Pre and Post natal growth of maxilla and nasomaxillary complex and its orthodontic implications.

1. GROWTH OF MAXILLA
AND NASOMAXILLARY
COMPLEX
PRESENTED BY :
RAAHAT VIKRAM SINGH
MDS – 1st Year

2. CONTENTS
 Growth and Development: Definitions
 Prenatal growth and development of maxiilla and Naso
maxillary complex
 Growth and development of palate
 Developmental anomalies of face
 Developmental anomalies of palate
 Postnatal development of maxilla and nasomaxillary complex
 References

3. GROWTH: DEFINITIONS
Different researchers have defined growth in different ways
 “Growth is defined as an increase in size and number” – Profit
 “Growth is an increase in size” – Todd
 “Increase in size, change in proportion and progressive complexity” –
Krogman
 “Normal changes in the amount of living substance” – Moyers

4. DEVELOPMENT: DEFINITIONS
 “Development is a progress towards maturity” – Todd
 Development connotes a maturational process involving progressive
differentiation at the cellular and tissue levels” – Enlows
 “Development refers to all naturally occurring, progressive,
unidirectional, sequential changes in the life of an individual from its
existence as a single cell to its elaboration as a multifunctional unit
terminating in death” – Moyers
 “Development is increase in complexity” – Profitt

5. GROWTH
PRENATAL
PERIOD OF
OVUM
PERIOD OF
EMBRYO
PERIOD OF
FETUS
POSTNATAL

6. Period of Ovum
 This period extends for
approximately two weeks
from the time of fertilization.
 During this period, cleavage
of the ovum and attachment
of the ovum to the
intrauterine wall occurs.

7. Period of Embryo
 This period extends from
the fourteenth day to the
fifty sixth day of
intrauterine life.
 During this period, the
major part of the
development of the face
and the cranial region
occurs

8. Period of Fetus
 This period extends from fifty
six days of intrauterine life till
birth.
 During this period, accelerated
growth of craniofacial
structures occurs, resulting in
an increase in size.
 A change in proportion
between various structures is
also observed.

9. PRENATAL EMBRYOLOGY OF THE FACE
UPPER 1/3RD : Embryonic frontonasal process
MIDDLE 1/3RD: Frontonasal and maxillary
prominence
LOWER 1/3RD: Mandibular prominence

10. PRE NATAL GROWTH
& DEVELOPMENT OF
MAXILLA &
NASOMAXILLARY
COMPLEX

11. ANATOMY OF MAXILLA
The face of an adult
comprises of 22 bones
The maxillae are a pair of
pneumatic bones that
articulate with one another
to form the upper jaw.
Each of the maxillary
bones house the largest
sinus of the body ie; the
maxillary sinus

12. Two maxillae articulate to form:
1. Whole upper jaw.
2. Roof of oral cavity.
3. Greater part of floor and lateral wall of nasal cavity
and part of nasal bridge.
4. Greater part of floor of each orbit.

13. PARTS OF MAXILLA
BODY OF
MAXILLA
4
FRONTAL ZYGOMATIC ALVEOLAR PALATINE

14. FRONTAL
PROCESS
ZYGOMATIC
PROCESS
PALATINE
PROCESS
ALVEOLAR
PROCESS
MAXILLA – MEDIAL
VIEW
MAXILLA – LATERAL
VIEW

15. PRENATAL GROWTH & DEVELOPMENT
OF THE MAXILLA
 Prenatal development of the maxilla begins in the 4th week
of intrauterine life.
 During this period, there is –
1. Migration of neural crest cells
2. Formation of branchial arches

16.  At the 4th week of intrauterine life, a
prominent bulge appears on the
ventral aspect of the embryo,
representing the developing brain.
 Below it, develops the pericardium
which is representative of the future
thorax.
 A shallow depression, known as the
stomatodaeum, which is the future
mouth, separates the two.

17.  Buccopharyngeal membrane
lines the floor of the
stomatodeum.
 There are a series of mesodermal
thickenings in the wall of the
cranial most part of the forgut.
These thickenings are known as
pharyngeal arches of branchial
arches

18.  The first of these arches is known as
the mandibular arch and the second;
the hyoid. The third, fourth and sixth
arches do not have special names.
 The fifth arch is seen to disappear soon
after formation. Thereby leaving on five
arches.
 It is the mesenchyme of the first arch
that is responsible for the formation of
the bones of the face including the
maxilla, mandible, zygomatic bones,
palatine bone and part of the temporal
bone.

