Abstract
Aim
The aim of this study was to compare the treatment outcome following fixation of midface fractures with microplates to that of miniplates.
Materials and Methods
The prospective study included 30 patients with confirmed diagnosis of midface fractures (Le Fort I, II, III, ZMC fractures or combination) and who gave written informed consent. The patients were categorized into microplate (1.2 mm) group and miniplate (2.0 mm) group with 15 patients in each group using computer-generated randomization. The clinical parameters like occlusion, stability of fixation, chewing efficiency, pain, infection, paresthesia, plate exposure, palpability, aesthetic outcomes and patient’s perspective were assessed on postoperative day 1, day 3, after 1 week, 1 month and after 3 months.
Results
There was no statistically significant difference between the two groups in terms of occlusion, stability of fixation, chewing efficiency, pain, infection, paresthesia, plate exposure, aesthetic outcomes and patient’s perspective. One patient in microplate group and five patients in miniplate group complained of plate palpability (P = 0.16), suggesting clinically significant difference but statistically no significant difference.
Conclusion
Microplate osteosynthesis gives equivalent results compared to miniplate osteosynthesis, in the fixation of midface fractures in terms of stability and function and clinically superior in terms of aesthetics.
Keywords: Midface fractures, Microplates, Miniplates, Rigid fixation, Stability, Le Fort fractures
Introduction
Maxillofacial fractures may occur as isolated or as a part of polytrauma and may be associated with head and cervical injuries. Road traffic accidents are the most common cause followed by self-falls, assaults and sports injuries. Fractures of the midface can be potentially disfiguring to the face. Therefore, management of midface fractures becomes crucial as it involves the restoration of both form and function through a complex interplay between the facial bony skeleton and its delicate soft tissue envelope. An essential component of fracture management is achieving adequate reduction and stabilization of the fracture segments with implants in the form of plates and screws [1]. In an ideal osteosynthesis, a minimum implant material that provides maximum stability should always be considered.
Maxillofacial fixation has evolved significantly over the past two decades with the introduction of different types of rigid internal fixation systems. One unique modification is the microplating system. Microplates have a smaller profile and are not palpable in the facial aesthetic regions [2]. However, there are very few studies in the literature with the use of microplate osteosynthesis for the fixation of midface fractures [3–8]. Therefore, the aim of our study was to compare the treatment outcomes following fixation of midface fractures with microplates to that of miniplates.
Materials and Methods
A prospective comparative study was conducted in the Department of Oral & Maxillofacial Surgery, Faculty of Dental Sciences (FDS), Ramaiah University of Applied Sciences (RUAS), Bengaluru, from September 2017 to August 2019. A total of 30 patients with midface fractures and who fulfilled the inclusion criteria (Le Fort I, II, III, zygomatico-maxillary complex (ZMC) fractures or combination) and gave written informed consent were included in the study. Patients with comminuted Le Fort & ZMC fractures, medically compromised like diabetes mellitus and immuno-compromised states, were excluded from the study. Ethical approval for the study was obtained from the University Ethics Committee for Human Trials of M S Ramaiah University of Applied Sciences. A preoperative CT scan with 3D reconstruction was done for all the patients (Figs. 1a, 4a). All patients underwent open reduction internal fixation (ORIF) under general anesthesia (GA).
Fig. 1.
a Preoperative CT scan with 3D reconstruction showing multiple midface fractures—microplate group, b post-op PNS X-ray—microplate group
Fig. 4.
a Preoperative CT scan with 3D reconstruction showing multiple midface fractures—miniplate group, b post-op PNS X-ray—miniplate group
The patients were categorized into microplate group and miniplate group with 15 patients in each group using computer-generated randomization. Allocation concealment was done using sealed opaque envelopes. The patients in microplate group were treated with 0.5 mm profile microplate and 1.2 mm diameter microscrews (Fig. 2). The patients in miniplate group were treated with 1.0 mm profile miniplate and 2.0 mm diameter screws (Fig. 3). Standard points of fixation were used in both the groups. Intraoperatively, pre-injury occlusion was achieved and inter-fragmentary stability of the fractures was ensured. Postoperative PNS X-ray was taken for assessment (Figs. 1b, 4b).
