Intraosseous Vascularization of Anterior Mandible

Intraosseous Vascularization of AnteriorMandible: A Radiographic Analysis

Roberto Di Bari, DDS,* Roberto Coronelli, MD, DDS,� and Andrea Cicconetti, MD*

Abstract: The anterior mandible was initially considered a safe zonefrom a surgical point of view. Over time, serious complications re-sulting from dental implantology procedures have been reported. Thishas led to a greater focus on vascularization of the interforaminal re-gion. The purpose of this article was to evaluate the anterior man-dibular region in relation to the presence of canals perforating thebuccal and lingual cortical plates.

DICOM (Digital Imaging and Communications in Medicine) filesof 100 cone beam computed tomography scans were analyzed byimaging software. All radiographic cross-sections between the mentalforamina were examined to detect the presence and location of per-forating buccal or lingual canals. Lingual perforating canals are pre-sent in 98% of the cohort. The most common site is the symphysisregion. The presence of 2 lingual canals cranially and caudally to thegenial apophysis has been found in 39%. Vestibular perforating canalsare absent in 61%.

The anterior mandible has several lingual perforating canals, whichare variable in number and location. Imaging software is a valuableaid in presurgical planning. Because of the higher prevalence of per-forating canals in the symphysis region, this site should be preserved.

Key Words: CBCT (cone beam computed tomography) imaging,mandibular symphysis, vascularization, computed tomography,perforating canals

(J Craniofac Surg 2014;25: 872Y879)

The anterior mandibular region is of particular anatomical interestin oral surgery for implant rehabilitation. It is also considered

a valid intraoral donor site of autologous bone for reconstructivepatient needs.1 Previous studies have analyzed the vascularizationof the anterior region of the mandible in relation to the hemorrhagicrisk during oral surgery.2

Thepurposeof this articlewas to evaluate this site in relation to thepresence of perforating canals. Differently from the available literature,this study was performed using high-resolution cone beam computedtomography (CBCT) images and three-dimensional reconstructions.The study aimed to analyze both lingual and buccal perforating canals.

Perforating canals were analyzed in relation to location (horizontal andvertical position), patient’s sex, age, and class of edentulism.

MATERIALS AND METHODSOne hundred CBCT scans, all obtained with the same x-ray

apparatus (GENDEX GXCB-500; Gendex Dental Systems, DesPlaines, IL) and the same acquiring parameters, were analyzed.

The cohort of 100 CBCT scans was composed of 61 femaleand 39 male patients. The ages of the patients ranged from 19 to91 years with subjects belonging to each band (Fig. 1). For eachcase, the dental formula was described, and the edentulism classwas evaluated by the Kennedy classification for partial edentulism(Table 1).

DICOM (Digital Imaging and Communications in Medicine)files of each CBCT scan were imported on SimPlant (SimPlant 3-DPro; Materialize, Leuven, Belgium). The software accepts the impor-tation of DICOM format images: the first standard format for sharingand viewing any kind of medical image. Once imported, images wereprocessed in axial, sagittal, and paraxial sections. The images werereal x-ray representations of jaw bones (reproduction scale 1:1) andallowed accurate measurements of anatomical structures. DICOMimages related to the mandibular region (230 images on 432) wereloaded through the “Image Selector” function of SimPlant.

Three-dimensional reconstruction of the mandibular regionwas obtained through the function “Segmentation” of the software;the “scattering” (linked to dentures or metal restorations in the mouth)was removed. The three-dimensional reconstruction was redirected tohave the mandible parallel to the floor. Then, using the function“create a panoramic curve,” a referral scout view in relation wasselected to which the software had rebuilt all the cross sections (1-mmstep). At this point, another tool, “create a nerve”was used to highlightthe path of the left and right mandibular canal both in cross sectionand in the three-dimensional reconstruction. Anterior mandible wasdefined as the region between the mental foramina, considering amargin of 5 mm medially to them (Fig. 2). All cross sections wereanalyzed to detect the presence and location of buccal or lingualperforating canals. For each case, the number of lingual and buccalperforating canals was recorded. Regarding canal position, distancesfrom the bottom edge of the cortex (hinf) and from the top edge ofthe alveolar process (hsup) were measured (Fig. 3).

