Extractions & The Airway

By Ashley Craig


When David* recognized his former Orthodontist while vacationing on a tropical island in 2010, he decided to confront him about his treatment as a child.

“Do you remember me?” he asked.  The orthodontist shook his head.  David smiled and pointed to his teeth.

 “Oh, I suppose you’re a former patient,” said the orthodontist.

“Yes.  Do you notice anything about my teeth?” David asked.  The orthodontist shook his head.

“They’ve returned to how they were before.  You really should change your treatment method.”

“Well, that’s your opinion,” the orthodontist responded.

Like many orthodontic patients, David had started with a minor case of crowding as a child.  His orthodontist removed four premolar teeth and subsequently applied fixed braces to close the gaps and align the teeth.  Shortly after their removal, his remaining teeth relapsed.  After enduring two years of his life in braces, thousands of dollars had gone toward a still-crooked smile, now with missing teeth.

Extraction of teeth is a common practice in the dental industry.  According to Orthodontist Chris Norton, over 60% of traditional orthodontic cases in the U.S. and over 80% in the U.K. involve extracting between four and eight permanent teeth. Removing teeth and straightening them into alignment may at first appear to be a simple and effective method of correcting teeth.  With myriad problems resulting from extraction treatment, however, one must question whether this method is an easy way out for the practitioner rather than an optimal solution for the patient.  In the short term extraction is hard on the body, with trauma to the surrounding tissue, use of anesthesia, and potential for complications such as bleeding and dry sockets.   Beyond these immediate issues, extracting teeth and closing the gaps narrows the dental arch, allowing less room for the tongue and potentially reducing the volume of the posterior airway.  The approach can lead to long-term conditions such as sleep apnea, and even damage the facial structure.  A narrow arch provides less bony support for the face, sometimes leading to a dished-in appearance from the side as well as a narrower facial structure and smile.

The difference between extraction and non-extraction treatment is exemplified by a paper published by Dr. H.L. Eirew in the British Dental Journal in 1976.  Two identical twin girls had presented with identical cases of crowded teeth. 


 One received extraction treatment, while the other had her palate expanded.  The resulting differences are nothing short of profound.

For many years, orthodontists have practiced with the belief that we have evolved to have smaller jaws that are unable to accommodate all 32 teeth. Looking at the history of malocclusion, however, it becomes apparent that the rise of crooked teeth is closely paralleled with the rapid rise of civilization – something that has only taken off in the last four hundred years; a relative blink of an eye with the process of evolution taking millions of years.  This amount of time is simply too short for our genes to have changed significantly.  As such, it seems that crooked teeth are not a result of genetically smaller jaws but rather a developmental effect of our modern lifestyles.

Once we accept that narrow jaws and malocclusion are environmental rather than genetic, the focus of orthodontic treatment necessarily changes from the easy route of extracting teeth to the optimal solution of expanding the jaw to accommodate the teeth.  

What About Wisdom Teeth?

Janet’s* story demonstrates how the dental industry can be overly extraction-happy.  She’s one of the lucky ones, with a wide dental arch and enough room to accommodate all 32 teeth.  Her wisdoms grew in straight without issue, and yet every six months at her dental check-up she receives the same advice from her dentist: “You might as well get your wisdom teeth removed; you don’t need them.”

Even if we were to accept the common “wisdom” that wisdom teeth are vestigial structures, it is alarming to think about the prevalence of wisdom tooth extraction.  After all, we do not have our appendix removed unless it causes us problems.  Why, then, do nearly 85% of adults go through the trauma of surgery for teeth that frequently remain dormant in the bone, or even erupt fully with no issue?  There appears to be a degree of fear mongering, with experts advising patients that problems like decay, infection or cysts will most likely flare up in time.  However, figures cited by organizations with a vested interest in promoting oral surgery are rarely backed by evidence.  In fact, when asked by the New York Times to back up its claim that 80% of young adults who retained wisdom teeth developed problems within seven years, The American Association of Oral and Maxillofacial Surgeons could not produce supporting evidence and deleted the statement from their website.  Critics of routine extraction cite many studies, among them one that found complications occurred for only 12% of 1,756 middle-aged people who did not have their wisdom teeth removed.

Perhaps many of us get along fine without our wisdom teeth, but are we really in optimal condition without them?  It’s certainly a thought to chew on.