Fig. 2.
a Fixation at the right infraorbital rim with 8 holes continuous curved orbital microplate, b fixation at right zygomatico-maxillary buttress with 5 holes L-shaped microplate, c fixation at left pyriform region with 4 holes with gap microplate
Fig. 3.
a Fixation at the left infraorbital rim with 4 holes with gap 2.0-mm miniplate, b fixation at right zygomatico-maxillary buttress with 4 holes with gap L-shaped miniplate
All patients received intravenous antibiotics, analgesics and anti-inflammatory drugs for a period of 5–7 days. The clinical parameters like occlusion, stability of fixation, chewing efficiency, aesthetics, plate palpability, plate exposure, pain, paresthesia, patients perspective and infection in terms of screw loosening, pus discharge, wound dehiscence, swelling were assessed on postoperative day 1, day 3, after 1 week, 1 month and 3 months (Table 1). The results were analyzed by using SPSS version 18 (IBM Corporation, SPSS Inc., Chicago, IL, USA). Results on categorical measurement were presented as frequency (percentage). Inferential statistics like Chi-square test/Fisher’s exact test and Mann–Whitney U test were used to check statistically significant difference between the two groups. P value less than 0.05 was considered to be statistically significant.
Table 1.
Clinical parameters with scores assigned
| S. no. | Parameters | Scores |
|---|---|---|
| 1 | Occlusion | |
| Satisfactory | 0 | |
| Unsatisfactory | 1 | |
| 2 |
Stability of the fixation and need for additional fixation (additional plates, IMF, etc.) |
|
| Stable + no need for additional plates, IMF | 0 | |
| Unstable (need for additional plates, IMF, elastics if any) | ||
| Mild | 1 | |
| Moderate | 2 | |
| Severe | 3 | |
| 3 | Palpability | |
| Not palpable | 0 | |
| Palpable | 1 | |
| 4 | Plate exposure | |
| Plate not exposed | 0 | |
| Plate exposed | 1 | |
| 5 | Pain | |
| Absent | 0 | |
| Present | 1 | |
| 6 | Infection (screw loosening pus discharge, wound dehiscence, swelling) | |
| Absent | 0 | |
| Present | 1 | |
| 7 | Paresthesia | |
| Absent | 0 | |
| Present | 1 | |
| 8 | Chewing efficiency (function) | |
| Not able to chew + liquid diet | 3 | |
| Able to chew with difficulty and minimal pain + soft diet | 2 | |
| Able to chew without pain + soft diet | 1 | |
| Able to chew comfortably without any pain +Normal diet | 0 | |
| Total score (sum of all the scores in the follow-up visits) for each patient was recorded, and final grading was done | ||
| Good | 0–5 | |
| Satisfactory | 6–10 | |
| Unsatisfactory | 11–15 | |
| 9 | Aesthetics: soft tissue assessment | |
| Good | 0 | |
| Satisfactory | 1 | |
| Unsatisfactory | 2 | |
| 10 | Aesthetics: hard tissue assessment | |
| Good | 0 | |
| Satisfactory | 1 | |
| Unsatisfactory | 2 | |
| 11 | Patients perspective | |
| Good | 0 | |
| Satisfactory | 1 | |
| Unsatisfactory | 2 | |
Results
A total of 30 patients were included in the study and randomly allocated into microplate group and miniplate group with 15 patients in each group. Each group had 14 males and 1 female. The age range in microplate group was 18–46 years (mean ± SD 29.93 ± 9.39) and in miniplate group was 23–58 years (mean ± SD 35.13 ± 10.29). The predominant age group was 21–30 years in both the groups with 46.67% (n = 7) of cases in microplate group and 40% (n = 6) of cases in miniplate group. There was no statistically significant difference in the distribution of age groups between the two groups, P value equal to 0.89. The most common etiology in both the groups was road traffic accidents (RTA), followed by assaults, self-falls and sports injury. The midface fractures occurred either in isolation or in combination. The distribution of fracture patterns was almost similar in both the groups. The majority of the cases were a combination of Le Fort fractures (Table 2).
Table 2.