Because of the nature of retrospective study, the present workdid not require a specific institutional review board approval. Thecurrent study followed the Declaration of Helsinki on medical pro-tocol and ethics.

RESULTSData on number of perforating canals are presented in Table 2.

Depending on the situations encountered, patients were divided into4 groups and 13 subgroups, characterized by an acronym, as follows:& Patients without canals, with a single homonym subgroupL0+V0Vpatients without canals& Patients with only lingual canals, with 3 subgroups

CLINICAL STUDY

872 The Journal of Craniofacial Surgery & Volume 25, Number 3, May 2014

From the *Department of Oral andMaxillofacial Sciences, School of Dentistry,SapienzaUniversityofRome; and†Dr.CoronelliDentalClinic,Rome, Italy.

Received August 10, 2013.Accepted for publication September 30, 2013.Address correspondence and reprint requests to Roberto Di Bari, DDS, Via

Simone Martini, 125-00142, Rome, Italy; E-mail: [email protected] authors report no conflicts of interest.Copyright * 2014 by Mutaz B. Habal, MDISSN: 1049-2275DOI: 10.1097/01.scs.0000436735.60042.49

Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.

mailto:[email protected]

L1Vpatients with 1 lingual canalL2Vpatients with 2 lingual canalsL3Vpatients with 3 lingual canals& Patients with only vestibular canals, with 2 subgroupsV1Vpatients with 1 vestibular canalV2Vpatients with 2 vestibular canals& Patients with lingual and vestibular canals, with 7 subgroupsL1+V1Vpatients with 1 lingual canal + 1 vestibular canalL2+V1Vpatients with 2 lingual canals + 1 vestibular canalL3+V1Vpatients with 3 lingual canals + 1 vestibular canalL1+V2Vpatients with 1 lingual canal + 2 vestibular canalsL1+V3Vpatients with 1 lingual canal + 3 vestibular canalsL2+V2Vpatients with 2 lingual canals + 2 vestibular canalsL3+V2Vpatients with 3 lingual canals + 2 vestibular canals

On the cohort of 100 patients, 209 canals were detected, in-cluding 158 lingual canals and 51 vestibular canals, distributed amongthe various groups and subgroups as described in the list. Both patientsand the detected canals were also divided according to sex of the pa-tients themselves between the various groups and subgroups.

The lingual canals have been identified in 98% of the cohort;there are no lingual canals in only 2% of the cohort. Vestibular per-forating canals are less frequent: no canal in 61% of cases. In thesymphysis region, a single lingual canal was present in 45%. Amiddle

symphysis structure characterized by 2 lingual perforating canals (lo-cated, respectively, cranially and caudally to genial apophysis) wasfound in 39% of cases. A slightly higher occurrence in males (on av-erage, 2.3 canals for male) than in females (on average, 1.9 canals forfemale) was recorded. Data on location of perforating canals arepresented in Table 3.

The distance of lingual perforating canals from the higheralveolar margin (hsup) is 19.11 (SD, 5.61)mm (range, 2.63Y31.39mm)on average, with a minimum value of hsup (2.63 mm) recorded inedentulous patient. The distance of lingual perforating canals fromthe lower margin (hinf) is, on average, 10.88 (SD, 4.91) mm (range,1.23Y19.86 mm). The distance between vestibular canals and theupper alveolar edge (hsup) is, on average, 17.69 (SD, 3.49) mm (range,9.90Y23.20 mm). The distance between vestibular canals and the in-ferior mandible margin (hinf) is, on average, 11.07 (SD, 2.00) mm(range, 6.92Y16.56 mm).

In Figure 4, the position of lingual perforating canals has beenrelated to the upper alveolar ridge (hsup) and patient’s age: the 158perforating lingual canals were numbered in such a way as to allow

FIGURE 1. Composition of the cohort by age and sex. The 100 patients, marked with an identification number, were ordered in ascending age; the figure shows anearly linear distribution of patients’ age in the considered range of 19Y91 years.

TABLE 1. Classification of the Cohort According to the Class of Edentulism

Class of Edentulism No. Cases

Full dentition 43

Class IVpartially edentulous 14

Class IIVpartially edentulous 12

Class IIIVpartially edentulous 30

Edentulous 1

Total no. cases 100FIGURE 2. Lateral limits (5 mm) from mental holes.

