Fluid control & Soft tissue management

Fluid control and

soft tissue

management

Soft tissue

displacement

Fluid controlMechanical

Chemical

Non surgical

Surgical

Recent advances

Why do we need fluid control?

Dry and clean operating field

Access and visibility

Sources of moisture in clinical environment

Saliva

• Salivary glands-parotid, submandibular, sublingual

The mean flow rate (+/- SD) of unstimulated saliva was 0.26 +/- 0.16 ml/min and that of saliva while chewing six different foods was 3.6 +/- 0.8 ml/min.

Blood

Inflamed gingival tissues/Iatrogenic damage

Water/dental materials

Rotary instruments, triplex syringe, etchants, irrigant

solutions

On a average a high speed rotatory cutting instrument

is 30 mL per minute

Gingival crevicular fluid

0.05 to 0.20 µL per minute

How is moisture control

important?

i. Patient related factors

Provides comfort.

Protects from swallowing or aspirating foreign bodies.

ii. Task/technique being performed

Dental materials are moisture sensitive, success of

adhesion and physical properties relies on a dry field.

iii. Operator related factors

Infection control to minimise aerosol production

Increased accessibility to operative site

Improves visibility of the working field

Less fogging of the dental mirror.

Prevents contamination.

Methods of fluid control

• Mechanical

• Chemical

• Others

Mechanical methods

• Rubber dam

• Suction devices

• High volume vacuum

• Saliva ejector

• Svedopter

• Cotton rolls

Rubber dam

Introduced by S C Barnum 1864

Uses

For core build up, pattern fabrication

Impression making of inlays and onlays

Removal of old restoration and caries

For cementation

Contraindication

Should not be used with poly-vinylsiloxane

interferes with polymerization

Patients allergic to latex

Advantages

Isolate one/more teeth

Eliminates saliva from operating site

Retracts soft tissue

Disadvantages

Time consuming and patients objection

Unusual tooth shapes or positions that cause inadequate clamp placement

Partially erupted teeth

Broken down teeth

Patients suffering from asthma

Rubber dam set

Rubber dam

Rubber dam punch

Rubber dam clamps

Rubber dam clamp forceps

Rubber dam frame/holder

High volume vacuum

Powerful suction device, use of 10mm diameter HVE tips, and a properly functioning suction pump set to evacuate one liter per minute of fluid

Uses

Apparatus also removes small operatory debris

Excellent lip retractor

Disadvantages

Cannot be used for impression &

cementation procedure

Data comparing aerosols present during air abrasion cutting

(a.a.) with and without use of HVE and the added effect of a

ceiling mounted air purifier (Phantom) used on different

settings in an 8x10 foot operatory with an 8-foot ceiling. The

figure shows a 95 percent reduction in aerosols due to use of

HVE alone when adjusted at optimal velocity and positioned

close to the operating site during a.a use

Saliva ejector

• Low volume suction devices

• 300 ml/ min is the suction rate

• Adjunct to high volume vacuum/ rubber dam/cotton

rolls

Uses

Removes saliva from the floor of mouth

Removes water slowly

Suction tips/ saliva ejectors

Disposable saliva ejectors

- Transparent [ plastic]

- Multi coloured [ plastic]

- Hygoformic saliva ejector

- Mirror vac

- Lingua fix

- Steel

- Saliva ejector with tongue guards

Reusable saliva ejectors

Svedopter

• Metal saliva ejector with a tongue retractor

• Used for mandibular arch

• Most effective when patient is in a nearly upright

position.

Commonest and cheap

Preparation in maxillary arch in mandibular arch

Cotton rolls

Controls small amounts of moisture and retracts

cheek and tongue

Keeps its shape and does not fall apart when full

of saliva

Provides acceptable dryness for procedures

Cementation

Impression making

Uses

Different types of cotton rolls

Wrapped

Braided

Cotton roll holder

Holds cotton rolls in place

Advantages

• Cheek and tongue are slightly

retracted

• Enhances visibility

Absorbents

Useful for short period of isolation

Alternatives when rubber dam application is impractical

Retracts cheek & provide absorbency

Different absorbent devices

Dry tips

Reflective shields

Dry tips

[Moisture absorbing cards]