Fracture patterns in microplate group and miniplate group
| Fracture pattern | No. of patients in microplate group | No. of patients in miniplate group |
|---|---|---|
| Isolated Le Fort I | ||
| Unilateral | 0 | 0 |
| Bilateral | 1 | 0 |
| Isolated Le Fort II | ||
| Unilateral | 1 | 0 |
| Bilateral | 0 | 0 |
| Isolated Le Fort III | ||
| Unilateral | 0 | 0 |
| Bilateral | 0 | 0 |
| Isolated ZMC | ||
| Right | 3 | 4 |
| Left | 2 | 1 |
| Combination of Le Fort fractures | ||
| Unilateral | 1 | 1 |
| Bilateral | 7 | 4 |
| Combination of Le Fort & ZMC fractures | ||
| Unilateral | 0 | 0 |
| Bilateral | 0 | 5 |
| Midface fracture + mandible fracture | 2 | 2 |
Deranged occlusion preoperatively was seen in 7 patients in microplate group and 9 patients in miniplate group. Postoperatively satisfactory occlusion and post-reduction stability was achieved in all patients except for 2 patients one in each group who presented with deranged occlusion with a P value of 1 for occlusion and P value of 0.96 for stability of fixation inferring statistically insignificant difference among both the groups (Tables 3, 4).
Table 3.
Comparison between microplate group and miniplate group for Occlusion
| Microplate group No. of patients n (%) |
Miniplate group No. of patients n (%) |
P value | |||||
|---|---|---|---|---|---|---|---|
| 0a | 1b | Mean ± SD | 0a | 1b | Mean ± SD | ||
| 1st post-op day | 14(93.3) | 1(6.7) | 0.07 ± 0.25 | 14(93.3) | 1(6.7) | 0.07 ± 0.25 | 1.00 |
| 3rd post-op day | 14(93.3) | 1(6.7) | 0.07 ± 0.25 | 14(93.3) | 1(6.7) | 0.07 ± 0.25 | 1.00 |
| 1st post-op week | 14(93.3) | 1(6.7) | 0.07 ± 0.25 | 14(93.3) | 1(6.7) | 0.07 ± 0.25 | 1.00 |
| 1st post-op month | 14(93.3) | 1(6.7) | 0.07 ± 0.25 | 15(100) | – | 0.0 | 1.00 |
| 3rd post-op month | 15(100) | – | 0.0 | 15(100) | – | 0.0 | 1.00 |
| Total | 0.07 ± 0.25 | 0.07 ± 0.25 | 1.00 | ||||
aSatisfactory
bUnsatisfactory
Table 4.
Comparison between microplate group and miniplate group for stability of fixation
| Microplate group No. of patients n (%) |
Miniplate group No. of patients n (%) |
P value | |||||||
|---|---|---|---|---|---|---|---|---|---|
| 0a | 1b | 2c | Mean ± SD | 0a | 1b | 2c | Mean ± SD | ||
| 1st post-op day | 14 (93.3) | – | 1 (6.7) | 0.13 ± 0.51 | 14 (93.3) | 1 (6.7) | – | 0.07 ± 0.25 | 0.99 |
| 3rd post-op day | 14 (93.3) | 1 (6.7) | 0.13 ± 0.51 | 14 (93.3) | 1 (6.7) | – | 0.07 ± 0.25 | 0.99 | |
| 1st post-op week | 14 (93.3) | 1 (6.7) | – | 0.07 ± 0.25 | 14 (93.3) | 1 (6.7) | – | 0.07 ± 0.25 | 1.00 |
| 1st post-op month | 15 (100) | – | – | 0.0 | 15 (100) | – | – | 0.0 | 1.00 |
| 3rd post-op month | 15 (100) | – | – | 0.0 | 15 (100) | – | – | 0.0 | 1.00 |
| Total | 0.13 ± 0.51 | 0.07 ± 0.25 | 0.962 | ||||||
aStable
bMild unstable + need for additional plates/IMF/elastics
cModerate unstable + need for additional plates/IMF/elastics
In both the groups, patients experienced mild pain on postoperative day 1 which subsequently decreased over time. Infraorbital nerve paresthesia was elicited in one patient in microplate group and two patients in miniplate group at the end of 1st postoperative week, which gradually recovery by 3rd month follow-up with a P value of 0.55, suggesting statistically no significant difference among both the groups in terms of paresthesia (Table 6).
Table 6.
