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MINIMAL INTERVENTION DENTISTRY

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Concepts of minimal intervention dentistry from British Dental journal MID series

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MINIMAL INTERVENTION DENTISTRY

  1. 1. MINIMAL INTERVENTION DENTISTRY 1
  2. 2. CONTENTS 2 • EVOLUTION FROM SURGICAL APPROACH TO MID • THE CONCEPT OF MID • MINIMAL INTERVENTION Vs MINIMALLY INVASIVE • BUILDING THE TREATMENT CARE PLAN • CARIES RISK ASSESSMENT IN ADULTS • CARIES RISK ASSESSMENT IN CHILDREN • DETECTION AND DIAGNOSIS OF INITIAL CARIES LESION • CARIES INHIBITION BY RESIN INFILTRATION • ART (ATRAUMATIC RESTORATIVE TREATMENT) • MINIMALLY INVASIVE OPERATIVE CARIES MANAGEMENT: RATIONALE AND TECHNIQUES
  3. 3. INTRODUCTION 3 G.V.BLACKS CLASSIFICATION OF DENTAL CARIES Surgical approach – removal of diseased portions EXTENSION FOR PREVENTION Extension to areas presumed to be caries resistant. A lack of understanding of the caries process, in particular the potential for remineralisation, and the poor physical properties of available restorative materials.
  4. 4. 4 Traditional preparation- removal of smaller amounts of caries as compared to healthy dentine
  5. 5.  Since the development of ultra-high speed rotary cutting instruments in the 1950s, there has been a tendency to extend a cavity even further, and the resultant weakening of the tooth crown has led to a marked increase in ‘replacement dentistry’, wherein there is further loss of tooth structure upon each replacement of a restoration REPLACEMENT DENTISTRY 5
  6. 6. Case study 6 A patient aged 33 at the time of the photograph, who has, judging by the number of endodontic treatments present, been obliged to visit the dentist on numerous occasions in the past. The problem of oral hygiene has not been resolved and, the caries process, which is very aggressive, has not been halted. Restorative and endodontic treatment do not in themselves solve problems of oral health
  7. 7. "a systematic respect for the original tissue." The concept bridges the traditional gap between prevention and surgical procedures. It integrates concepts of prevention, control and treatment and is based on all factors that affect the onset and progression of oral diseases. So there is a shift from compulsive restorative dentistry to rational therapeutic strategies with least invasive solutions. THE CONCEPT 7 The profession should now be encouraged to adopt an entirely new attitude to the repair and restoration of demineralised tooth structure
  8. 8. “ a philosophy of professional care concerned with the first occurrence, earliest detection, and earliest possible cure of disease on micro (molecular) levels, followed by minimally invasive and patient-friendly treatment to repair irreversible damage caused by such disease” DEFINITION 8 Tyas MJ, Anusavice KJ, Frencken JE, Mount GJ. Minimal intervention dentistry—a review. FDI Commission Project 1-97. Int Dent J 2000;50:1–12.
  9. 9. Minimal intervention deals with causes of dental disease and not just the symptoms and is based on biological solutions rather than purely restorative, that is prevention and control of disease. Minimal invasive dentistry or ultraconservative and micro dentistry embraces operative restorative approaches. It is a component of the minimal intervention dentistry. INTERVENTION Vs INVASIVE 9
  10. 10. Is a concept of patient care that deals with causes of dental disease and not just the symptoms. Biological solutions rather than purely restorative treatment Prevention and control of oral disease. MINIMAL INTERVENTION DENTISTRY 10
  11. 11. Primary prevention (prevention of new cases) • Community level: Artificial fluoridation of water/school oral health programmes • Individual level: prevent early colonization of children's teeth by cariogenic bacteria. • Also management of cariogenic diet rich in fermentable carbohydrates with poor oral hygiene habits. LEVELS OF PREVENTION 11 Secondary prevention (prevent disease from becoming established and progressing) • Screening to detect carious lesions at the earliest Tertiary prevention: (prevent recurrence) • Prevent failure of preventive and restorative care initially implemented When it involves MID involves carious lesion therapeutic strategies are required but in this case the least invasive solutions are chosen ex: remineralisation, therapeutic sealant, restorative care aimed at conserving the maximum amount of tissue
  12. 12. Operative approaches that respect both the dental tissues and patients comfort. Objective: preserve sound tooth tissue and also tissues which has potential to remineralize. Use of adhesive biomaterials are preferred ex resin composites and glass-ionomer cements MINIMALLY INVASIVE DENTISTRY, ULTRA- CONSERVATIVE OR MICRO-DENTISTRY 12
  13. 13. How is it different from traditional dentistry? 13  In TD preparation and restoration of cavities are the only systematic response to presence of carious lesions.  In MID, Placement of restorations is an ancillary phase of the overall management of patient care where restorations are indicated only when the lesion has advanced to frank cavitation and where remineralisation techniques have reached their limits.  Micro-dentistry is performed preferably using optical aids (magnification, microscopes, intra-oral cameras)  sophisticated devices other than traditional rotary instruments mounted on a contra-angle handpiece or air- turbine, such as chemo-mechanical, air-abrasion, sono-abrasion and laser systems.