The Journal of Craniofacial Surgery & Volume 25, Number 3, May 2014 Intraosseous Vascularization of Mandible

* 2014 Mutaz B. Habal, MD 873


the recognition of the corresponding number of the originating pa-tient with age and sex.

DISCUSSIONIn the literature, several studies have analyzed the presence of

perforating canals in the interforaminal region; over time, variousterminologies have been used to describe these structures.3

These studies have used different methods of investigation:examination of traditional x-ray records, multislice CT, CBCT scans,anatomical dissection, magnetic resonance imaging, and Doppler.4

FIGURE 3. Data collected on a lingual canal (hsup = distance from thealveolar ridge; hinf = distance from the inferior mandible margin).

TABLE 3. Data on Lingual/Vestibular Canal Location

Canal h Distance FromAverage

Value, mm SD, mm Range, mm

Lingual canal hsup The alveolar ridge 19.11 T 5.61 2.63Y31.39

hinf The inferiormandible margin

10.88 T 4.91 1.23Y19.86

Vestibular canal hsup The alveolar ridge 17.69 T 3.49 9.90Y23.20

hinf The inferiormandible margin

11.07 T 2.00 6.92Y16.56

hsup indicates distance from the alveolar ridge; hinf, distance from the inferiormandible margin.

TABLE 2. Presence of Lingual/Vestibular Canals in Cohort

Patients Canals

Group No. Patients Subgroup AcronymNo.

Patients SexNo.

PatientsNo.

Lingual CanalsNo. Vestibular

CanalsNo.

Total Canals

Patients without canals 1 Patients without canals L0+V0 1 M 1

F 0

Patients with onlylingual canals

60 Patients with 1 lingual canal L1 26 M 7 7 7

F 19 19 19

Patients with 2 lingual canals L2 30 M 12 24 24

F 18 36 36

Patients with 3 lingual canals L3 4 M 3 9 9

F 1 3 3

Patients with onlyvestibular canals

1 Patients with 1 vestibular canal V1 0 M 0

F 0

Patients with 2 vestibular canals V2 1 M 0

F 1 2 2

Patients with lingualand vestibular canals

38 Patients with 1 lingual canal+ 1 vestibular canal

L1+V1 13 M 4 4 4 8

F 9 9 9 18

Patients with 2 lingual canals+ 1 vestibular canal

L2+V1 12 M 5 10 5 15

F 7 14 7 21

Patients with 3 lingual canals+ 1 Vestibular canal

L3+V1 2 M 2 6 2 8

F 0

Patients with 1 lingual canal+ 2 vestibular canals

L1+V2 6 M 3 3 6 9

F 3 3 6 9

Patients with 1 lingual canal+ 3 vestibular canals

L1+V3 0 M 0

F 0

Patients with 2 lingual canals+ 2 vestibular canals

L2+V2 4 M 1 2 2 4

F 3 6 6 12

Patients with 3 lingual canals+ 2 vestibular canals

L3+V2 1 M 1 3 2 5

F 0

Total 100 100 M 39 158 51 209

F 61

M indicates male; F, female.

Di Bari et al The Journal of Craniofacial Surgery & Volume 25, Number 3, May 2014

874 * 2014 Mutaz B. Habal, MD


Only dissective studies provide the vascular-nervous contentof perforating canals, but the study of their characteristics (frequency,location, diameter, etc) requires a number of analyzed cases that canhardly be obtained with such studies.

Radiographic studies allow a wider cohort. Traditional x-rayexaminations do not allow a precise identification of the perforat-ing canals, because of beam orientation: canals are visible only whenthe beam direction coincides with that of the same canals.5

Multislice CTand CBCT images are not affected by this factorand are thus more useful to canal detection.6 The development andwidespread use ofCBCT technology combine a highly accurate surveywith a low biological cost to the patient.4 The resolution distinguishingelement of CBCT is the voxel (three-dimensional pixel). The smallestis the voxel, and the most defined is the cone beam imaging.7

Studied CBCT scans have excellent resolution (voxel size, 0.2 mm).Several studies tested the dimensional accuracy of CBCT

and the validity of linear and volumetric measurements obtained onthem. Most of them experienced no significant statistical differ-ences in accuracy between CBCT and multislice CT; other studiesconfirmed the congruence between linear measurements performedon CBCT images and measures on anatomical dry mandible.8Y11

A three-dimensional image was created for each analyzedcase, achieved through an appropriate density value threshold(Figs. 5A, B). Even if recent studies demonstrate the reliability of

these images,12 all measurements were, however, performed on radio-graphic cross section.

