L7 InsertionImmediate

Complete Dentures¹

Preclinical

Insertion, Post-Operative Review & Immediate Dentures²

Complete Denture Overview

Treatment Schedule

Visit	Operator	Procedure
Visit 1	Clinician Laboratory	Patient evaluation & primary impressions Diagnostic casts & special trays
Visit 2	Clinician Laboratory	Secondary impressions Bead & box, master casts, base & rims
Visit 3	Clinician Laboratory	Contour rims, OVD, MMR, shade & mould selection Articulation & tooth setting
Visit 4	Clinician Laboratory	Wax try-in Finalisation & processing
Visit 5	Clinician	Assessment & issue Instructions for care
Visit 6	Clinician	Post operative review, post insertion instructions

Note

The topics discussed constitute the fifth visit in the standard treatment schedule for complete dentures. This visit involves two primary tasks:

1. Assessment: The dentures are checked for fabrication quality, fit, function, and aesthetics before being issued to the patient.
2. Patient Education: The patient is instructed on the use, care, and functional limitations of their new dentures.

Assessment & Issue³

Extra-oral Examination of Dentures

Intra-oral Examination of Dentures

Instructions to the Patient⁴

Assessment & Issue³

Extra-oral Examination of dentures

1. Sharp projections and acrylic nodules

• Check the intaglio (tissue) surface for any rough edges that could cause discomfort or ulceration.

2. Sharp edges
3. Over-extension into bony undercuts

• Ensure there are no overextensions which could cause abrasion lesions during insertion or removal.

4. Hand relate dentures to confirm stable occlusion

• If the dentures can be rocked while held in occlusion, a premature contact is likely present and needs adjustment.

Assessment & Issue³

Intra-Oral Examination of Dentures

1. Check extension, retention and stability
   • psychologic comfort
   • physiologic comfort
   • longevity
   • Check retention
   • Check lateral stability
   • Check A – P stability

• Retention: This is the resistance to dislodgement in a direction perpendicular to the residual ridge.
  • Test: Grasp the anterior teeth of each denture and pull away from the ridge. There should be noticeable resistance.
• Stability: This is the resistance to horizontal or lateral displacement.
  • Lateral Stability Test: Press alternately on the occlusal surfaces of the posterior teeth in each quadrant. The contralateral side should not lift or displace.
  • Anteroposterior Stability Test: Apply pressure to the incisal edges of the anterior teeth. There should be no displacement.

Note: The image OCR text was prioritized. The PDF text provided context for the structure and terminology used in the image, confirming the headings and key assessment points. The Venn diagram was described as an image since it contains sparse text and visual elements.

Assessment & Issue³

Intra-Oral Examination of Dentures

1. Check extension, retention and stability
2. Evaluate aesthetics
   • Form, colour & contour of teeth
   • Midline

• The upper and lower dental midlines should coincide with each other and be parallel to the facial midline.

  • Lip line
  • Smile line
  • Buccal corridor

• A natural-looking space should be visible between the cheeks and the buccal surfaces of the posterior teeth when the patient smiles.

• Tooth Display

  • Check the amount of tooth visible at rest and during a full smile.

Assessment & Issue³

Intra-Oral Examination of Dentures

1. Check extension, retention and stability
2. Evaluate aesthetics
3. Evaluate phonetics
   • Posterior border of denture
     • /ah/ sound establishes the vibrating line and thus the posterior extension of the denture
   • Occlusal vertical dimension
     • Distinct /s/ sound helps establish correct OVD

• ==When making sibilant sounds like

  - With insufficient vertical height /p/ and /b/ will be affected
  - With too great an OVD opposing teeth will click together
  

  • Height of the anterior teeth (and thus the occlusal plane)
    • Inability to enunciate /f/ or /v/ sounds indicates that the anterior teeth are either too far above or below the functional plane of occlusion
  • Overjet
    • May be established by using the /s/ sound
  • Labiolingual position of the mandibular anterior teeth
    • A lisp in the /s/ sound indicates that the teeth are placed too far lingually
  • Thickness of the anterior region of the palate
    • A lisp with the /t/ sound indicates excessive thickness
  • Thickness of the posterior palatal seal
    • Excessive thickness may cause difficulty in saying /g/

Assessment & Issue³

Intra-Oral Examination of Dentures

1. Check extension, retention and stability
2. Evaluate aesthetics
3. Evaluate phonetics
4. Evaluate occlusion
   • Centric occlusion (intercuspal position)

• There should be intimate intercuspation and even contacts. Use articulating paper to confirm.