Keeps parotid gland in check for 15 minute

Absorbs more moisture compared to cotton rolls

Reflective shields

Mirror-like reflective film allows illumination

Checks saliva control for parotid gland

Ideal for sealant and dental hygiene procedures

Chemical methods of fluid control

Administer for patient with excessive salivation

Anti- sialagogues

Local anesthetics

Anti sialagogues

• Gastrointestinal anti cholinergic drugs that inhibit action of

myo-epithelial cells of salivary gland

Common drugs

• Bromide (Banthine) 50 mg 1 hr before procedure

• Propantheline bromide (Pro-Banthine) 15mg 1 hr before

procedure

• Clonidine hydrochloride (Antihypertensive) 0.2mg 1 hr before

procedure

• Atropine 1 tablet of 0.4mg per day

Contraindication of anti-sialogogues

Methantheline and propanthelin contraindication

Hypersensitivity to drugs

Glaucoma

Asthma

Congestive heart failure

Obstructive condition of GI tracts or urinary tracts

Clonidine hydrochloride

• Its an anti hypertensive drug hence should be

given cautiously

• Causes drowsiness

Gingival retraction

Definition

• Gingival Retraction is the deflection of the

marginal gingiva away from a tooth.

• Gingival retraction is a process of exposing

margins when making impression of prepared

teeth.

Need of gingival displacement

• For accurate impressions in case of finish line at or

below the gingival sulcus.

• For restoration of cervical lesions

Classification of gingival tissue displacement

Non-surgical Surgical

Mechanical Mechano-chemical

Non surgical gingival

retraction

Mechanical methods

Retraction crown/sleeve

Mechanical retractor

Retraction cord

Mechano- chemical

Retraction cord with hemostatic

Retraction paste with hemostatic

Retraction crown /sleeve

Temporary crown adapted to the finish line

Excess of temporary material lined on the finish line

Crown placed on prepared tooth

Excess material is removed

Disadvantages of retraction crown/sleeve

• Recession of gingiva in case it is placed for more

than 12 hours

• Delayed impression

• Cervical region of teeth becomes sensitive and

susceptible to caries

Anatomic compression cap

Anatomic compression caps placed on patient’ s

teeth

Instruct the patient to bite on it

Advantages of compression cap

• Stops bleeding due to compression

• Opens the sulcus wide

• Ensures clean , dry area with well defined

gingival margin

Modified impression

techniques

Copper band impressions

Means of carrying the impression material and a

mechanism for gingival retraction.

Gingival margin are crimped to adapt to gingival contour

Temporary acrylic resin coping constructed

Tray adhesive applied

Filled with elastomeric impression material and reseated

Tissue displacement occurs

Full arch impression made

Temporary acrylic coping

Gingival protector

• It has a crescent shaped tip on an adjustable

ball joint attached to a metal handle

Uses

Veneer preparation

Finishing porcelain/resin

Sub gingival caries

Check fitting of margins of crown

Matrices and wedges

Placed inter proximally

Uses

Depresses gingiva

Matrices with gingival extension provides

displace gingival tissue

Rubber dam

• Heavy and extra heavy rubber dams were used

• Retraction is done by rubber dam and clamps

(No. 212 cervical retainer)

• Produced retraction by compression

Advantages

Control of seepage and hemorrhage.

Ease of application.

Disadvantages

Full arch models cannot be made.

Severe cervical extension

preparations.

Cannot be used with polyvinyl-

siloxane impression materials

Mechano chemical

method

Gingival retraction cords

Gingival retraction cord is a tapered diameter cordthat can be wrapped several times about a tooththat causes flared gingival crevice.

Plain cord provides mechanical retraction

Gingival retraction using chemically impregnated

retraction cord is a mechanico-chemical method of

displacement

Classification of retraction cords

Depending on the configuration

Twisted

Knitted

Braided

Depending on surface finish

Wax

Unwaxed

Depending on the chemical treatment

Plain

Impregnated

Depending on number strands

Single

Double-string

Depending on the thickness (color coded)

Black - 000

Yellow - 00

Purple - 0

Blue - 1

Green - 2

Red - 3

Desirable properties of retraction cord

• Dark color maximizes contrast with tooth & tissue

• Absorbent – can take liquid medicament

• Available in different diameters

Twisted gingival retraction cords

Allow the dentist to customize the cord as

individual strands can be removed

Knitted gingival retraction cord

• Interlocking loops

• Longitudinally elastic

• Transversely resilient

Braided gingival retraction cord

Firm

Flexible

Multistrand

Indications of #000

Anterior teeth

Double packing

Substitute for black silk

suture as lower cord in

the "two-cord" technique

Indications of #00

• Preparing and cementing

veneers

• Restorative procedures

dealing with thin, friable

tissues

Indications of #0

• Lower anteriors

• When luting near gingival and

subgingival veneers

• Class III, IV and V restorations

•

• Second cord for "two-cord"

technique

Indications of #1

• Tissue control and/or displacement

when soaked in coagulative

hemostatic solution prior to and/or

after crown preparations

• Protective "pre-preparation" cord

on anteriors

Indications of #2

• Upper cord for "two-cord" technique

• Tissue control and/or displacement

when soaked in coagulative

hemostatic solution prior to and/or

after crown preparations

• Protective "pre-preparation" cord on

anteriors

Indications of #3

• Areas that have fairly thick

gingival tissues where a

significant amount of force is

required

• Upper cord for those desiring

the "two-cord" technique

Instruments used for gingival retraction

• Evacuator

• Scissors

• Cotton pliers

• Mouth mirror

• Explorer

• Fisher ultrapak packer

• DE plastic filling instrument IPPA

• Cotton rolls

• Retraction cord

• Hemodent liquid

• Dappen dish

• Cotton pellets

• 2x2 gauge sponges

• Small Packer (45 degrees to handle)