  14. 14. ‘Rational’ clinical practice is based on four key elements: 1. Control of the disease by identifying and managing the risk factors 2. The detection and remineralisation of early lesions 3. Minimally invasive surgical intervention 4. Where possible the repair rather than replacement of defective restorations MINIMAL INTERVENTION DENTISTRY: BUILDING THE TREATMENT (CARE) PLAN? 14
  15. 15. A cariology-based care plan comprises three main phases 15
  16. 16. • Why the disease (caries) has occurred and is used to evaluate the severity of the damage caused. • The determination of the individual caries risk factors and detection of carious lesions (presence and activity). DIAGNOSTIC PHASE 16 RISK PREDICTORS • Past exposure to caries • Presence of cavitated caries lesions • recent restorations placed due to caries • demographic factors relating to age, level of education and disabilities that potentially expose the patient to risk habits . Ex: • A teenager with uncontrolled eating habits, • Elderly where oral hygiene is more difficult to maintain due to loss of motor skills
  17. 17. Aims to readjust the balance between pathological and protective factors. Measures required to curb the phenomena of demineralisation and to initiate remineralisation are implemented. Recommendations relating to Hygiene and dietary habits Antibacterial therapy Prescription of appropriate fluoride measures Placement of preventive sealants. In the case of patients with cavitated lesions involving the dentine, atraumatic restorative care can complement the arsenal of prophylactic or partial excavation of caries. PROPHYLACTIC PHASE 17
  18. 18. • It concerns the reinforcement of patient education, monitoring the effectiveness of all preventive and control measures implemented for example, fluoride and preventive sealants, and therapeutic measures for example, the integrity of therapeutic sealants and restorations. • During follow-up visits, potential failures can be intercepted and the recall interval adjusted based on new clinical findings and the behaviour of the patient FOLLOW UP AND MAINTAINANCE 18
  19. 19. Fit between control and surveillance Required when the caries process has resulted in significant loss of dental tissue, to eliminate the retention of plaque within cavities and restore physiological masticatory function and aesthetics. Follow a minimally invasive approach, where caries removal/ cavity preparation is delayed until there are cavitated dentine lesions and through the use of adhesive materials, these cavities can remain minimally invasive. Defective restorations are not systematically removed and replaced. These radical solutions need to be rethought and nuanced; polishing reduces the indications for the complete replacement of the restoration, the margins of restorations can be sealed and restorations can be repaired. RESTORATIVE PHASE 19
  20. 20. 20 CARIES RISK ASSESSMENT IN ADULTS
  21. 21. Risk-based prevention and disease management have been recognised as the cornerstones of modern caries management. CONTROVERSIES SURROUNDING CARIES RISK ASSESSMENT It is difficult to identify such patients accurately and that even if we could, the evidence for preventive measures on high-risk individuals is still not very strong. But when the wellbeing of the patient is considered, it is more important to carry out a risk assessment incorporating the best available evidence than just doing nothing due to lack of strong evidence. Similar preventive measures should be administered to the whole population, regardless of the risk Dental caries is unequally distributed in most populations around the world, with a small percentage of individuals carrying the heavier burden of caries disease. For most dentists in private practice, it becomes imperative to be able to identify a patient’s risk status in order to be able to develop the most cost-effective treatment strategy for that individual. RISK ASSESSMENT IS IT NEEDED? 21