  • Eccentric movements
  • Occlusal vertical dimension

Assessment & Issue³

Intra-Oral Examination of Dentures

Remount Procedure (if required)

1. Check extension, retention and stability
2. Evaluate aesthetics
3. Evaluate phonetics
4. Evaluate occlusion
   • Occlusal vertical dimension

• Interocclusal Clearance (Freeway Space): ==Should be between 2-5 mm. The

  • Centric occlusion
  • Eccentric movements

• Check for even contacts during lateral and protrusive movements, ensuring no premature contacts exist.

5. Occlusal adjustment (not normally required at insertion appointment)

Info

If the preceding fabrication stages were done carefully, major adjustments should not be necessary.

Balanced occlusion: Bilateral, simultaneous, anterior, and posterior occlusal contact of teeth in centric and eccentric positions. Balanced occlusion in complete dentures is unique, as it does not occur with natural teeth.

Assessment & Issue³

Instructions for Care

• Insertion and removal of dentures
  • ✔️ Rinse mouth out before putting dentures in.
  • ✔️ Press upper denture against the roof of mouth.
  • ✔️ Fit lower denture onto lower gums.
  • ✔️ Bite down a few times to press the dentures into place
• Limitations of the dentures

Patient Expectations

Dentures are an alternative to being edentulous, not a perfect substitute for natural teeth. An adjustment period of a few weeks to several months is normal.

• ✔️ Adjustment period required (Habituation)

  • i. Initial feeling of bulk – will pass with time
  • ii. Practice reading aloud (10 – 15 mins per day)
  • iii. Hypersalivation (swallow frequently)

• ✔️ Difficulty with eating

  • i. Soft diet
  • ii. Cut food into small portions
  • iii. Chew with posterior teeth (bilateral mastication)
  • iv. Avoid sticky foods (espec. chewing gum)

• ✔️ Risk of breakage (espec. with mishandled lower denture)

• ✔️ Retention issues

  • i. Dental adhesives may be helpful

• Adhesives may be used initially to help build confidence in denture retention.

• Expected tissue response

  • ✔️ Short term
    • i. Initial discomfort
      • ➤ Remove denture(s), replace when settled
      • ➤ Do not self-adjust
    • ii. Ulceration or severe soreness
      • ➤ Discontinue use & make urgent appointment for remediation
  • ✔️ Long term
    • i. Moderate to severe alveolar resorption

• Risk of breakage

  • Dentures can break if dropped on a hard surface or if the lower denture is gripped across its heels when outside the mouth.

• Care of the prosthesis and tissue

  • ✔️ No night wear (or 8 hours respite every 24)
  • ✔️ Store overnight in fresh cold water (+/- cleanser tablet)
  • ✔️ Clean after every meal where possible
  • ✔️ Use soft brush and non-abrasive soap (no toothpaste)
  • ✔️ Enzymatic soaking denture cleaner weekly

• Desirable follow-up treatment

  • ✔️ Proper daily care
  • ✔️ Routine dental visits – wear denture before any review appointments
    • i. 24 hour check
    • ii. One week follow-up (with subsequent weekly visits until symptom free)
    • iii. Annual reviews
  • ✔️ Maintenance as needed

Post-Operative Review⁵⁶

24 Hour Check

Scheduling

Schedule the insertion and 24-hour review appointments at the same time to ensure availability. Avoid scheduling insertions on a Friday.

• Inquire about patient’s problems
• Conduct a thorough examination
• Check the denture for pressure areas and adjust as needed with PIP or Fit-Checker
• Check borders for overextension and adjust as needed
• Evaluate occlusion, refine as necessary and recheck, finish and polish
• One week follow-up (and subsequent weekly visits until comfortable)

Post-Operative Review⁵⁶

Common Problems

1. Pain
2. Loss of retention and/or stability
3. Difficulty chewing
4. Nausea
5. Noise on eating and speaking
6. Poor aesthetics
7. Problems relating to speech

Post-Operative Review⁵⁶

1. Pain

History:

• How long has the pain been there?
• Does the pain disappear after the dentures are removed?
• Is the pain specific to a certain area or is it widespread?
• Does the pain only occur during insertion and removal of the dentures?
• Is the pain continuous whilst wearing the dentures, or does it increase only at certain times – such as when eating?