Comparison between microplate group and miniplate group for change in variables from baseline for all parameters
| Clinical parameters | Microplate group (mean value) | Miniplate group (mean value) | P value |
|---|---|---|---|
| Occlusion | 0.07 ± 0.25 | 0.07 ± 0.25 | 1.00 |
| Stability of fixation | 0.13 ± 0.51 | 0.07 ± 0.25 | 0.962 |
| Pain | 1.0 ± 0.00 | 1.0 ± 0.00 | 1.00 |
| Infection | 0.0 ± 0.00 | 0.0 ± 0.00 | 1.00 |
| Paresthesia | 0.07 ± 0.25 | 0.13 ± 0.35 | 0.55 |
| Palpability | 0.20 ± 0.77 | 1.60 ± 2.35 | 0.16 |
| Plate exposure | 0.0 ± 0.00 | 0.0 ± 0.00 | 1.00 |
| Function: chewing efficiency | 2.66 ± 0.48 | 2.60 ± 0.50 | 0.71 |
| Aesthetics: soft tissue | 0.07 ± 0.25 | 0.13 ± 0.35 | 1.00 |
| Aesthetics: hard tissues | 0.0 | 0.0 | 1.00 |
| Patient’s perspective | 0.0 | 0.13 ± 0.35 | 1.00 |
One patient in microplate group complained of plate palpability in the infraorbital region and five patients in miniplate group, complained of plate palpability of which 2 were in the fronto-zygomatic suture region and 3 in the infraorbital region with P value of 0.16, suggesting clinically significant difference but statistically no significant difference (Table 5, Fig. 5). No postoperative complications like infection in terms of screw loosening, pus discharge, wound dehiscence, swelling and plate exposure were seen in either of the groups with a P value of 1.
Table 5.
Comparison between microplate group and miniplate group for plate palpability
| Microplate group No. of patients n (%) |
Miniplate group No. of patients n (%) |
P value | |||||
|---|---|---|---|---|---|---|---|
| 0a | 1b | Mean ± SD | 0a | 1b | Mean ± SD | ||
| 1st post-op day | 15 (100) | – | 0.0 | 11 (73.3) | 4 (26.7) | 0.27 ± 0.45 | 0.09 |
| 3rd post-op day | 15 (100) | – | 0.0 | 10 (66.7) | 5 (33.3) | 0.33 ± 0.48 | 0.04* |
| 1st post-op week | 14 (93.3) | 1 (6.7) | 0.07 ± 0.25 | 10 (66.7) | 5 (33.3) | 0.33 ± 0.48 | 0.16 |
| 1st post-op month | 14 (93.3) | 1 (6.7) | 0.07 ± 0.25 | 10 (66.7) | 5 (33.3) | 0.33 ± 0.48 | 0.16 |
| 3rd post-op month | 15 (100) | – | 0.0 | 10 (66.7) | 5 (33.3) | 0.33 ± 0.48 | 0.16 |
| Total | 0.20 ± 0.77 | 1.60 ± 2.35 | 0.16 | ||||
aNot palpable
bPalpable
*P value < 0.05
Fig. 5.
Bar graph showing mean values (y-axis) for plate palpability for microplate (blue) and miniplate (red) group
The diet of the patients and their chewing efficiency were monitored in the postoperative period. There was no statistical significance between the two groups with a P value of 0.71 (Table 6). Patients with multiple midface fractures including bilateral fractures took more time to come back to normal masticatory function than those with single fractures. Aesthetic outcome was assessed in terms of soft tissue as well as hard tissue. For soft tissue assessment, pre- and postoperative facial photographs were compared. All patients had a good facial symmetry except one patient in microplate group, and two patients in miniplate group, where mild asymmetry was noted in the postoperative photograph.
For hard tissue assessment, postoperative PNS X-rays were compared to the preoperative 3D CT scan images for Dolan’s lines and Mc-Gregor Campbell lines. In both the groups, no irregularity was recorded along these lines on the PNS X-rays with a P value of 1. Patient’s perspective regarding the treatment received for their facial fractures was recorded at the 3rd postoperative month follow-up visit. All the patients gave a score as good except for two patients in miniplate group who gave a score as satisfactory, accounting to P value of 1.00, suggesting statistically no significant difference among the two groups in terms of aesthetic outcome and patient’s perspective (Table 6).
Discussion
Midface is the central focus of our gaze. Anatomically, the midface is located between the cranium superiorly and the occlusal plane inferiorly [9]. The fractures of the midface can be potentially disfiguring. Therefore, management of midface fractures becomes crucial and is a challenging task for the oral and maxillofacial surgeons.