19.  Proliferation of mesoderm covering developing forebrain.
 Downward projection of mesoderm is called the frontonasal
process.
Development of Frontonasal Process

20.  The pharyngeal arches that are
laid down on the ventral walls
of the most cranial part of the
foregut, lie in close proximity
to the stomodaeum.
 It is therefore, appreciated that
the face develops from
structures around the
stomatodaeum ie; -
(A) the frontonasal process
(B) the first pharyngeal (or
mandibular) arch of each side.

21. Budding of Maxillary & Mandibular Process
 Mandibular arch forms
the lateral wall of the
stomatodaeum.
 This gives off a bud
from its dorsal end –
the maxillary process &
grows ventro-medially
– Mandibular process.

22. Formation of Nasal Placodes & Nasal Pit
 The ectoderm overlying
the frontonasal process
shows bilateral localised
thickenings.
 These are called nasal
placodes and are situated
a little above the
stomatodaeum.
 These placodes soon sink
below the surface to form
nasal pits.

23. Development of Medial and Lateral Nasal
processes
 The nasal pits are seen to be continuous with the stomatodaeum
below.
 The edges of each pit are raised above the surface
The medial raised edge
LATERAL NASAL PROCESS
The lateral raised edge
MEDIAL NASAL PROCESS

24. Around the 7th week of intrauterine life
Formation
of upper lip
Intramembranous
bone ossification
takes place
Formation of
nasal septum
Formation of
nasolacrimal
duct
Formation of the
primary palate

25. Formation of the Lips
 The mandibular processes of the
two sides grow towards each
other and fuse in the midline,
forming the lower margin of the
stomatodaeum.
 It is understood that the fused
mandibular processes give rise to
the lower lip.
LOWER LIP

26.  Each maxillary process grows
medially and fuses first with the
lateral nasal process and then
with the medial nasal process.
 Medial and lateral nasal
processes also fuse with one
another.
 Results in formation of external
nares

27.  The maxillary processes undergo considerable amount of growth towards one
another
 At the same time, the frontonasal process becomes much narrower from side to
side, with the result that the two external nares move closer together.
 The stomatodaeum is now bounded above by the upper lip.
 The mesodermal basis of the lateral part of the lip is formed from the maxillary
process and the overlying skin is derived from the ectoderm covering this process.
 The mesodermal basis of the median part of the lip(called the philtrum) is from
the frontonasal process while the ectoderm of the maxillary process overgrows
and meets that of the opposite . This results in the skin of the entire upper lip
being innvervated by the maxillary nerves.

28. Formation of the Nose
 Receives contributions from the frontonasal process and the medial
and lateral nasal processes of the right and left sides.
 As seen earlier, the external nares are formed when the nasal pits are
cut off from the stomatodaeum by the fusion of the maxillary process
with the medial nasal processes.
 Gradual narrowing of the frontonasal process  External nares
approach one another.
 The deeper part of this frontonasal process forms the nasal septum
ultimately.
 As the nose becomes prominent, the external nares come to open
downwards instead of forwards.

29. Formation of the Nasolacrimal duct
 It is seen that the maxillary
process fuses with the lateral
nasal process
 However, this fusion not only
occurs in the region of the lip but
also extends from the
stomatodaeum to the medial
angle of the developing eye.
 This line of fusion is marked by a
groove called the naso-optic
furrow or the nasolacrimal sulcus.
 A strip of ectoderm is buried
along the furrow and this gives
rise to the nasolacrimal duct

30. Development of Nasal Cavities and Nasal
Septum
 Nasal cavities are formed by the
extension of the nasal pits.
 Initially, they are in open
communication with the
stomatodaeum.
 Soon, the medial and lateral nasal
processes fuse forming a partition
between the pits and the
stomatodaeum. This partition is
called the primitive palate

31.  The nasal pits
deepen to form the
nasal sacs
 The dorsal part of
the sac is seperated
from the
stomatodaeum by
a thin membrane
called the
bucconasal
membrane or the
nasal fin.