Post-Operative Review⁵⁶

1. Pain

May be:

• a. Localised (in a specific region of the supporting tissues)
• b. Generalised (involving a major part of the supporting tissues)
• c. Diffuse (involving all of the supporting tissues)
• d. Resulting from lip or cheek biting
• e. Pain in the tongue
• f. Pain that occurs at the TMJ

Post-Operative Review⁵⁶

1a. Localised Pain

Appears in a specific region of the maxillary or mandibular dentures and can be due to:

• Over-extended denture flanges
• Deeply or sharply prepared posterior palatal seal area
• Irregularities on the tissue surface of the denture
• Premature occlusal contacts
• Excessive undercuts on the denture bearing area
• Irregularities and/or thin mucosa along the alveolar crest
• Possible pathologies of the supporting tissues – such as tori
• Pressure over the mental foramen following crestal resorption

Post-Operative Review⁵⁶

1b. Generalised Pain

Involves a major part of the supportive tissues and manifests as hyperaemic areas. It may be due to:

• The existence of thin mucosa
• Reduced salivary flow, which may be due to:
  • Age-related salivary gland atrophy
  • Radiation therapy of the head and neck
  • Systemic diseases (diabetes mellitus, chronic nephritis, uraemia, Sjogren’s syndrome)
  • Drugs (either prescribed or recreational)
• Anatomical defects on the alveolar crests
  • Sharp margin of mandibular alveolar crest
  • Prominent genial tubercles

Post-Operative Review⁵⁶

1c. Diffuse Pain

Involves all of the supportive tissues and manifests as fiery red hyperaemic areas. It may be due to:

• Excessive occlusal vertical dimension.
• Patient’s allergy to Methyl Methacrylate.
  • Allergic reactions usually originate from the presence of excess monomer due to insufficient polymerisation or from acrylic resin pigments.
  • Allergy is commonly confused with denture stomatitis. An allergic reaction manifests soon after placement of a new denture, but denture stomatitis only occurs after a long period of denture use.
  • True denture allergies are very rare. If antihistamines are given to the patient and the symptoms resolve, then an acrylic allergy should be suspected. This can be confirmed by a patch test.

Post-Operative Review⁵⁶

1d. Pain due to biting

May be due to:

• Excessive interocclusal space
  • Occurs with an over-closed occlusal vertical dimension. Until the chewing muscles adapt to the new height the lips or cheeks may be bitten during function.
• Lack of posterior overjet
  • The buccal surfaces of the lower posterior teeth need to be re-arranged, by grinding if the discrepancy is small, or by repositioning if the discrepancy is large.
• Cheek impactions due to posterior baseplate contact
  • This often is best managed by thinning of the upper baseplate
• Existence of cross-bite
• Anterior teeth in an edge to edge position
• Teeth outside of the neutral zone

Post-Operative Review⁵⁶

1e. Pain the Tongue

May be due to:

• A rough lingual surface of the mandibular denture or irregular areas on the mandibular teeth
  • Irregularities should be ground away and the denture repolished
• Mandibular teeth lingually positioned
  • When tongue space is reduced there may be tongue pain related to cramps
  • If the lingual displacement is excessive, or the occlusal plane too low, the tongue may be bitten
• On very rare occasions, where a diastema has been created between the lower incisors in response to a patient’s request, the result may be pain along the anterior edge of the tongue.
  • If the existence of the diastema is non-negotiable then the addition of some transparent acrylic resin may solve the problem

Post-Operative Review⁵⁶

1f. Pain in the TMJ

Is generally caused by:

• Insufficient interocclusal clearance (freeway space) due to inaccurate jaw relation records.

Post-Operative Review⁵⁶

2. Loss of Retention & Stability

A complaint of “loose” dentures can be due either to a loss of retention or of stability.