More often, majority of the midface fractures occur in combination and rarely isolated Le Fort fractures are seen. This could be attributed to the high-velocity motor vehicle accidents that occur nowadays [10, 11]. In the present study, 43% (n = 13) of the cases were combination of Le Fort fractures and 40% (n = 12) of the cases were combination of Le Fort & ZMC fractures. Only 16% (n = 5) of the cases were either isolated Le Fort or ZMC fractures. These findings were similar to those of RS Patil et al. [10] and P Satish et al. [11]. Three patients in microplate group and two patients in miniplate group had associated head injury and were operated along with neurosurgical intervention.
Titanium miniplates and screws are the gold standard for fixation of maxillofacial fractures [12]. However, miniplates have a plate profile of around 1 mm, and therefore, palpability and plate exposure are the major concerns with their use in the facial aesthetic region, where the overlying soft tissue envelope is thin and delicate. In osteosynthesis, the requirement of a minimum implant material with maximum stability should always be considered. Keeping this in mind, titanium microplates with a plate profile of less than 1 mm were introduced to overcome the shortcomings of miniplates [2]. The purpose of our study was to evaluate the efficiency of microplates in the fixation of midface fractures when compared to miniplates.
In the present study, standard points of fixation were used (Figs. 2, 3). For Le Fort fractures, fixation was done at the anterior and posterior vertical buttresses. This was followed by fixation at the infraorbital rim and fronto-nasal region as indicated. In ZMC fractures, 1, 2 or 3 point fixation was done depending on the degree of displacement and post-reduction stability. Intraoperatively, fracture fragment stability was satisfactory in both the microplate and miniplate groups.
Occlusion is considered as a reliable indicator of post-reduction stability [9]. In the present study, the postoperative occlusion was stable in both the groups except for one case in microplate group and another case in miniplate group. The patient in microplate group developed bilateral open bite in the premolar region which was around 3 mm on the left side and 2 mm on the right side. This patient had multiple fractures (combination of Le Fort & FNOE complex fractures) and associated head injury for which he needed ventilatory support in the immediate postoperative period and could not be managed with supplementary intermaxillary fixation. Occlusal corrections were done in the subsequent visits and satisfactory results achieved by the end of 3rd postoperative month. The patient in miniplate group had bilateral Le Fort II & Right ZMC fractures and developed mild open bite for which supplementary fixation in the form of intermaxillary elastics for 2 weeks was done, following which the occlusion was stable by the end of one month.
Function was assessed by the chewing efficiency and type of diet (liquid, soft or normal) taken by the patients in the postoperative period. By the end of 1st postoperative month, 10 patients in the microplate group and 9 patients in miniplate group were able to return back to their normal diet, while the other patients were still on soft diet. However, there was no statistical significance between the two groups (Table 6). We believe that the chewing ability could be affected by multiple factors such as the presence of dentoalveolar fractures, mandible fractures, peri-oral soft tissue injuries, bilateral midface fractures and stability of fracture fixation which are in turn proportional to the pain experience of the patient and thereby function. In the present study, the anatomic form of the midface following fixation of the fractures was assessed by comparing postoperative PNS X-rays with preoperative 3D-CT scan images. Good anatomic form was achieved in all cases irrespective of the plating system used.
Several problems concerning the use of microplating systems such as breakage of the microdrill or microscrews, stripping of the microscrew head are mentioned in the literature [2]. However, in our study, no hardware-related complications were encountered in both the groups. Paresthesia in the infraorbital region is a common postoperative finding due to traction of the infraorbital nerve. In our study, one patient in microplate group and two patients in miniplate group developed infraorbital nerve paresthesia in the postoperative period for which vitamin B6 & B12 supplements were given. The paresthesia gradually resolved within 3 months. These results were similar to those of Sridhar et al. [13]. The microplates are smaller in size as compared to miniplates, and therefore, they can be placed through smaller incisions with minimal traction to the surrounding soft tissues with less chance of temporary nerve dysfunction.