• Small Packer (90 degrees to handle)

Fischer ultrapakpackers

45 degrees

Heads at 45 degrees

Three packing sides.

Small packer for

lower anteriors and upper lateral incisors.

90 degrees

Three sided heads

One of the heads in line with shank

Second is at a right angle to the shank.

Single cord technique.

Double cord technique.

Infusion technique of gingival displacement.

Every other tooth technique.

Techniques of gingival retraction

Technique of cord placement

Retraction cord drawn

from bottle

Twisting of retraction cord

Looping of gingival cord

Cord placement from

mesial surface

Placement of cord

sub gingivally

Occasional use of extra instrument to hold

the cord and packing with other

Instrument must be angled towards

the root

Excess cord cut off in the mesial

area

Placement of distal end till it s overlapping

the mesial part of cord

Double cord technique

Indication

• Impression of multiple prepared teeth

• Impression for compromised tissue health

Procedure

Small diameter cord is placed in sulcus

Second cord soaked with hemostatic agent

Placed over small cord for 8-10 minutes

Impression made

Infusion technique

Indication Controls hemorrhage

Procedure

Retraction cord packed into the sulcus for 1-3 minutes.

Infuser used with a burnishing motion in the sulcus circumferentially 360° around the sulcus

Every other tooth technique

Anterior tooth preparation when the roots are

in proximity

Prevents collapse of gingival papilla.

Gingival displacement medicaments

• Chemicals used along with retraction cords

are classified as

Vasoconstrictors

Astringents

Mechanism of action of vasoconstrictors

Physiologically restricts blood supply to the area by three ways

Decreasing the size of the blood capillaries

Tissue fluid seepage

Consequently size of the free gingiva.

(Ex: epinephrine and norepinephrine)

Epinephrine

• 0.1%-8% racemic epinephrine is used

• 0.2 mg -1 mg of epinephrine per inch of cord

Contraindications of epinephrine

Cardiovascular disease

Hypertension

Diabetes

Hyperthyroidism

Known hypersensitivity to epinephrine

Patients taking

Mono-amineoxidase

Tricyclic depressants

Ganglionic blockers

Cocaine

Sympathomimetic amine

Tetrahydrozoline HCL- 0.05%

Oxymetazoline-0.05%

Phenyl epinephrine HCL-0.05%

Advantages

More acceptable pH

Astringent

Mechanism of action

Precipitation of protein

Inhibit tran-scapillary movement of plasma protein

Act as caustics at low concentration & irritants in moderate concentration.

Low cell permeability.

Alum (Potassium aluminium sulfate)

100% of alum soaked in retraction cord

Advantages

Safer and fewer systemic effects than

epinephrine

Good tissue recovery

Can be placed inside the sulcus safely for 20 min

Disadvantages

0.1% of crestal bone loss

Aluminum chloride

Mechanism

Precipitate protein

Constrict blood vessels

Extract fluid from tissues

Used in 5-25% concentration for 10 min

Least irritating

Disadvantage

Interferes with the setting of PVS materials

Ferric sub-sulfate

• Also known as monsel’s solution

• More effective than epinephrine

• Good tissue recovery

• Recommended time- 3 min

Disadvantages

Solution is messy

Corrosive and injurious to soft tissues

Stain teeth

High acidity

Ferric sulfate

Recommended concentration-13- 20%

Provides hemostasis on exposed connective tissue

Recommended packing time-1-3 min

Disadvantages

Modify setting reaction of polyvinyl siloxane

Stains gingival tissue yellow-brown to black

Tannic acid

• Recommended concentration-20-100%

• Recommended time- 10 min

• Good tissue recovery

Drug Advantages Disadvantages

Epinephrine Good tissue displacement

Minimal tissue loss

Good hemostasis

Systemic reactions

Epinephrine syndrome

Alum Minimal tissue loss

Extended working time

Less hemostasis &

tissue displacement

Aluminum chloride Minimal tissue loss

Good hemostasis

Local tissue destruction

Ferric sulfate Compatible with aluminum

chloride

Good displacement

Non compatible with

epinephrine

Tissue discoloration

Tannic acid Good tissue response Less displacement

Minimal hemostasis

• 1) 20% ferric sulphate, 2) 15.5% ferric chloride, 3) 21.3% aluminiumsulphate, 4) aluminium chloride, 5) 8% epinephrine.