Want to fight unnecessary extraction and help save the wisdom teeth of the world?  Click here to donate to our research fund and receive a free T-shirt with a donation of $30 or more.

*Name changed 

Showing 59 reactions

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  • Inquisitive
    commented 2020-10-10 07:29:48 -0700
    Pretty negligent thing to do, isn’t it? It can be done during retraction of retruding teeth if control is lost during space closure.

    I am speaking of the increase in mandbular plane angle, yes, which is not a direct effect of the extractions themselves, no. I agree, of course.

    What do you think could be the cause of this to happen in what happens to be an extraction case, however?
  • Kim Henry
    commented 2020-10-10 06:23:57 -0700
    I don’t know how anyone would “severely narrow” the maxilla non-surgically. Widening it is easy in a child using a Hyrax or similar device . The maxilla is two bones connected by a suture in the middle, until the suture fuses in the late teens. We cannot narrow maxillas without surgery. Why would we want to when arches are crowded anyway?

    Again, I have measured many ceph x-rays, and I do not find “recessed maxillas by the norms in class IIIs,” except in the occasional Mongol patient. What you are alleging is in fact not correct. I use Nasion Peripinduluar on cephs as an indication of antero-posterior maxillary position.

    By mandibular “falling open” are you saying increasing mandibular plane angle? I don’t get your terminology. Increasing mandibular plane angle is not a result of premolar extraction.
  • Inquisitive
    commented 2020-10-10 06:07:19 -0700
    So, then the only way that what i mentioned below could happen to someone durung treatment is to severely narrow the maxilla. I suppose this is happening to this particular person’s mandible because the severe narrowing of the maxilla restricted the growth of the mandible. Would you agree?
  • Inquisitive
    commented 2020-10-10 06:04:03 -0700
    You’ll often find that the maxilla is extemely recessed in a class three patient.

    I said “the lower jaw falls open and swings back”. So down and back. You’re telling me that you don’t think that is possible from negligent orthodontics treatment?
  • Kim Henry
    commented 2020-10-10 05:54:52 -0700
    A mandible falling open does not “squash” anyone’s airway. When we are short on breath, we open our jaws to breathe, do we not?

    I would have that teenager imaged via CAT scan and examined by an ENT to find the true cause.

    You are wrong about class III. True maxillary retrognathism is very rare except in Asians. In Negroes and Caucasians, the problem is almost always an overly large mandible. We used to used chin-cups early to try to stunt mandibular growth but they never worked. To this day we cannot retard the growth of someone showing a tendency to mandibular prognathism. It is a highly heritable trait. Almost always one parent, or at least one grandparent, has the trait.

    Restraining mandibular growth is very difficult. Potentiating possible growth via unlocking a deep bite is easier.
  • Inquisitive
    commented 2020-10-10 04:13:40 -0700
    “IF WE COULD, WE WOULD PREVENT CLASS III PROGNATHISM. Everything we have tried to stem that seems to have failed!”

    Generally a class three patient doesn’t have a mandible which is too large – that’s the case sometimes, but rare. Generally the maxilla is narrow and set back.

    Do you think it is possible for poor extractuon treatment to force the mandible back? And do you think it is possible for extraction treatment to go so wrong that a 15 year teenager complains midway through treatment, that when lying on his or her side during sleep, the lower jaw falls open and swings back, squashing that teen’s airway? And if you do think it is possible, what are some of the likely causes?
  • Kim Henry
    commented 2020-10-09 18:38:08 -0700
    Orthodontic treatment, poor or not, has a limited ability to affect antero-posterior growth. Growth potential is mostly genetically determined. Lateral growth is one thing that can be influenced by tongue posture. Premaxially growth can be potentiated by thumb-sucking.

    That being said, I recently encountered a boy whose maxilla was overly expanded by a Hyrax by trying to do orthodontics non-extraction. The damage is irreversible. That case is an outlier, though.

    A natural deep bite has a greater tendency to restrict mandibular development than anything we do orthodontically. If we get lucky, when we unlock deep bites, sometimes we see mandibular growth forward. But not always. One can never know what genetic growth potential the kid had. If both parents were retrognathic, you’d better do some praying.