32.  The nasal sac now has a ventral orifice that opens on the face – Anterior or
external nares, and a dorsal orifice that opens into the stomatodaeum
(primitive posterior nasal aperture).
 At first, the two nasal sacs are widely separated from one another by the
frontonasal process.
 Progressively, however, the frontonasal process becomes narrower.
 This narrowing of the frontonasal process and enlargement of the cavities
themselves leads to the coming closer of the cavities.
 The intervening tissue becomes thinner to form the nasal septum.

34. Ossification of Maxilla
 Ossification of the maxilla begins around the 7th week of intrauterine life.
 It is of intramembranous type.
 The primary centre for ossification appears in the angle between the division
of a nerve i.e where the anterosuperior dental nerve is given off from the
inferior branch of infra orbital nerve, above the part of the dental lamina from
which develop the enamel organ of the canine.
From this centre, the bone spreads:
• Posteriorly: below the orbit towards the
developing zygoma
•Anteriorly: towards the future incisor region
•Superiorly: to form the frontal process

35. SECONDARY CENTERS FOR OSSIFICATION
IN THE MAXILLA ARE
Zygomatic Orbitonasal Nasopalatine Intermaxillary
One TwoOneOne
INITIATED AT:
8TH week 7th week8th week8th week

36. 8th week of Intra Uterine Life
 At the 8th week of intrauterine life, intramembranous
ossification centers for the following appear:
 Nasal and lacrimal bones
 Medial plates of sphenoid
 Vomer
 Zygomatic bone

37. GROWTH AND
DEVELOPMENT OF
PALATE

38. Structure of Palate
PRIMARY PALATE SECONDARY PALATE

39. PRENATAL GROWTH AND DEVELOPMENT OF PALATE
Formation of primary
and secondary palate
Elevation of Palatal
Shelves
Fusion of palatal
shelves

40. Development of the Primary Palate
 All three prominences –
frontonasal process,
medial nasal and lateral
nasal processes
contribute to the
separation of the oral
cavity with the nasal pit.
This separation is known
as the primary palate.
PRIMARY
PALATE

41. Secondary Palate
 Begins at about the 6th week of IUL
 It is characterised by:
1. Formation of palatal shelves on the maxillary prominences
2. Elevation of these shelves to a horizontal position
3. Palatal fusion between the horizontal shelves
4. Fusion of palatal shelves anteriorly with the primary palate
 This forms what is known as the roof of the mouth or the hard palate.

42. MAXILLARY PROCESS
TWO LATERAL (HORIZONTAL) PALATINE PROCESSES
FUSE WITH
NASAL SEPTUM PRIMARY PALATE EACH OTHER

44. Fusion of Palatal Shelves
Tongue is initially positioned between the two palatine process and
partially fills the nasal cavity
As the palatal shelves grow medially, their fusion is prevented by the
presence of the tongue.
Palatal shelves initially grow in the vertical direction
At 7th week the Transformation occurs
Horizontal direction
Shelves elevate, makes contact , and fuse with each other above the
tongue

46. Ossification of Palate
 It occurs from the 8th week of intra-uterine life.
 The palate ossifies from a single centre derived from the maxilla.
 The mid-palatal sutural structure is first seen at 10.5 weeks post
conception and ossifies by 12-14 years of age.
 Therefore, expansion can be carried out before the mid palatal
ossification.

47.  At about the 8th week of IUL, the mesoderm in the palate
undergoes intramembranous ossification to form the hard palate.
 This ossification however, does not extend into the most posterior
portion, which remains as the soft palate.
 The part of the palate derived from the frontonasal process forms
the premaxilla, which carries the incisor teeth.

49. DEVELOPMENTAL ANOMALIES OF FACE
CLEFT LIP:
 Failure of maxillary prominence to
fuse with the medial nasal process
of the affected side: Unilateral
cleft lip.
 Failure of maxillary prominences
to meet and unite with medial
nasal processes on both sides:
Bilateral cleft lip.
 Failure of mesial nasal processes
to join and form the inter
maxillary segments : Median Cleft
Lip

50. OBLIQUE FACIAL CLEFT
 Non fusion of the
maxillary and lateral
nasal processes gives
to a cleft that runs from
the medial angle of the
eye to the mouth. In this
case, the naso lacrimal
duct is not formed.