  22. 22. Caries risk assessment should be useful in the clinical management of dental caries by helping to • Determine lesion activity • Estimate the degree of risk so the intensity of the treatment (for example, fluoride concentration and delivery method) and frequency of appointments can be customised • Identify the main aetiological agents contributing to the current disease that might be targeted in the management of the disease (for example, diet control) • Establish the need for additional diagnostic procedures (for example, salivary flow rate/buffering measurements) • Formulate the best restorative treatment (care) plan for this patient (for example, dental material selection) • Enhance the overall prognosis of the patient • Appraise the efficacy of the caries management plan established at recall visits. CARIES RISK ASSESSMENT IN PRACTICE 22
  23. 23. Clinical observations that tell about the past caries history and activity and includes variables related to disease experience. RISK INDICATORS 23 CARIES EXPERIENCE - Past caries experience and current lesion activity -Epidemiological studies have shown a positive strong correlation between past caries experience and future caries development, which is why all available risk tools include this indicator very prominently In adults, there is also a clear association between coronal caries and the risk of developing root caries. Socio-demographic indicators • Is a stronger predictor of caries risk in children than in adults, it is still important in adults. • Because dental caries generally is more prevalent in lower than higher socioeconomic classes the dentist should consider the social environment of the patient (for example, education, income, occupation etc) elicited through history.
  24. 24. A risk factor plays an essential role in the aetiology of the disease, while a risk indicator is indirectly associated with the disease. Risk factors are the biologic reasons, or factors, that have caused or contributed to the disease, or will contribute to its future manifestation on the tooth. RISK FACTORS 24 Genetics Only factor that cannot be measured currently in clinical practice The amount of evidence relating to genes and caries experience has increased significantly in the last decade Genes have been identified linking tooth development, salivary function and diet/taste to caries risk or protection. :as the understanding of genetics associated with caries risk increase, so does the future possibility of using salivary diagnostics based on genetic scans to develop either better risk assessment tools or to better target specific interventions”
  25. 25. SALIVA Most common salivary paramteres for risk assessment include salivary flow rate, buffering capacity and ph. Hypo- salivation – strongest salivary indicators for an increased risk of dental caries. Unfortunately, subjective complaint of xerostomia often does not correlate with objective findings of reduced salivary flow rate. Recommended that dental care professionals ask their patients the following questions: Does your mouth feel dry when eating a meal? Do you sip liquids to aid swallowing dry foods? Do you have difficulty swallowing any foods? Does the amount of saliva in your mouth seem to be too little, too much or do you not notice it? Rather than ‘is your mouth dry?’ 25 BACTERIA People with high numbers of cariogenic bacteria are at higher risk for developing future lesions. Plaque indices - ineffective predictors of future caries DC- fissures and interproximal areas PI - based on smooth surface scores Salivary bacterial tests - controversy in the literature regarding the accuracy of salivary tests for mutans streptococci and lactobacilli in predicting future caries in adults. No proper tests for caries risk assessment but these tests can be useful for patient motivation.