    Headgear was never applied to the mandible. We can only potentiate genetically programmed growth in the mandible by unlocking deep bites. We cannot do much to restrict mandibular growth. IF WE COULD, WE WOULD PREVENT CLASS III PROGNATHISM. Everything we have tried to stem that seems to have failed!
  • Inquisitive
    commented 2020-10-09 17:14:48 -0700
    Do you agree or disagree that poor orthodontic treatment has the abiliity to negatively effect growth? Do you agree or disagree that poor orthodontic treatment has the ability to push a mandible too far back?
  • Kim Henry
    commented 2020-10-09 16:07:44 -0700
    I am not trying to “defend” anything. I am debunking hocus-pocus blame games.

    There are a lot of factors that go into the final shape of a patient’s face and airway. The top ones are genetics and allergies. You seem to forget that ugly smiles are debilitating to many people. They want them improved. The fact is we cannot always fix ugly smiles without extractions. The way to REALLY retard the maxilla would be not to extract teeth, but to try to distalize the molars via 24 hour headgear. Which would you want? Pick your poison. That is why distalization headgear was so rarely tried back when I started doing fixed cases.

    Plenty of people have sleep apnea and other airway problems who have never had orthodontics. It is impossible to know in a particular patient whether orthodontics contributed to airway problems or not. The closest thing we can do is look at airway space on x-ray pre-op, then look at it post-op to see if there are any changes. Rarely do I see any.

    “Children and adults know their bodies. A 7 year old is extremely aware, often more so than an adult. "

    This is pure nonsense. No 7 year olds can understand their orthodontic diagnosis, or even have a clue what caused their ugly smile. All they know is they have an ugly smile and are teased by other children. And they usually want it corrected. And it can’t always be corrected non-extraction. Even IF orthodontics caused airway restriction, the average kid with ugly teeth would want it corrected.

    When I comment, I am referencing about the standard of care in the US. I have to admit relative ignorance of the standards in the UK. From what I have seen, it appears like the Brit orthodontic standard of care, particularly under NHS, is far below that of in the US.
  • Inquisitive
    commented 2020-10-09 11:38:41 -0700
    Thank you for; “You completely misunderstand what is happening in orthodontic mechanics. You actually do not have a clue what is going on from reading website drivel”

    That makes me understand your ignorance.

    Personally, i have reviewed the orthodontic literature, papers on the importance of space closure technique and mechanisms, what can go wrong during space closure technique, how this can then inpede on growth, how the maxilla can held back from growth or pushed back during growth or after, how bone loss effects growth, how elastics can pull a maxilla down and back, the link between the maxilla and nasal cavity, the importance of nose breathig etc. I’ve read books, spoken to professors. I’ve also seen a case where by a child’s face was completely destroyed in a matter of 6 months from too much pressure being put on the maxillae and how the elastics pulled maxilla back into the face of a 14 year old boy. This child was then diagnosed with sleep apnea and he is being offered no help to put this case right.

    Extractions will always cause some kind of damage, but if handled correctly, the damage will be negligible. They will always narrow a palate. Non extraction treatment can also be harmful.

    There are few studies on whether the damage is a direct cause of the narrowed arches and bone loss, but we do know that bone loss and a narrow arch has some negative effect on growth. Its not rocket science. This is biology.

    You’ve builled these people on here instead of trying to help them. People, ‘professionals’ who defend themselves in this way are not generally interested in further education but rather their ego. I am not sure what you are trying ro achieve.

    Children and adults know their bodies. A 7 year old is extremely aware, often more so than an adult.

    You are very aware of what damage CAN be caused by treatment, so stop defending it and let these people express themselves and allow others to learn from their experiences, to enable them to make informed decisions about their future treatment.
  • Kim Henry
    commented 2020-10-08 17:35:41 -0700
    We don’t typically retract anterior teeth in an extraction case unless they are demonstrably procumbent and the patient is unhappy with them that way. We extract teeth to decrowd the anteriors, not retract them. Once aligned, we “burn anchorage” by moving molar teeth forward, if there is any leftover space. We don’t retract molars like you keep saying we do. Molars usually end up going forward in extraction cases. These days we anchor molars during decrowding via transpalatal arches and TADs and not headgear.

    You completely misunderstand what is happening in orthodontic mechanics. You actually do not have a clue what is going on from reading website drivel.