51.  Inadequate fusion of maxillary
and mandibular processes
with one another
Macrostomia.
 Lack of fusion may be present
only on one side  Lateral
facial cleft
 Excessive fusion
Microstomia

52.  BIFID NOSE: Associated with a
median cleft lip, there may be a
bifid nose, occurring due to the
bifurcation of the frontonasal
process.
 Sometimes, one half of it may be
absent altogether.
 PROBOSCIS
 CYCLOPS
 HYPERTELORISM

53.  MANDIBULOFACIAL DYSOSTOSIS:
the entire first arch remains
underdeveloped on either one, or
both sides.
 This effects the lower eyelid, the
maxilla, the mandible and the
external ear.
 The prominence of the cheek is
absent and the ear may be
displaced ventrally and caudally
 There may also be occurrence of
cleft palate and faulty dentition.
 Also known as  Treacher Collin
Syndrome or First Arch Syndrome.

54. DEVELOPMENTAL ANOMALIES OF
PALATE
 Epithelial Pearls
 Torus Palatinus
 High Arched Palate:
 Marfans Syndrome
 Curzon's Syndrome
 Cleidocranial dysostosis

55. CLEFT PALATE
 Delayed elevation of palatal shelves from vertical oreintation.
 Failure of fusion of the lateral palatal processes to one another or
the median palatine process.
 Clefts that extend to the anterior end of the palate are associated
with harelip, as both the upper lip and the palate are formed by
fusion of maxillary processes with the frontonasal process.
 Palatal clefts lead to anomalous communications between the
mouth and the nose which may be unilateral of bilateral.

56. POST NATAL
DEVELOPMENT OF
MAXILLA AND NASO
MAXILLARY COMPLEX

57.  The post natal development of maxilla is dominated by –
 Surface apposition
 Sutural growth
 Nasal septum growth
 Spheno occipital synchondrosis
 In contrast to cranial base maxilla is dominated by intra membranous
ossification.

58. Displacement
 Growth occurring via displacement involves the movement of the
entire bone while it expands.
DISPLACEMENT MAY BE
PRIMARY SECONDAR

59. Primary Displacement
This kind of displacement is
not caused by pushing
against the articular surface
of other bones but rather
carried away by the
expansile force of the soft
tissue surrounding it and
new bone is added to the
contact surface

60. Secondary Displacement
 Movement of whole bone
caused by enlargement of other
bone

61. PRIMARY
DISPLACEMENT
Sutural theory
Cartilagenous
theory
Functional
Matirx Theory

62. SUTURAL THEORY
 Given by Sicher
 Sutures have an innate growth potential
 Oblique nature
 Sliding effect

63. Growth at Sutures
The maxilla is connected to the
cranium & cranial base by a
number of sutures which include
:
The fronto-nasal suture
The fronto-maxillary
suture
The zygomatico-temporal
suture
The zygomatico-maxillary
suture

64. These sutures are all oblique, and more or less parallel
to each other, which allows the downward & forward
repositioning of the maxilla as the growth occurs at
these sutures – Weinmann & Sicher.

65. CARTILAGENOUS THEORY
 Given by: Scott
 He viewed cartilaginous sites throughout
the skull as primary centers of growth.
 Nasal septum – innate growth potential
 More role in a-p than vertical plane
 Surgical removal of nasal septum leads to
a mid facial deficiency.

66. Expansion of cartilage of nasal
septum
Push maxilla
Sets tension at sutures
Secondary bone growth at
sutures

67. FUNCTIONAL MATRIX THEORY
 Given by Moss in 1962.
 This theory was introduced by Melvin Moss based on the
functional cranial component by Van der Klaaus.
 It claimed that the control for growth was not in cartilage
or bone but in the adjacent soft tissue thus emphasizing
that neither the nasal septum now the mandibular condyle
are determinants of growth.

68.  “the functional matrix is primary and the origin, development,
and maintainence of skeletal unit is secondary, compensatory
and mechanically obligatory response to change in shape and
special position of its related functional matrix.”
 Each function is carried out by a group of soft tissue which are
supported and /or protected by related skeletal element.

69. SKELETAL UNIT FUNCTIONAL MATRIX
Basal body Infraorbital Nerve
Orbital Unit Eyeball
Nasal Unit Septal cartilage
Alveolar Unit Teeth

70. Surface Remodeling
Massive surface remodeling by bone deposition and resorption
brings about
increase in size
change in shape of bone
change in functional relationship.