The study of Maloney et al13 tests the hypothesis that linear(vertical and horizontal) measures calculated using a radiographicmachine software (I-CAT; Imaging Science International,Hatfield, PA)and SimPlant are as accurate as the criterion standard, represented bymeasures obtained through a digital gauge on mandibular anatomicalsections. They found no statistically significant differences between thevarious methods. These data confirm the validity of the measurementmethod adopted in present protocol.

At first, anterior mandibular region has been defined. In ac-cordance with the indications emerged in previous works, a surgicaloperation must provide a safety margin of 5 mm medially to themental foramina to prevent iatrogenic injury to nervous structures.14

To obtain a greater clinical significance the same parameters werechosen. On 100 CBCT scans, 3 cases of unilateral double mentalforamen were found. In such cases, the mesial foramen was chosen asreference margin15 (Fig. 6).

FIGURE 4. Lingual canal’s position related with patient age (cases sorted in order of age). The figure shows the typical pattern of the trend: the distance of the canalfrom the alveolar ridge decreases with the age of the patient due to the physiological/pathological resorption of alveolar bone. This trend is not evident with chart datarelated to hinf because of substantial stability of the mandibular lower margin.

FIGURE 5. A and B, Masks obtained by different thresholding values. FIGURE 6. Twin mental holes.




The interforaminal region was initially considered a safe zonefrom a surgical point of view. However, in the literature, serious com-plications resulting from dental implantology procedures have beenreported.2 This may occur during implant’s placement, when theaccidental perforation of the lingual cortical plate is caused, withinjury to adjacent vascular structures.16 The bleeding causes infarctionof the connective tissues of the floor of the mouth. The resultinglifting of the tongue causing upper airway obstruction may neces-sitate an emergency tracheotomy.17

Some authors believe that injury to the intrabone canalswithout lingual plate perforation can also cause bleeding that exposesthe patient to increased risk of death. This occurs, in particular, inthe case of severe mandibular atrophy, if the patient takes anticoag-ulants for a prolonged period of time, or if he has coagulopathy orhypertension.2,4,18

According to Vandewalle et al,3 the artery present in the per-forated canal is of sufficient size to cause severe bleeding, whendamaged during oral surgery. According toGahleitner et al,6 the vesselpresent in the bone canal is proportional to the original sublingualartery and is therefore able to determine significant intraoperativebleeding. To confirm these observations, Lustig et al19 clearly de-fine how the blood flow within these vessels has an arterial originand is directed toward the bone: the blood flowwas detected in 0.7 to3.7 mL/min. The study of Eiseman et al20 performed with Doppler

and duplex ultrasound technique indicates that there is a decrease inmandibular blood flow as age increases.

In the study of vascularization of the mandible, 2 importantfactors must be taken into account: the edentulism class and the ageof the patient. The latter is linked to increased incidence of athero-sclerosis in the elderly: this leads to a general reduction in bloodsupply.20

However, in the mandible, an important role is played bythe presence of dental elements, as the alveolar ridge is uniquelyvascularized by dental branches of the inferior alveolar artery21: whenthe tooth is lost, the dental alveolar bone loses the nutritional intake too.Multiple dental extractions can also cause inferior alveolar arterythrombosis resulting in ischemia and atrophy of tissues placed down-stream vascular disruption.

Castelli et al22 demonstrated the development of a collateralcirculation after proximal obstruction of the inferior alveolar artery.A collateral blood supply comes from the sublingual branch of thelingual artery, from 2 branches of the facial artery (submental andinferior labial) and from the hyoid artery. As these arteries are re-sponsible for perforating vessels in the interforaminal region, it isreasonable to expect an increased flow and therefore an increasedrisk of bleeding in patients with severe atrophy.