    Nothing is clear from the above photos of the twins. To understand what has happened, we would need traced cephalometric x-rays.
  • Kim Henry
    commented 2020-03-31 15:21:33 -0700
    You and politicians are not competent to judge whether children need orthodontics or what type they may have, despite the inflated knowledge you think you gained from reading this website. You may pursue your former orthodontist in a court of law if he is still alive.
  • Alexander Illi
    commented 2020-03-31 08:05:16 -0700
    Kim, you are trying to talk a simple matter to death, in a manner reminiscent of psychological harrassment.
    I had healthy teeth, and no-one complained about them before the dentist.
    I may petition lawmakers for whatever I like.
    If you continue addressing me here, I will treat is as stlking attempt.
  • Kim Henry
    commented 2020-03-30 18:56:03 -0700
    Again, a positive overbite and overjet are normal. You still are confused about terms.

    I cannot Monday morning quarterback without examining your treatment records pre- and post-op. You do not clearly say whether you were maxillary prognathic or mandibular retrognathic or neither.

    Esthetics cannot be internationally legislated, as beauty varies from culture to culture. There is a trip in Africa that extracts the lower permanent incisors on all boys and thinks it looks great.

    So you think governments should legislate orthodontic treatment? Wow, you have a lot of faith in government that you think it should supervise lower craniofacial esthetics.

    If you have photos of your childhood “perfect teeth,” why not post them? Please include occlusal mirror shots of the upper and lower arches, as well as mirror views of both sides. Front smile views alone do not tell much.
  • Alexander Illi
    commented 2020-03-30 03:37:45 -0700
    The dentist proposed to my mother, that I had an overbite and “would not look well” when I became adult. That’s why I’m here – I don’t want dentists to be allowed to suggest such interferences to parents, when there are no medical reasons*. My mum was very busy, a little bit distracted maybe due to her large work load, and just trusted the dentist, so she gave her consent. A few years later, I myself would have vigorously objected to such a treatment, but at about ten years of age I was not mature enough to do so.

    Now, I don’t even have an overbite, my front row of teeth meet head-on.

    *In my opinion, medical reasons have to be legally defined internationally, before treatments of children are allowed to be suggested to parents or caretakers.

    I have childhood fotos to prove that I had perfect teeth.
  • Kim Henry
    commented 2020-03-26 18:27:34 -0700
    If you did not have crooked or crowded teeth, why did you parents seek orthodontic treatment for you? A phenomenon called “mesial drift” during life tends to close spaces and create crowding as time goes on. This happens with or without orthodontics.

    Everyone has overbite. They should. Our treatment goal in orthodontics is 2mm overbite and 2mm overjet.

    One person’s “natural” smile is another person’s “hideous” smile. Parents often ask me if their child “needs” orthodontics. I tell them nobody has ever died from crooked teeth. So if they and their child wants straighter teeth, I can help them. SOMETIMES it takes extractions to do this.
  • Alexander Illi
    commented 2020-03-25 05:02:05 -0700
    Kim, I didn’t have crooked or crowded teeth – now I have crowded teeth, pulled together by the brace, so that no tooth silk will fit in between. Please stop throwing my experience together with whatever random allegations you have. It seems you didn’t have patience to read my comments correctly – since the beginning you are accusing me of things I did not write.

    BTW, I’m not one of those who like a standardized ideal of beauty, I personally found slighty irregular teeth (to a certain extent) attractive – and I never spoke of clinical cases with extraordinary deformities, but about obviously lacking standards for “aesthetic” orthodontics.
    I was speaking about a healthy boy (me) with a miniscule “overbite”.
  • Kim Henry
    commented 2020-03-24 19:00:06 -0700
    So you call orthodontics “unwarranted mutiliation of minors?” So parents who want their kid’s smile to be attractive want their children MUTILATED? So you are saying parents are accessories to some crime???

    Tooth size/arch length discrepancy is a FACT. If you don’t believe it look at some of my pre-op casts. Some kids have large teeth and short jaws. You can gain SOME space by stripping and/or expansion, but not 9millimeters or more. Just not possible. A few months back I had a kid ruined by some goofball dentist like you idolize. He expanded the maxilla so much just to fit all the teeth in without extractions. Guess what? The kid’s mandible will never be as wide as his maxilla. There is NO WAY, even with surgery, to make upper and lower teeth fit. The parents are desperate. I had to tell them their kids lower face is ruined for life. All because of ignorance like the type you recite.