71. Primary Displacement & Surface
Remodeling
Interestingly, as the
maxilla grows
downward and
forward, its front
surfaces are
remodeled, and
bone is removed
from most of the
anterior surface

72. To understand this paradox, it is
necessary to comprehend that two
very different processes are going
on simultaneously. The overall
growth changes are the result of
both downward and forward
translation of the maxilla and a
simultaneous surface remodeling.
The whole bony naso- maxillary
complex is moving downward and
forward relative to the cranium,
being translated in space.

73. The Maxillary Tuberosity and Arch
Lengthening
 The horizontal
lengthening of the bony
maxillary arch is
produced by
remodelling at the
maxillary tuberosity.
 This is primary
displacement.

74.  The nature of the force that produces this anterior movement is
subject of great controversy:
 1st theory
Additions of new bone on the posterior surface of the elongating
maxillary tuberosity "push" the maxilla against the adjacent muscle-
supported pterygoid plates.
 Failure of theory
Bone's osteogenic membrane do not have the physiologic capacity
to actually push the whole bone away from the other bones by
itself. Surface force exerting pressure causes compression that
would press closed the sensitive capillary plexus within the vascular
osteogenic connective tissue. This leads to necrosis.

75.  2nd theory
bone growth within the various maxillary sutures produces a
pushing-apart of the bones.
 Failure of theory
bone tissue is not capable of growth in a field that requires the
levels of compression needed to produce a "pushing" type of
displacement.
The sutural connective tissue is not adapted to a pressure-
growth process (in contrast to cartilaginous tissues which are
compression tolerant). The suture is essentially a tension-
adapted tissue.

76. Nasomaxillary Remodeling
 An important concept, clinically as well as biologically, is that
all inside and outside parts, regions and surfaces participate
directly in growth.

77. The Lacrimal Suture: A Key Growth
Mediator
 The lacrimal bone is a diminutive flake of a
bony island bounded by sutural connective
tissue contacts separating it from the the
many other surrounding bone.
 As all these other separate bones enlarge or
become displaced in many directions, at
different rates and different times, the sutural
system of the lacrimal bone provides for the
"slippage" of the multiple bones along sutural
interfaces as they all enlarge differentially.

78.  The lacrimal sutures make it possible for the maxilla
to "slide" downward along its orbital contacts. This
allows the whole maxilla to become displaced
inferiorly.
 Without the formation of this “perilacrimal sutural
system”, a developmental gridlock would occur
among the various developing parts.
 Thus, the lacrimal bone and its suture proves to be a
developmental hub providing key traffic controls.
 The lacrimal bone itself undergoes a remodelling
rotation, wherein the more medial superior part
remains with the lesser-expanding nasal bridge,
while the more lateral inferior part moves
markedly outward to keep pace with the great
expansion of the ethmoidal sinuses.

79. The Maxillary Tuberosity
The growth of the bony maxillary arch occurs by 3 processes
It lengthens
by deposition on the
posterior-facing
maxillary tuberosity
It grows laterally by
deposits on the buccal
surface thus widening
the posterior part of
the arch.
It grows downward by
deposition of bone along
alveolar ridges and also on
the lateral side, because this
outer surface slopes slightly
downward
“The increase in length is primarily because of growth in posterior
border.”
(AJO-DO: vol1987Jan.(29-41); Baumrind, Korn, and Ben-Bassat : Quantitation of Maxillary
Remodelling)

80. The Key Ridge
 A major change in surface contour
occurs along the vertical crest just
below the malar protuberance. This
crest is called the "key ridge”.
 Part of the bony arch in area b is
concave, and the labial (outside)
surface faces upward, rather than
downward. The resorptive nature of
this surface provides an inferior
direction of arch remodelling in
conjunction with the downward
growth of the palate. This is in
contrast to area a , which grows
downward by periosteal disposition.