  26. 26. Diet Sugar exposure is an important aetiological factor in caries development. Self-reported sugar intake seems to have little value at identifying, by itself, patients at risk. Other dietary considerations include the retentiveness of the food, frequency of consumption (this being the most important), consumption between meals, the presence of protective factors in foods (for example, calcium, fluoride) and the type of carbohydrate. Excessive frequent consumption of soft drinks remains a major risk factor that may be partly responsible for the high rate of caries in 26 Others Mental and/or physical disabilities that affect regular oral hygiene. Enamel defects, such as hypoplasia, have also been related to increase caries risk, especially in children
  27. 27. Although the clinician should analyse all protective factors the patient is exposed to, of great importance is the exposure to fluorides. The dental care professional should consider all fluoride sources to which the patient is exposed, for example, fluoridated drinking water, foods/ drinks, home topical fluoride products and periodic professional fluoride exposures. As the risk is increased, so should be the level of fluoride exposure, both at home and in office. PROTECTIVE FACTORS 27
  28. 28. CARIES RISK ASSESSMENT TOOLS 28
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  30. 30. 30 An infant oral health visit consists of a six-step protocol: 1. Caries risk assessment 2. Proper positioning of the child (knee-to-knee exam) 3. Age appropriate tooth brushing prophylaxis 4. Clinical examination of the child’s oral cavity and dentition 5. Fluoride varnish treatment 6. Assignment of risk, anticipatory guidance and counselling. Paediatric dental care –prevention and management protocols using caries risk assessment for infants and young children
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  34. 34. 34 DETECTION AND DIAGNOSIS OF INITIAL CARIES LESIONS
  35. 35. The initial caries lesion can be defined as a primary lesion which has not reached the stage of an established lesion with cavitation . High evidence-level studies are in agreement that the ideal tool for detection of the initial lesion, the ‘gold standard,’ has not yet been identified. The conventional and validated tools for detecting early carious lesions include visual and tactile examination and radiography (bitewings). TOOLS FOR DETECTING EARLY LESIONS 35
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  38. 38. None of the new caries detection techniques developed in recent years is 100% reliable when used alone They are classified on the basis of the physical principles that underpin them. The most prominent include Transillumination Fluorescence systems (Diagno.cam, Kavo®) (DIAGNOdent, Kavo®; CS 1600 Kodak; staCam iX, DürrDental®; SoproLife, Acteon®). NEW DIAGNOSTIC AIDS 38 1. Laser fluorescence 2. Fiber-optic transillumination 3.Digital imaging fiber-optic transillumination 4. Ultraviolet illumination 5. Electronic caries detector 6. Dye penetration method 7.Quantitative light-induced fluorescence (QLF) 8. Ultrasound imaging 9. Endoscope / Videoscope
  39. 39. 39 CARIES INHIBITION BY RESIN INFILTRATION
  40. 40. Resin infiltration of carious lesions represents an approach to the treatment of non- cavitated lesions on proximal and smooth surfaces of primary and permanent teeth. The principal feature of this technique is that it is non-invasive, preserves tooth structure and can be completed in a single visit. The concept was first developed in Germany, at the Charité University Hospital in Berlin, from in vitro studies on the penetration of resin into caries and marketed under the brand name of Icon® (DMG America Company, Englewood, NJ). 40 RESIN INFILTRATION
  41. 41. THE PRINCIPLE 41 The principle of resin infiltration is to perfuse porous enamel with resin by capillary action, thereby stopping the process of demineralisation and stabilising the carious lesion. The principle can be compared with the saturation of a sugar cube or sponge with a liquid.
  42. 42. 42 The infiltration takes place within the enamel, in contrast to pit and fissure sealants, which forms a superficial mechanical barrier on the outer surface of the initial lesion, depriving the bacteria that colonise the surface of the lesion of nutrients from the biofilm) Bacteria that have penetrated the demineralised enamel are trapped in the infiltrating resin once it has been cured.
  43. 43. INDICATION 43
  44. 44. ARMEMENTARIUM TECHNIQUE 44
  45. 45. EVIDENCE 45 A systematic review of the literature comparing techniques for sealing and infiltration in the treatment of initial caries lesion, concludes, with a good level of evidence, that the sealants act by forming a superficial barrier against the penetration of bacteria and their by-products, while infiltration techniques create an internal barrier in the lesion by replacing lost minerals with low viscosity light-cured resin.
  46. 46. Minimally invasive operative caries management: rationale and techniques 46 Minimally Invasive Dentistry describes contemporary ultraconservative operative management of cavitated lesions requiring surgical intervention.
  47. 47. Minimally Invasive Operative Caries Management Strategy (MI OCMS) 47 The histology of the dental substrate being treated The chemistry/han dling of the adhesive materials used to restore the cavity Consideration of the practical operative techniques available to excavate caries minimally. ‘Golden triangle’ of MID MINIMAL INTERVENTION DENTISTRY
  48. 48. ENAMEL CARIES Carious enamel with its unsupported prismatic structure is weak under stress from compressive/ shear occlusal loads or from tensile shrinkage forces from photo-cured resin-based adhesive materials.. If carious enamel is retained at the margin of the cavity and subsequently restored. Then, 1) Cohesive microleakage 2) Secondary’ caries development along margins LESION HISTOLOGY 48 DENTINAL CARIES Two histopathological zones 1) The peripheral caries-infected zone Irreversibly damaged, necrotic and softened by long standing bacterial contamination and proteolytic denaturation of collagen and acid demineralization of the inorganic component 2) deeper caries-affected zone Reversibly damaged by virtue of carious process, which has the potential to repair under the correct conditions as the collagen is not denatured.