    You don’t want kids to be “mutilated” by orthodontics? Then convince parents that crowded, crooked teeth should not be a concern!
  • Alexander Illi
    commented 2020-02-27 23:34:03 -0800
    Aesthetic orthodontics ( extractions & braces ) are an unwarranted mutilation of minors, potentially none less disastrous in later life than the often maligned FGM (Female Genital Mutilation).

    They alter the facial structure enough to outwardly change the face form, which is the “reason” dentists and orthodontists prescribe it in the first place.

    The stunting of the jaws leads to slackened tissue in the whole oral and nasal area, e.g. the velum, which in turn can lead to chronically blocked airways (including a higher incidence of infections), snoring and on-set of sleep apnoe. Furthermore it can shove the teeth together, so that not even tooth silk will fit in between them, which is of course optimal for pathogens (bacteria etc.) to settle there. If the top row of teeth recedes, the nose will appear more jutting out, and the upper lip and the labial angle (upper mouth corners) will wrinkle earlier. Since a slight ‘overbite’ is a natural protection against the teeth hitting together, the lower jaw will be held receded, leading to the impression of a fleeting chin.

    For what “reason” are aesthetic orthodontics usually applied on children?
    The dentist tells the parents their child will be disfigured later. That’s basically all – even though they often use terms like “correction of an overbite” instead.
    Parents, being concerned about their childrens’ well-being, then usually agree to the professional advice. Then teeth get pulled out, and so on…

    It’s a perfect money-making device for dentists and orthodontists.

    All of theses have been my experiences, and the negative effects become more apparent once one gets older.

    As a child, I was trusting to have been born in more enlightened times, but basically it’s a system very well comparable to e.g. FGM practised in so-called primitive cultures.
  • Alexander Illi
    commented 2020-02-03 09:52:51 -0800
    Thank you, Kim.
  • Kim Henry
    commented 2020-02-02 18:41:00 -0800
    Alexander, if you “feel” your tongue is about 7mm too long, convince an oral surgeon to reduce the size. WARNING: It is a very difficult surgery.

    You may be in fact CARRYING your tongue further forward due to pharyngeal muscle collapse.

    It is impossible for extraction orthodontics with or without headgear to shorten the maxilla by 7mm. Sorry, just not possible.

    Treatment is not based on “feeling,” but facts. Have you traced your airway on a ceph x-ray or cone beam image? Have you compared pre and post treatment cephalometric films to assess the REAL changes by orthodontics? I have on many cases, and relative bone changes are usually very small.

    Finally, if you have missing teeth the tongue can enlarge by compensation, and this makes apnea more likely.
  • Alexander Illi
    commented 2020-02-01 23:32:58 -0800
    Dear Kim Henry,

    it was without addressing your earlier comments that I dropped by.

    Now that we are in conversation, however, I would first like to point out you made a strawman-argument:
    I have never stated “that sleep disorders are ALWAYS caused by small jaws”.

    Secondly, I would like to say that I already respect you a lot, since at least you are concerned about the topic, which is more awareness than the vast majority of orthodontists show.

    What I (and you) feel/perceive/deduct is not immaterial, it is all that counts for a person subjectively. But I know what you mean (if I may infer), i.e. that it might be illusionary.
    To that I can say that I have an excellent perception of the inner workings of my body (proprioception ASO) compared to the average, as I have seen again and again by my premonitions being confirmed by scientific studies later and by being alert earlier than others about infections spreading in a group and likewise situations (which you of course may say is due to deluding myself). Anyway, my tongue feels just about the ~7mm too long, that they have ripped out of my jaw. 7mm is enough to slacken the velum and compress the airways leading from the nose. I’m not old and tired, as you may see from my currently up-to-date profile pic.
  • Alexander Illi
    commented 2020-02-01 23:31:09 -0800
    So of course you may always discard my opinion as self-delusion, but then you’ll have to live only by scientific studies (good luck with studying the methodology of each and every one before you make any life-decisions ; ) or whatever ‘material’ evidence you go by. As a layperson, I don’t count that among my responsibility or practicability and neither will I blindly trust every word of the so-called white-clad demi-gods, i.e. orthodontists etc., as I have achieved an academic degree myself and thus surely know that this does not imply anyone being omniscient or free of bias in their respective fields.