81. The Vertical Drift of Teeth
 As a tooth drifts mesially by the process of alveolar remodelling
(resorption and deposition) vertical movement of the tooth also occurs
in same way.
 As the maxilla and mandible enlarge and develop, the dentition drifts
both vertically and horizontally to keep pace in respective anatomic
positions. The process of drift moves the whole tooth and its socket;
that is, the tooth does not drift vertically out of its alveolar housing as it
does in eruption (or as implicit in the term "extrusion"). Rather, in
vertical drift, the socket and its resident tooth drift together as a unit.
 The horizontal and vertical distances moved by the socket, its tooth,
and the periodontal membrane can be substantial. By harnessing the
vertical drift movement, the orthodontist can more readily guide teeth
into calculated positions, thereby taking advantage of the growth
process

82. The Nasal Airway
Lining surfaces of the bony walls and
floor of the nasal chambers-
resorptive.
“The sagittal sections of the hard palate revealed a marked resorption on the
superior nasal surface and a pronounced apposition on the oral surface covering
also the posterior margin.”
(AJO-DO:vol1982Oct.(329-342); Melsen and Melsen – Postnatal Development of Palatomaxillary
Regions)
Produces a lateral and anterior expansion
of the nasal chambers and a downward
relocation of the palate

83. The ethmoidal conchae - depository
surfaces on their lateral and inferior
sides and resorptive surfaces on the
superior and medial facing sides of
their thin bony plates.
The lining cortical surfaces of the maxillary sinuses are all resorptive, except laterally to
accommodate nasal expansion.
This moves them downward and
laterally
Expansion of the entire nasal region.

84.  The breadth of the nasal bridge
does not increase from early
childhood to adulthood.
 More inferiorly in the
interorbital area, the medial
wall of each orbit (lateral walls
of the nasal chambers between
the orbits) expands and
balloons out considerably in a
lateral direction in conjunction
with the considerable extent of
lateral enlargement of the nasal
chambers. The ethmoidal
sinuses are thereby enlarged
greatly.

85. Zygomatic Arch
Resorption
at anterior
surface
Deposition
at posterior
and lateral
surfaces
Zygomatic
arch moves
posteriorly
and bilaterally
outwards

86. Palate
 Also follows the V principle.
 In early pre natal life the palate is relatively long but from the 4th
month it widens as a result of mid palatal suture growth and
appositional growth along the lateral alveolar margins.
 Growth of the mid palatal suture occurs between 1 and 2 years of
age. It is larger in its posterior than in its anterior part, so that the
posterior part of the nasal cavity widens more than the anterior
part.
 Lateral appositional growth continues until 7 years of age by this
time the palate achieves its maximum anterior width. Posterior
appositional growth continues after the lateral growth has ceased,
so that the palate becomes longer and wider during late
childhood.

87.  The appositional growth of the alveolar processes contributes
to deepening as well as widening of the vault of the boney
palate at the same time adding to the height and breadth of
maxillae.
 Ossification does not occur in the posterior part of the palate,
giving rise to the region of soft palate.

88. Orbit
 Orbit also follows the V
principle.
 Sutural bone growth
occurs at the many
sutures within and outside
the orbit, the orbital floor
is displaced and enlarges
in a progressive
downward and forward
direction along with the
rest of the nasomaxillary
complex.

89.  The floor of the orbit moves upward as the whole maxilla
displaces inferiorly. Deposition takes place on the
intraorbital (superior) side of the orbital floor and
resorption on the maxillary (inferior) sinus side .
 Thus, the orbital and nasal floors are necessarily displaced
in the same direction because they are parts of the same
bone, but they undergo remodeling relocation movements
in opposing directions.

90.  The orbits relocates anteriorly
by the V principle, which itself
serves to enlarge the orbital
size.
 The multiple parts of the
whole orbit become displaced
out and away from each other
at the same time in
association with bone
deposition at the various
orbital sutures.

91.  “The pharynx, like the maxilla, is small in all
dimensions. The small pharynx, the thick soft
palate with retropositioned maxilla and nose are
factors contributing to a compromised airway.”
(J Indian Soc Pedo Prev Dent September (2002) 20 (3): 118-123)

92. REFERENCES
 Human Embryology: Eighth Edition – Inderbir Singh, GP Pal; Pgs.
34-44, 106, 109, 126-137.
 Human Anatomy: Volume 3-Head, Neck and Brain – B.D.
Chaurasia; Pgs. 210-214.
 Essentials of Facial Growth: Enlow and Hans
Principles and practice of Orthodontics - Graber
 Contemporary Orthodontics- 5th Edition: William R. Proffit, Henry
W. Fields, David M. Sarver; Pgs. 96, 97.

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