  49. 49. Propylene glycol-based indicator dyes were developed to act as a marker for that carious dentine requiring excavation, but many conflicting studies exist regarding their efficacy in this regard. The removal of grossly softened caries-infected dentine is recommended in most situations (except perhaps in a deep lesion overlying the pulp where its vitality assessment leans towards an acute inflammatory response and an adequate clinical seal can be achieved at the periphery of the cavity). Peripheral caries removal should extend to sound dentine where inadequate quantity and How much dentine caries should be excavated? 49
  50. 50. There are several clinical technologies available for cutting teeth and removing caries. MINIMALLY INVASIVE OPERATIVE TECHNIQUES 50
  51. 51. Retention rate of PFS • Meta-analyses have shown that auto-polymerizing sealants were found to have a five-year retention rate of 64.7%. • Resin-based light-polymerizing sealants and fluoride-releasing products showed five-year retention rates of 83.8% and 69.9% respectively. • However, poor retention rates of <19.3% were documented for UV-light- polymerizing materials, compomers and GIC based sealants. PIT and FISSURE SEALANTS 51
  52. 52. PRR is indicated in teeth with minimal teeth and fissures decay. After etching, rinsing and drying the cavity is condensed with a normal composite or GIC. PREVENTIVE RESIN RESTORATION 52 SURVIVAL RATE OF PRR
  53. 53. The manual selective excavation of tissues destroyed by the caries process, involving excavation of the infected dentine while conserving the affected dentin. A sealant restoration is then placed, which comprises a conventional adhesive restoration combined with the sealing of adjacent pits and fissures. Initially, this approach was proposed for the management of patients in developing countries because it can be performed using only manual instruments. The excellent results from clinical studies suggest that it also has its applications in industrialised countries especially for patients with multiple caries lesions during the stabilisation and motivation phase. ATRAUMATIC RESTORATIVE TREATMENT 53
  54. 54. SURVIVAL RATE OF ART 54
  55. 55. AIR ABRASION • The instrument was first developed in the 1940’s by Dr. Robert Black. • It is a method of tooth structure removal that is considered to be an effective alternative to the standard dental drill. • It removes tooth structure using a stream of aluminium oxide particles generated from compressed air or bottled carbon dioxide or nitrogen gas. • The abrasive particles strike the tooth with high velocity and remove a small amount of tooth structure. AIR ABRASION AND LASERS 55 LASERS (light amplification by stimulated emission of radiation) • In 1997, the Food and Drug Administration approved the use of Erbium: Yttrium Aluminium Garnet laser for caries removal in the USA. • It operates at a wavelength of 2.94 μm and is used for the caries removal, cavity preparation in both enamel and dentine and for the preparation of root canals. • Laser treatment is appreciated by patients as they are more comfortable than drilling.