    Thank you for your concerned question about an ENT check-up, but I’m living in rural Africa without health insurance and with minimal income from agroforestry and some support from my mum, married, with three sons, and only visit Europe very briefly every few years to help my mum with repairs, maintenance and such issues, where I’m also not insured…
  • Alexander Illi
    commented 2020-02-01 23:28:50 -0800
    (OK, must be character limit, so I’m a gonna chop this up : )

    I simply had an ever-so-slight “overbite”, that never caused me any discomfort – I’m actually sure it’s a common evolutionary adaption, that in case of concussions to the head (accidents, fights…) the incisors don’t meet head-to-head and break. Basically the same reasons that the spine in never perfectly symmetric, if you have been following recent scientific developments.
    Now my lower yaw is permanently instinctively retracted to avoid the incisors meeting head-on, which is an involuntary adaption since after the ‘ortho’-dontic ‘treatment’.

    I was also a perfectly normal and even handsome lad, but the dentist told my mother I’d be disfigured later. (At a school inspection, BTW, they also told my mum I had flat feet, which is also not the case at all, and sent me to an orthopedician – if not my mum’s feet had been totally destroyed by ‘orthopedic’ insoles and ‘treatments’ in her infancy, she might have also believed that and consented to insoles for me).

    If you really wish to go into my allegations without debating strawmen, then I’d be interested in what you perceive as a fundamental difference between ripping out a healthy boy’s teeth and e.g. FGM (Female Genital Mutilation) in primitive cultures.
  • Alexander Illi
    commented 2020-02-01 23:26:24 -0800
    Hi Kim, seems I can’t post comments, or there may be a limit of length, so I just try with this test-comment.
  • Kim Henry
    commented 2020-02-01 05:53:56 -0800
    The allegation that sleep disorders are ALWAYS caused by small jaws is not correct. There are many causes- low draping soft palate over tongue, overly large tonsils, overly large tongue resulting from tooth loss, and tired old muscles that don’t hold the pharynx open are a few. It is LUDICROUS to blame it all on improperly formed jaws from faulty orthodontics. What you “FEEL” is immaterial. Have you had any imaging done by an ENT of your airway.
  • Alexander Illi
    commented 2020-01-31 22:11:53 -0800
    You have nailed it. However, you’ve couched your allegations in too conservative terms when it comes to “aesthetic” extractions & braces: they are a mutilation of minors, whom are too young to object.
    My tongue feels crammed in and my nostrils are constantly somewhat flared to compensate for the tightening of the airways. (Heck, I would look even better without that ‘treatment’ my dentist arbitrarily decided on, when I was about 10 years old. She had trouble getting my very strong teeth out, BTW). I do oral interior muscle exercises to keep the slackened muscles under control, as not to start snoring. Apnoe is a gradual killer.

    If I could afford it, I would get braces again to reverse the damage, as my friend has done.
    …at least her children have afforded a big house right after she died.

    All for unasked-for subjective ‘aesthetic’ reasons of dentists and orthodontists – I didn’t know they have all studied visual arts.
  • Kim Henry
    commented 2020-01-31 05:33:03 -0800
    Those photos might be of identical twins, but the one on the left appears to have a narrower skull at the outset. Both have attractive smiles in the second photos. The difference is not “profound.” So what is your beef?

    I have had identical twins in the practice that grew differently even with no orthodontics. Life is like that sometimes; nobody knows why.
  • Kim Henry
    commented 2020-01-31 05:10:34 -0800
    We do far fewer extraction cases than we have in the past. One reason is we have some orthodontic mechanics now that did not exist before. But not every arch can be expanded to fit all the teeth.

    I got news for you: even when the wisdom teeth can all be erupted, the gums usually are not healthy around them. Food impaction frequently causes decay on the back of the second molars, sometimes dooming them. It is a rare patient that can maintain wisdom teeth.

    Modern jaws are shorter than human jaws 100,000 years ago. That is a fact. The upper cranium enlarged to accomodate a larger brain, and the jaws were shortchanged in size. Sometimes it is impossible to fit all the teeth in jaws of patients. There is a limit to growth and expansion.

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