Retention is resistance to displacement in a direction opposite to that of insertion Stability is resistance to horizontal displacement

Retention can be maximised by :

• Covering the entire denture-bearing area
• Having minimal space between the denture and the tissue
• Having optimal viscosity of the saliva

Loss of retention may be due to:

• Physiological reasons
  • Loss of weight
  • Diabetes or periodontal disease
  • Tumours
  • Hyposalivation
• Anatomical problems
  • Presence of excessive undercuts in the denture bearing area
• Clinical errors

Post-Operative Review⁵⁶

2. Loss of Retention

Maxillary Denture

Loss of retention most often due to:

• Lack of peripheral seal at:
  • Posterior palatal seal
    • Test by addition of impression compound or impression wax
  • Buccal and labial flanges
    • Over-extension will result in pain rather than movement
    • Test for under-extension by addition of impression compound
• Lack of intimate tissue contact
  • Test with Fit-checker
• Hyposalivation
  • Test with artificial saliva

Post-Operative Review⁵⁶

2. Loss of Retention

Mandibular Denture

Loss of retention most often due to:

• Overextended labial and buccal flanges
  • Test for over-extension by gentle stretching of fraena areas
• Over-extended lingual flanges
  • Test by guiding patient through specific tongue movements
• Technical problems causing lack of intimate tissue contact
  • Test using Fit-checker, rebase if necessary

Post-Operative Review⁵⁶

2. Loss of Stability

• Teeth placed along an inclined alveolar ridge (e.g. retromolar pad)
• Premature occlusal contacts
• Use of teeth with high cuspal angles on atrophic alveolar ridges
• Position of artificial teeth
  • Incisors
  • Molars
  • Occlusal Plane
• Faults in polished surfaces – generally should be concave
• Anatomical reasons – such as tori or excessively resorbed alveolar ridges
• Physiological reasons
  • Difficulty with habituation
  • Drugs
  • Systemic diseases

Post-Operative Review⁵⁶

3. Difficulty Chewing

• Lack of denture experience
  • Patient needs time to develop the necessary muscular control
• Incorrect position of occlusal plane
  • Should be a few mm below the back of the resting tongue
• Excessive occlusal vertical dimension
  • Causes problems with manipulating the food bolus
• Reduced occlusal vertical dimension
  • Results in reduced chewing force
• Lack of balanced contacts in occlusion
  • Lack of balance prevents efficient chewing of food
• Pain in the denture-bearing area
  • Causes reluctance to chew

Post-Operative Review⁵⁶

4. Nausea

The glossopharyngeal nerve is responsible for the gag reflex and innervates the posterior third of the tongue and soft palate.

With maxillary dentures the gag reflex may be initiated if:

• The posterior border of the upper denture is overextended
• The posterior denture base is thicker than normal
• The denture lacks retention and moves under function
• The occlusal vertical dimension is over-closed and the tongue is in constant contact with the upper denture
• Premature occlusal contacts cause the dentures to drop during function

Post-Operative Review⁵⁶

4. Nausea

With mandibular dentures the gag reflex may be initiated if:

• The denture has insufficient tongue space
• The denture base is over-extended in the posterior tongue region
• There is insufficient interocclusal clearance
• The teeth are positioned away from the neutral position and/or there is an excessively bulky denture reducing tongue space
• Premature occlusal contacts cause the dentures to drop during function

Post-Operative Review⁵⁶

5. Noise on Eating & Speaking

Noise can occur as a result of premature contacts of teeth.

There are four main reasons for dentures causing noise:

• Lack of retention of either denture
• Excessive occlusal vertical dimension
• Cuspal interferences
• The use of porcelain teeth

Post-Operative Review⁵⁶

6. Poor Aesthetics

Aesthetic problems are generally a result of not taking sufficient care at the trial insertion stage. Generally, the complaints fall into these categories:

Info

These problems constitute about 16% of post-insertion issues.

• Unsatisfactory lip and face support – either too great or too little
• Incorrect occlusal vertical dimension - either open or closed
• Reduced height of lower third of face
• Colour, size and shape of teeth
• The visibility of the teeth

Post-Operative Review⁵⁶

7. Problems Relating to Speech

Patients need time for habituation when receiving a new denture. During this period some sounds may be pronounced incorrectly, such as:

• The “s” sound – which is produced by the passage of air through the small space between the tongue and the anterior palate. Lisping means the space is too small.
• The “t”, “d”, “l” & “r” sounds – which rely on the ability of the dorsum of the tongue to seal against the posterior palate.
• The “p”, “b”, “m”, and “n” sounds – which are verbalised while the upper and lower lips are touching each other.
• The “f” and “v” sounds – which is caused by incorrect antero-posterior position of the maxillary incisors relative to the lower lip
• The “g” and “k” sounds - which are articulated when the dorsum of the tongue is in contact with the posterior palate. A denture that is thick in this area may cause this problem.