Some studies show that excessive bleeding during implantplacement can affect the healing process, resulting in the proliferationof endothelial cells of blood vessels on the implant surface with im-pairment of the osteointegration process.4,23

Finally, the nerve ending lesions within the canals were corre-lated to the incidence of postoperative neurosensory disorders.3 Thecirculation of the anterior mandible is mediated by 3 major arteries:the inferior alveolar artery (and its branch,mylohyoid artery), the facialartery (and its branch, submental artery), and the lingual artery (andits branch, sublingual artery).4

In fact, it is believed that both the facial and lingual arteriescan be damaged as a result of incidents during oral surgery. In an

TABLE 4. Elements of Neurovascular Bundle (Lingual Canals)

Neurovascular Bundle (Lingual Canals) Vascular Element Nervous Element

Superior lingual canal Lingual artery Lingual nerve

Inferior lingual canal Submental artery Mylohyoid nerve

FIGURE 7. A and B, Single lingual canal in three-dimensional mask (A) andradiographic cross section (B).

FIGURE 8. A and B, Superior and inferior lingual canal in three-dimensionalmask (A) and radiographic cross section (B). FIGURE 9. Sublingual region anatomy.




emergency situation, it remains a controversial choice to performexternal binding of either artery. Manual compression of the ante-gonial landmark at the bottom edge of the mandible helps to dis-tinguish which of the 2 arteries was injured. If compression of theantegonial landmark stops the bleeding, then the facial/submentalartery is most likely the cause.18

Several authors have studied mouth floor vascularization inrelation to the interforaminal region, and studies confirm that thevascular structures potentially involved are the submental branch ofthe facial artery and the sublingual branch of the lingual artery.16

Scientific studies based on anatomical dissection or by usingCT examinations confirm that terminal vessels of the sublingualand submental arteries can penetrate the lingual cortical plate of theinterforaminal region.24

The main investigated factors were number of canals, locali-zation, diameter, intraosseous direction, content, correlation betweenpresence of canal and sex of the patient, and correlation betweencanal position and age of the patient.

In this work, the lingual canals have been identified in 98%of the cohort. Previous studies found a frequency of canals in themedian portion ranging between 85% and 99%.5,25,26 The study ofVandewalle et al3 on macroanatomical evaluation of 354 dried man-dibles reveals a similar percentage.

Generally, radiographic-based examinations reveal an inci-dence lower than anatomical studies: high-resolution x-ray imageanalysis and three-dimensional reconstruction offered by SimPlanthave allowed a greater correspondence with anatomical and dis-section studies.

In this work, the lingual foramen diameters have not beenevaluated, as in the literature there are overlapping data. Longoniet al27 refer to a diameter between 0.3 and 1.1 mm (mean value,0.6 [SD, 0.2] mm). Gahleitner et al6 distinguish the vessel diameterdepending on their position: middle position (0.7 [SD, 0.3] mm) andpremolar position (0.6 [SD, 0.2] mm). Lustig et al19 refer to a diameterof 0.18 to 1.8 mm. Vandewalle et al3 performed a very thorough in-vestigation on the lingual foramen located in the upper position inrespect to the genial apophysis, recording diameter data substan-tially similar to those described previously. According to the studyby Vandewalle et al,3 the shape of the entering foramen appearsgenerally funnel shaped or round. The length of the intraosseouscanal course has not been studied in this article, but Romanoset al23 indicate a value between 5 and 15 mm with a mean value of10.55 mm. Tepper et al26 describe the intraosseous course distinguishing

between the middle and side canals: median canals show a buccal-to-lingual course, whereas side canals have a ventral direction. The currentstudy confirms these data. In the middle section, when multiple vesselsare present, their intraosseous course frequently appears convergent,thus forming anastomoses between them.

An accurate study of perforating bone canals must providea distinction according to their location. The literature shows thatauthors have chosen different criteria for topographic grouping ofcanals from time to time. More frequently, the horizontal positionof the canals was placed in relation to dental elements present inthat region: thus, there are canals in premolar, lateral incisors, andin the middle section or symphysis region.

In the current study, a similar classification was used. How-ever, vessels in the premolar region were not studied, because of alimit of 5 mm from the mental foramina. The study of Gahleitneret al6 reported an incidence of perforating canals in the premolararea of 34% (right side) and 38% (left side). The investigativemethod of the current study appears similar to that adopted byLongoni et al.27 In their article, they studied the number, location,and size of lingual perforating canals; the analysis was carried outon a cohort of 100 dry mandibles, and the results were comparedwith those obtained by radiographic analyses performed on CTof the same mandibles.

