work fast and effectively. This is your time to stop, take a breath,
take a time out! and make sure you are doing the right thing. Your patients will be
grateful and you will have created more value for your treatment.
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If your anesthesia technique is improper, stop! Go back and study it. The extraction
process cant be done without profound local anesthesia. Excel in it!
All of your patients are different and have different needs and clinical situations.
Sometimes these differences are very subtle.
I recommend you keep an open mind and be prepared to execute different treatments
based on the clinical scenarios you are faced with. There will be several forks in the
road where you will have to use your clinical judgment and make the right decision.
Try not to get confused. Decisions need to be made by clinicians at all levels.
Each decision should have logic behind it. Its not a guarantee for success. However, if
you make more decisions with a good rationale behind them, your success rates will
be very high. Youll consider alternatives and evaluate risks versus benefits for each
decision.
There will be Forks in the road and you are expected to walk the right path. From
this point on, the treatment of the Money Tooth depends on the particular scenario
you are facing.
I gave this issue a lot of thought. Decision trees and algorithms are very confusing
and not always applicable in oral surgery. I therefore decided to give you a few general
guidelines and be more specific later on in this eBook.
Quick disclaimer: This is not the only way to do things and there are other and
perhaps even better ways out there. It is simply my current methodology that works
great for me at the time of writing this eBook. You should explore the wealth of
knowledge that is in this world and decide on the best way yourself.
Just making sure we are all on the same page and the following are general guidelines
for extraction of the Money Tooth.
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If possible, use forceps to only luxate the tooth around its axis
between 30-40 seconds before attempting removal.
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Safety:
Safety is the most important aspect of surgery.
Keep it at high priority. Always.
I like to use two 2X2 gauze around the tooth to
be extracted. I fold one gauze and place it in the
vestibule (arrow 1). This protects the buccal
tissue and is a cushion for the instruments.
The second gauze is opened and placed on the
lingual aspect above on the lateral aspect of the
tongue (arrow 2). It acts as a safety net to
prevent anything from being swallowed or aspirated by your patient. Explain what
you are doing (especially for gaggers). All patients will appreciate your careful
approach and will be very understanding.
Start by separating the soft tissues using #15 blade or an
Orban knife. If the tooth structure is relatively intact, I
use universal forceps first. I place them below the height
of contour and find the best grab. Its not always buccallingual. Sometimes the best position is at the line angles.
Take your time and test the best position that will allow
you to do rotational motions around the tooths axis.
I take care not to pinch the gingiva especially when the tissue quality is poor (a
gingivectomy is not welcome!)
Remember. Im not extracting the tooth yet.
Im only carefully moving and vibrating it to create inflammation in the PDL space.
Some bleeding occurs too. The inflammation increases with time and will facilitates
the next steps.
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I tell my patient about feeling vibrations and light pressure. You are creating small
and repeating motions around the tooth axis which will be perceived as vibrations.
You need to have patience and not go for the removal yet. 30-40 seconds is a good start.
If I detected many Extraction Enemies I may do this 2 or 3 rounds of vibration a
few minutes apart (between 5-10 minutes).
During the process I gauge how tight the tooth feels. For mobile periodontally
involved teeth, this process will naturally result in a quick extraction. For most cases
the process takes some time but is well worth the effort.
If the adjacent teeth are not restored, I also use a medium size straight elevator.
When placed in mesial aspect of the tooth (between the premolar and the molar), the
elevator will luxate the tooth in a distal direction. Its a classic lever effect and you will
see movement. Still, try to only mobilize the tooth without attempting an extraction.
Using both the forceps and elevator will cause inflammation in the PDL that will
gradually increase. There will be an increase in mobility due to socket expansion in
some cases but also increase in inflammation in the PDL space. To see a substantial
change may take a few rounds of vibrations and rest. Pay attention to the increasing
mobility. In cases of relatively straight and parallel roots and when the mobility
becomes substantial, extraction can be attempted. You can move your forceps in a
coronal direction while vibrating and an extraction can be completed. Success!
If you are gauging no significant change in mobilization after a few attempts, you
are dealing with very dense bone and/or significant curvature. Dont get discouraged
about the time you spent vibrating with no extraction. The inflammation you
created is beneficial for the next steps.
You can now proceed with the splitting process.
I Use the #702L bur to split the tooth initially. It is large and aggressive
enough to do this effectively. Make sure your split is through-andthrough in a buccal-lingual direction. Ensure that the roots are
completely separated.
Teeth with long root trunks may require you to pass the
bur several times. During this process be cautious not
to traumatize the buccal and lingual bone as well as the
furcation bone. Its important to preserve as much of
the inter-radicular bone as possible (it is your future
osteotomy).
How to Extract the Money Tooth & Create a Great Implant Site
#702L
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#15 blade
Orban knife
Periosteal elevator
Your suturing and overall healing will be much better if you take good care of the soft
tissues. So as basic as it may sound, take your time and focus on good flap reflection.
Now you have full access to the remaining tooth structure. Retract the flap with a
periosteal elevator and protect it while you section the tooth with straight fissure bur.
Similar to the previous plan, you can use a medium straight elevator to mobilize the
roots. You can also carefully use a thin carbide bur to create some space between the
root and the bone. Create this space at the expense of the root an not the bone as best
as you can. With the proper access, using leverage or root forceps, both parts can be
removed. Success!
The key in Plan B is creating access and visibility while preventing damage to the soft
tissues.