Immediate Dentures⁷

Preclinical

Complete, Partial & Implant⁸

Immediate dentures⁹

Any fixed or removable dental prosthesis fabricated for placement immediately following the removal of a natural tooth/teeth

• Use of immediate dentures to follow the removal of natural teeth is not new (Richardson 1860)
• Today the procedure is increasingly demanded by an appearance-conscious public

This may include:

• ✓ Complete dentures
• ✓ Partial dentures
  • i. Removable partial dentures
  • ii. Fixed prosthesis
• ✓ Implant supported or retained prostheses

Immediate dentures⁹

Advantages

• Prevent patient embarrassment
  • ✓ Insert at time of tooth extraction
• Promote patient health
  • ✓ Prevent prolonged retention of diseased teeth
• Provide guide for optimal aesthetics
  • ✓ Can copy the form, size, colour & arrangement of the natural teeth
• Provide guide for occlusal vertical dimension
  • ✓ Remaining natural teeth may act as a guide
• Promote better healing
  • ✓ Denture acts as a surgical stent
• May promote better ridge form
• Prevent collapse of facial musculature
• Hasten patient adaptation to dentures

Immediate dentures⁹

Disadvantages

• Increased complexity of clinical procedures
  • ✓ Presence of natural teeth may compromise impression making
    • i. Mobile teeth – risk of involuntary extraction
    • ii. Deep undercuts
  • ✓ Record bases around natural teeth generally less stable and retentive
  • ✓ Natural teeth may prevent closure in centric relation
• Limited evaluation of trial dentures
  • ✓ Aesthetic and phonetic qualities limited by presence of natural teeth
  • ✓ Impedes clinical evaluation of any desired positional change of anterior teeth
• Increased patient discomfort
  • ✓ Combination of post-extraction pain with possible denture-related trauma
• Increased denture maintenance
  • ✓ Rapid resorption for one month post extraction
  • ✓ Moderate resorption for next five months
  • ✓ Eight to twelve further months before residual ridge becomes more stable
• Increased number of patient visits
  • ✓ Due to patient discomfort and continuing changes in ridge contour
• Increased treatment cost
  • ✓ Increased complexity of clinical procedures
  • ✓ Increased number of patient visits
  • ✓ Increased need for denture maintenance
    • i. Soft liners
    • ii. Relines

Immediate dentures⁹

Contraindications

• Radiation therapy to head & neck may be a contraindication
• Any systemic condition that adversely affects blood clotting, wound healing or tissue regeneration
• Aged or medically compromised patients who cannot tolerate multiple extractions
• Excessively mobile teeth and large abscesses that require surgical drainage
• Psychological disorder or diminished mental capacity
• Patient who does not want the increased discomfort, time and expense

Immediate Complete Dentures¹⁰¹¹

Clinical Procedures

Examination & Diagnosis

• Thorough visual, digital & radiographic examinations
• Assess patient expectations re aesthetics & function
• Where indicated arrange pre-prosthetic surgery prior to preliminary impressions
  • ✔ Tuberosity reduction
  • ✔ Tori reduction
  • ✔ Displaceable redundant tissue
  • ✔ Labial/buccal frenula (or at time of anterior tooth removal)

Immediate Complete Dentures¹⁰¹¹

Clinical Procedures

Treatment Planning (2 phase schedule preferred)

• Single-Stage Treatment

  • An impression is made, jaw relations recorded, and at the next visit, all remaining teeth are extracted and the denture is inserted. This often requires more post-insertion adjustments.

• Stage 1

  • ✓ Removal of posterior teeth - can retain first premolar as centric stop if needed
  • ✓ Fabricate interim RPD
    • i. Impression at 7 – 14 days after extraction of posteriors
    • ii. Allows chewing on posterior teeth, rather than just anteriors
    • iii. RPD teeth support musculature of lips and cheeks – muscle memory
    • iv. Provides learning period and eases transition to complete denture
    • v. A failed remaining tooth can be easily added to the denture
  • ✓ Residual ridge healing – at least 6 months
  • ✓ Impression for definitive denture and fabrication of surgical stent

• Stage 2

  • ✓ Removal of anterior teeth at the time of complete denture placement
  • ✓ Maintenance as required

Immediate Complete Dentures¹⁰¹¹

Clinical Procedures

Impression Techniques

• Stage 1

  • ✓ Stock impression trays

• Stage 2

  • ✓ Custom impression trays

• One-Piece Tray: Can be used if there are no significant bony undercuts.