According to the study of Longoni et al,27 most mandibles(45%) present a single lingual canal in the symphysis region; othertypical location is the lateral incisor region (Figs. 7A, B). The presentwork reveals the recurrence (39%) of a middle symphysis structurecharacterized by 2 lingual perforating canals located, respectively,cranially and caudally to genial apophysis (Figs. 8A, B). This patternemerges also in the work of Liang et al25: their dissective exami-nation indicates that the upper perforating canal is a terminal branchof the sublingual artery, whereas the lower is a terminal branch of thesubmental artery (Table 4; Fig. 9). Another pattern is the verticalposition of the canal, which could be related with the upper alveolarridge or with the lower margin of the mandible.

In the present work, both of these values have been recorded:hsup and hinf. The distance of lingual perforating canals from the higheralveolar margin (hsup) is 19.11 (SD, 5.61)mm (range, 2.63Y31.39mm)on average; this result is obviously of surgical interest but is highlyinfluenced by the presence or absence of dental elements and by thedegree of resorption of the edentulous sites. Confirming that, a

FIGURE 11. Position of neurovascular bundles in edentule mandible.

FIGURE 10. A and B, Mandibular canal’s position in edentule (A) and dentate(B) mandible.




minimum value of hsup (2.63 mm) was recorded in the edentulouspatient (Figs. 10A, B) (Fig. 11).

The studies of Rosano et al28 and Loukas et al29 describe anaverage distance of a perforating canals from the alveolar margin of10.3 mm. This difference is related to the class of edentulism of thecohort. The medium hsup evaluated in the current study registers avalue halfway between upper and lower perforating canal distancefrom the genial apophysis in 39% of cases. If only the values ofthe upper perforating canals were considered, similar values to thoseof the studies listed above would be obtained.

Figure 4 shows the typical pattern of the trend: the distanceof the canal from the alveolar ridge decreases with the age of thepatient due to the physiological/pathological resorption of alveolarbone. This trend is not evident with chart data related to hinf becauseof substantial stability of the mandibular lower margin. The dis-tance of perforating canals from the lower margin (hinf) is, on av-erage, 10.88 (SD, 4.91) mm (range, 1.23Y19.86 mm). This value isthe same as that recorded by Vandewalle et al3 (10.6 [SD, 1.6] mm)and Gahleitner et al6 (10.0 [SD, 5.5] mm).

The choice of the implant length must then be correlated withthe presence and location of perforating canals: bicorticalism is nolonger considered a key factor,30 and data are emerging supportingthe use of short implants.31

In the study of Romanos et al,4 no differences emerged in thefrequency of perforating canals between male and female patients.

In the current study, a slightly higher occurrence inmale patients(on average, 2.3 canals for male patients) than in female patients (onaverage, 1.9 canals for female patients) was recorded.

Vandewalle et al3 suggest differences between ethnic groups.The substantial overlap of the present work’s results (Italian cohort)with thoseofVandewalle et al3 (Indian cohort) doesnot seem to supportthis hypothesis.

The presence of buccal perforating canals was also investi-gated (Figs. 12A, B). These canals appear smaller than lingual ones.The distance between these buccal vessels and the upper alveolaredge is, on average, 17.69 (SD, 3.49) mm (range, 9.90Y23.20 mm).

The anterior mandibular region has many lingual perforatingcanals, which are variable in number and position. A careful radio-graphic assessment and a surgical safeguarding of this region appearadvisable, especially of the lingual plate (there are no lingual canals inonly 2% of the cohort). Particular attention is reserved for edentulous,periodontopathic, and elderly patients: marginal alveolar bone resorp-tion causes a relative superficialization of perforating canals, increasingthe chance to intercept them during surgery. Vestibular perforatingcanals are less frequent: they do not represent a serious surgical risk (nocanal in 61% of cases).

All surgical intervention for bone grafting or placing implantsshould be preceded by a thorough radiographic analysis of the anteriormandibular region. A careful choice of implant length is required. Inrelation to the higher prevalence of vascular structures near themidlineregion, this should possibly be preserved.

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Intraosseous Vascularization of Anterior Mandible

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