Plate palpability is a major concern in the facial aesthetic region. The plate palpability with miniplates is around 0.5–3% according to Campbell and Lin [14]. Miniplates can be palpable in the infraorbital, fronto-zygomatic and nasal regions where the overlying skin is thin and delicate. In the present study, plate palpability was recorded in 5 cases in miniplate group in the postoperative period, of which 2 were in the fronto-zygomatic suture region and 3 in the infraorbital region. Only one patient in microplate group complained of partial plate palpability in the infraorbital region who sustained comminuted fracture of the infraorbital rim and a long 10 hole continuous orbital microplate was used to bridge the segments. None of these patients opted for plate removal in either of the groups. Microplates are more malleable and have greater adaptability to the contours of the facial skeleton [14]. In midface fractures where the vertical pillars have to be reconstituted and the anterolateral wall of the maxilla is comminuted, the maxillary contour can be restored using microplates. The microscrews are uniquely effective in stabilizing these thin and fragile bones [15]. From this study, we observed that microplates are more convenient in the fixation of pyriform buttress and zygomatico-maxillary buttress regions where these small-sized plates and screws can be placed without damaging the roots of the teeth when compared to larger miniplates and screws.
Ozkan et al. [6] recommend the use of a combination of miniplates and microplates in the fixation of ZMC fractures, with a microplate at the fronto-zygomatic suture and infraorbital region (if required) and a miniplate in the zygomatico-maxillary buttress region. Strong and Sykes [16] recommend the use of 1.0–1.2-mm microplates at the inferior orbital rim, 1.5–1.7-mm low profile miniplates at fronto-zygomatic buttress and 2.0-mm miniplates at zygomatico-maxillary buttress. From our experience in treating midface fractures, microplates should be preferred over miniplates at sites in the facial region where the overlying soft tissue is thin and delicate like infraorbital rim, naso-maxillary process, fronto-nasal and fronto-zygomatic suture region, as they are less palpable and more aesthetic.
Patient’s perspective about the overall treatment received was noted at the end of the study. All the patients in both the groups were satisfied with the treatment and gave a score as good except for two patients in the miniplate group who gave a score as satisfactory, since the plates were palpable. Therefore, plate palpability affected the overall treatment satisfaction of the patients in miniplate group.
Limitations of the Study
The present study consisted of a small sample size and a short follow-up of 3 months.
Conclusion
From the present study, we can conclude that microplate osteosynthesis gives equivalent results compared to miniplate osteosynthesis in the fixation of Midface fractures, in terms of stability and function and is clinically superior in terms of aesthetics. Microplates are more malleable and have greater adaptability to the contours of the underlying bone and also demands for minimal skin exposure for its placement. Microplates have a low profile and therefore are less palpable in facial aesthetic areas where the overlying skin is thin and delicate. Considering the results from the present study, microplate osteosynthesis has provided satisfactory stability and function in the fixation of Midface fractures. In panfacial trauma, where multiple points of fixation are needed, microplates should be preferred over miniplates wherever possible, as the total metal hardware used in the patient will be less. There is insufficient information in the literature with regard to the comparison of the efficacy of microplates to that of miniplates in the fixation of Midface fractures; therefore, more number of randomized studies with larger sample size and longer follow-ups should be undertaken to strengthen the evidence for the use of microplates in the management of midface fractures.
Acknowledgements
We would like to thank Dr. Amit Thakur for helping us in the statistical analysis of the study.
Funding
This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.
Data Availability
Not applicable.
Compliance with Ethical Standards
Conflict of interest
The authors declare that they have no conflict of interest.
Ethical Approval
Ethical approval for the study was obtained from the University Ethics Committee for Human Trials of M S Ramaiah University of Applied Sciences and was performed in accordance with the ethical standards as laid down in the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards.
Informed Consent
Informed consent was obtained from all individual participants included in the study.
Consent for Publication
Not applicable.
Footnotes
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Contributor Information
Tanvy Sansgiri, Email: tanvy2192@gmail.com.
Kavitha Prasad, Email: kavithaprasad.os.ds@msruas.ac.in.
Vineeth Kumar, Email: drvineethk@gmail.com.
K. Ranganath, Email: ranganath.os.ds@msruas.ac.in
B. R. Rajanikanth, Email: rajanikanth.os.ds@msruas.ac.in
K. M. Sejal, Email: sejalkumarpal.os.ds@msruas.ac.in
Parimala Sagar, Email: parimalasagar.os.ds@msruas.ac.in.
G. Prathibha, Email: prathibha.os.ds@msruas.ac.in
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