  • Two-Piece Combination Tray: Used when undercuts are present. The first section captures the edentulous areas and periphery, while the second section, with relief over the teeth, statically records the remaining teeth.

  • Split Tray: Used when only anterior teeth remain. The tray is split, and the impression is taken in two parts (palatal first, then labial) and reassembled outside the mouth.

  • ✓ Combination impression technique

  • ✓ Sectional tray technique

Immediate Complete Dentures¹⁰¹¹

Clinical Procedures

Risk Mitigation during Impression-making

• block undercuts in bridges (blue-wax, bite registration paste, alginate)
• splint mobile teeth if necessary (composite/fiberglass reinforcements)
• consider if extraction is more suitable

Immediate Complete Dentures¹⁰¹¹

Clinical Procedures

Maxillo-Mandibular Relationship Records

• Sufficient Natural Teeth: If enough teeth remain to provide a stable intercuspal position at the correct OVD, a PVS bite registration can be used.

• Insufficient Tooth Contacts: If large edentulous areas exist, occlusal rims on accurate baseplates are required.

• The recording technique used will depend on the distribution of the remaining natural teeth

• Determine appropriate occlusal vertical dimension

• Where there are insufficient occlusal stops an accurate baseplate is required

  • ✅ Extend base onto palatal and lingual surfaces of remaining teeth where possible
  • ✅ Use ball clasps for retention
  • ✅ Use of mesial hooks where possible to help resist posterior displacement of baseplate

• Record the occlusal plane and required degree of lip support

• Notched wax rims used in edentulous areas

• Facebow record

• Centric relation record

• Tooth Selection

• Measure pocket depths on remaining teeth (used to guide cast trimming in lab)

• Post-operative instructions given to patient prior to denture insertion

Immediate Complete Dentures¹⁰¹¹

Laboratory Procedures

Arrangement of Anterior Teeth

Note

The goal is to remove only as much of the stone cast as is essential to place the artificial teeth.

• Primary aim is preservation of alveolar bone

• Cast trimming is aided by marking the pocket depths on the cast and drawing a line through them

  • ✓ If arrangement of the natural tooth is to be copied, denture teeth are set individually

• To do this, socket and set alternate teeth one by one.

  • ✓ For deep pockets around the remaining teeth the cast is reduced prior to tooth arrangement
  • ✓ Correct placement of necks of teeth and minimal bulk in flange area contribute to patient comfort
  • ✓ With a correctly trimmed cast only minor osseous reduction is needed at the time of surgery

Immediate Complete Dentures¹⁰¹¹

Laboratory Procedures

Fabrication of Clear Surgical Template

• Can either be heat processed acrylic or vacuum-formed stent
• Made from an alginate impression of the trimmed cast
• Facilitates accurate bone trimming at the time of surgery
• Palatal hole facilitates seating and allows clinician to check that the template is fully seated

Using the Template

When pressure is applied to the seated template, blanching of the soft tissue indicates high spots that need further osseous reduction.

Immediate Removable Partial Dentures¹²¹³¹⁴

Info

These follow the same design principles as immediate complete dentures. Teeth that are to be retained must be adequately restored before denture fabrication.

Clinical Example

1. Hopeless maxillary teeth were identified for extraction, while sound teeth (e.g., 13, 15, 16, 24, 26) were retained.
2. Jaw relations were recorded and an interim acrylic partial denture was fabricated.
3. The hopeless teeth were extracted, and the interim denture was inserted.
4. After a six-month healing period, a definitive prosthesis (in this case, an implant-supported partial) was made.

Thank You¹⁵¹⁶¹⁷

Thank you for your attention.

Any questions? Contact me

Dr Ian Lander ian.lander@uwa.edu.au

Contact me

If you have any questions, please contact me at the email address below.

Dr Ian Lander
ian.lander@uwa.edu.au

Footnotes

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