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PLAN C
You are now in a more challenging extraction process. On one hand, youd like to
preserve as much as the surrounding bone as possible. On the other hand, you are
tempted move fast forward and be more aggressive with bone removal for a faster
extraction.
There is a fine balance between the 2 goals.
Dont rush. Think.
Try to understand what is holding the procedure back.
o Are you dealing with very dense bone and a challenge creating mobility?
o Are the roots not completely separated?
o Is the root curvature an issue?
o Is the tooth structure very compromised and fragile and thats why it
breaks easily?
o Do you have poor access and visibility?
o Ankylosis? (quite rare).
There could also be a combination of the above.
You can go back and look at the Extraction Enemies. They are now haunting you
and making the extraction process more difficult.
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PLAN D
You followed plans A, B and C. In spite of your best efforts, you still cant retrieve
the root tip(s). It may be due to very long roots and your burs are not long enough.
Root tips can get caught deep in bone and the area is in an undercut of an adjacent
tooth (therefore with no direct access). Root ankylosis or hypercementosis could also
a hopeless situation for broken root tips. Regardless of the reason, if PLAN C didnt
work, its time to execute PLAN D.
Its almost the last resort.
PLAN D involves drilling out the residual root tip (grinding it down until its gone).
Yes. It is possible to do that. This is not ideal but it is certainly acceptable under these
circumstances.
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The challenge of PLAN D is having long enough drills to execute this. PLAN D is not
very common in my practice but happens once or twice a year. The bur of choice is a
surgical length medium size round diamond bur. You will need to know the location
of the residual root tip and aim for it with the bur. Complete the extraction process
by taking a final radiograph that shows a socket without tooth remnants.
The heat that is generated and additional trauma can cause slower healing and
occasionally alveolar osteitis (dry socket).
DONE!
You survived a simple Money Tooth extraction using PLAN A all the way to a
difficult extraction with PLAN D.
You followed the protocol through the different plans and applied the appropriate
methods.
Resorting to PLAN D doesnt mean that you did something wrong or that you dont
have good surgical skills. Resorting to PLAN D is a testament to a difficult situation
and your methodical extraction approach that lead to it.
You can be proud of yourself.
Is there a PLAN E?
Yes.
PLAN E occurs when a root tip breaks and you are not able to retrieve it or if the
retrieval will cause more harm then good.
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Basically, in PLAN E you are forced to leave a root tip behind. That scenario can
happen to you and is luckily uncommon.
If you went through PLANS A -> D and the final radiograph still shows a root tip, you
are in the last fork in the road. Evaluation the situation carefully and ask yourself the
following question: Is it realistic for me under the current circumstances to remove
this root tip without causing damage and harm?
If the answer is Yes: Keep working at it.
If the answer is no: PLAN E
Your transition into PLAN E is after you tried your best with all the previous protocols.
The timing of this step can vary between clinicians and depends on experience and
expertise.
As an example, a root tip laying on top of a nerve canal should ideally be left behind
so nerve damage doesnt occur (PLAN E). The risks and potential damage from
retrieval attempt are greater then the minor issues of leaving it.
If you resorted to PLAN E, discuss this with your patient and explain the reasons
a root tip was left behind. If you feel that leaving a root tip is detrimental, refer the
patient to another expert to assess the situation and treat it as necessary.
For your information and not just to make you feel better: Retained root tips rarely
cause a problem. In a world of dentin grafting and the socket shield technique, I
personally dont see it as a challenge. PLAN E is technically not a PLAN. It is rare
occurrence and you deserve to know about it.
If you followed all the steps I described, you will be able to remove at least 50-70% of
Money Teeth very predictably using PLAN A and PLAN B.
Less frequently (~29-49%), youll need to execute PLAN C and rarely (<1%) PLAN
D & E are rare.
I cant guarantee this will always work out smoothly. But I do guarantee that if you
follow a defined methodical protocol consistently, your success rates will be excellent.
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Being systematic will also keep you calm and your patients will have a better treatment
experience and outcome.
So now that the extraction protocol of the Money Tooth has been completed
confirm that the socket is empty and repeat after me:
Now, start with implant planning and work towards replacing the tooth (yes, I will
also reveal my protocol to place a Money Tooth implant).
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Final words
Be understanding and sensitive communicating with your patient. Loosing a tooth
that has been there since 6 years of age is not easy for anyone. The Money Tooth has
a lot of history and you now know why its called this way.
o Be a good communicator.
o Talk and listen to your patients.
o Explain and answer questions.
o Put your patient at ease and be present in the moment with confidence
now that you have more knowledge.
After reading this eBook you can now be more confident and replicate the methods
I described to you. Creating a great patient experience will mean the world for
the patient. Creating a great implant site and providing a good replacement is an
incredible service. You can be great at this.
It works!
Its YOUR turn now.
Start slow, follow the steps and focus on patient safety. If there is one thing you need
to know, its the tissues and structures you are operating on. You need to know the
anatomy because anatomy is life (-saving)!
If you found this eBook helpful, I would be delighted if you share it with other dentists.
We can all learn together and get better by sharing knowledge. I certainly learned a
lot just by writing this book. The most up-to-date version of the eBook can be found
on www.moneytoothbook.com. Go there now and download the latest version. It gets
updated all the time. Sign up for my videos and blogs is at www.surgicalmaster.com.
It would be awesome if you could e-mail and give me feedback on this eBook (good
and bad). Let me know if it was helpful and if there are any other problems youd like
me to help you solve.
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