  56. 56. • Many manufacturers are now producing smaller burs for cavity preparation using MI techniques. The burs are spherical, tapered or elliptical. Examples include fissurotomy burs (SS White, USA) and narrow diamond burs (Brassler, USA). • The instruments are manufactured using a special high-tensile steel to produce a thin neck MICRO-PREPARATION AND FISSUROTOMY BURS 56 SMART BURS (POLYMER BURS) • Hardness is lesser than healthy dentin but greater than infected dentin. • These burs can easily remove the soft carious dentin, but when they come in contact with hard dentin, they blunt out, so that unnecessary cutting does not occur
  57. 57. A non invasive technique for eliminating infected dentin via a chemical agent. This is a method of caries removal based on dissolution. The chemicals used can be in the form of liquid (caridex) or gel (carisolv). CHEMO MECHANICAL CARIES REMOVAL 57 Caridex • Nmono chloroglycine and amino butyric acid and was called as GK 101 E. • The solution was claimed to cause disruption of collagen in the carious dentine, thus facilitating its removal. It constitutes amino acids and 0.5% sodium hypochlorite and is applied to the dentin. The new system is marketed in two syringes: Red Gel: Glutamic acid, leucine, lysine, sodium chloride, erthrosine , water and sodium hydroxide. Transparent Gel: 0.5% Sodium hypochlorite CARISOLV
  58. 58. TUNNEL PREPARATION It could be used when the lesion is more than 2.5 mm below the crest of the marginal ridge and the contact area may remain sound and the marginal ridge may be quite strong. Access to the lesion through the occlusal surfaces should be limited to the extent required to achieve visibility and should be undertaken from an area that is not under direct occlusal load. Access may be gained through the occlusal surface with No. 2 bur about 2.0 mm from the marginal ridge. Resin-modified glass ionomer cement is the current material of choice for this restoration. They are radiopaque and have been shown to prevent microleakage. CAVITY DESIGNS FOR MINIMAL INTERVENTION 58
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  60. 60. It could be used when the lesion is less than 2.5 mm below the crest of the marginal ridge. The basic principles of cavity design remain the same, with the objective of removing only that tooth structure that has broken beyond the possibility of remineralization. SLOT PREPARATION 60
  61. 61. In this preparation, the excavation of the dentin lesion is same as for the previous preparations. The design differs only in the handling of the enamel. Initially, the integrity of enamel wall needs to be preserved by extending the margins where it can be considered stable and durable. A full box need not to be developed. MINI BOX FULL BOX 61 It is a very common procedure, where the enamel is in hopelessly poor condition and needs refining after eradicating the dentin lesion. The final refinement will depend on the type of restoration to be placed. For example, the preparation design for an amalgam or composite restoration differs from the design for a porcelain or gold inlay
  62. 62. CONCLUSION In the twenty-first century, greater Emphasis must be placed on assessing Caries risk, shifting patients to a Low caries risk status, remineralising Noncavitated lesions, abandoning the Surgical approach to caries management, And repairing rather than Replacing defective restorations. 62
  63. 63. WAY FORWARD 63 FUTURE RESEARCH - Improve the sensitivity of diagnostic methods to develop site-specific indicators of future caries risk - Clear guidelines on management of caries - Analyse the cost-benefit ratio of minimal intervention techniques
  64. 64. REFERENCES 64 1. Tyas, M.J., et al., Minimal intervention dentistry--a review. FDI 2. Featherstone JD, Doméjean S. Minimal intervention dentistry: part 1. From'compulsive'restorative dentistry to rational therapeutic strategies. British dental journal. 2012 Nov;213(9):441. 3. Fontana M, Gonzalez-Cabezas C. Minimal intervention dentistry: part 2. Caries risk assessment in adults. British dental journal. 2012 Nov;213(9):447. 4. Holmgren C, Gaucher C, Decerle N, Doméjean S. Minimal intervention dentistry II: part 3. Management of non-cavitated (initial) occlusal caries lesions–non-invasive approaches through remineralisation and therapeutic sealants. British dental journal. 2014 Mar;216(5):237.
  65. 65. 65 5) Guerrieri A, Gaucher C, Bonte E, Lasfargues JJ. Minimal intervention dentistry: part 4. Detection and diagnosis of initial caries lesions. British dental journal. 2012 Dec;213(11):551. 6) Holmgren CJ, Roux D, Doméjean S. Minimal intervention dentistry: part 5. Atraumatic restorative treatment (ART)–a minimum intervention and minimally invasive approach for the management of dental caries. British dental journal. 2013 Jan;214(1):11. 7) Holmgren CJ, Roux D, Doméjean S. Minimal intervention dentistry: part 5. Atraumatic restorative treatment (ART)–a minimum intervention and minimally invasive approach for the management of dental caries. British dental journal. 2013 Jan;214(1):11. 8) Banerjee A. Minimal intervention dentistry: part 7. Minimally invasive operative caries management: rationale and techniques. British dental journal. 2013 Feb;214(3):107.
  66. 66. THANK YOU 66

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