• Chemicals containing iron and epinephrine should not be used while managing the tissues as they cause black discolouration which is unaesthetic. Aluminium containing chemicals can safely be used in retraction cords .

Manikya Arabolu , Effect of chemicals impregnated in the retraction cords on

freshly prepared teeth, KDJ - Vol.34, No. 1, January 2011

Surgical method

Rotary gingival curettage

“Gingitage” or “Denttage”

Troughing technique

Purpose is limited removal of epithelial tissue while a chamfer finish line is being created

Amsterdam gave the concept further developed by Hansing and Ingraham.

Criteria for rotary curettage

Done on healthy and inflammation free tissue to prevent tissue shrinkage

Absence of bleeding on probing

Sulcus depth less than 3.0 mm

Presence of adequate keratinized gingiva

Technique

Shoulder finish line preparation prepared at gingival crest using flat end tapered diamond

Finish line extended apically1/2-2/3 the depth of the sulcus by torpedo diamond

Aluminum chloride impregnated retraction cord placed in sulcus

Cord removed after 4-8 minutes

Shoulder prepared at the

gingival level

Torpedo diamond bur to form

chamfer finish line and removal

of epithelial sulcus

Cord placed in the troughed sulcus

Electro Surgery

Electrosurgery denotes surgical reduction of

sulcular epithelium using an electrode to produce

gingival retraction

Mechanism of action

Controlled tissue destruction.

Current flows through a small cutting electrode

a vacuum tube or a transistor to deliver a highfrequency electrical current of at least 1.0 MHz

The procedure is also called as “SurgicalDiathermy”

Types of current

Fully Rectified current (modulated)

• Continuous flow of current

• Good cutting characteristics

• Enlargement of gingival sulcus

Fully Rectified current (filtered)

• Continuous current wave

• Excellent cutting characteristics

• Less injury than modulated current

Partially rectified current (damped)

Considerable tissue destruction.

Slow healing.

Used for spot coagulation

Un rectified current (damped)

Recurring peaks of current that rapidly diminish.

Causes intrinsic dehydration and necrosis.

Slow and painful healing.

Not used in dental surgery.

Un rectified damped current

Fully rectified filtered

currentFully rectified current

Partially rectified damped

current

Tissue considerations

Keep electrode in motion.

5-10 seconds between applications.

Patient should be properly grounded.

Tissue must be moist.

Electrode must remain free of tissue fragments.

Electrode must not touch any metallic restorations.

Advantages

Clear operating area without or no bleeding

Healing by primary intension

Less tissue loss after healing

Disadvantages

Unpleasant odour.

Slight loss of crestal bone

Burn mark on the root surface

Not suitable for thin gingiva.

Contraindications

Patients with cardiac pace maker.

Patients with delayed wound healing.

Patients on steroid therapy.

In the recently irradiated areas.

Technique

Anesthesia

A drop of aromatic smelling oil.

Complete seating of electrodes in handpiece.

Light pressure and quick ,deft stoke

5-10 seconds between each stroke.

Grounding For patient’s safety

Circuit should be complete by using ground

electrode

Ground

Back to the unit

Tissue Goo

Composition

25% aluminum sulfate and colorants

Medium viscosity, not too thick

Matrix impression system

(Described by Levaditis)

Lasers

Indication

Controlled tissue removal before impression

making

Tissue contouring

Properties of laser depends on

Wavelength

Waveform

Types of lasers

Neodymium: yttrium-aluminium-garnet

Erbium: yttrium- aluminum-garnet

Advantages

Advantage

Minimum pain and discomfort

Less fear ,anxiety and stress

Minimum or no anesthesia

No drill sounds

Less chair time

Reduced post operative complications

Minimum or no bleeding

Disadvantage

Overuse causes shrinkage of tissue and also results in exposure of crown margin

• Introduced by Satalec Pierre Rolland

• Cordless gingival retraction (SDS/Kerr Company)

Composition Aluminum chloride-15% astringent & hemostatic

agent

Kaolin

Excipients

Expasyl

Mechanism of action

• It has both mechanical and chemical action

Aluminum chloride provides- hemostasis

Viscosity of Kaolin- retracts the tissue

Recommended time of application-1-2 min

Advantages

Effectively achieves hemostasis.

Effectively retracts gingival tissues

Less traumatic to tissues than cord packing.

Faster than traditional cord.

Easy removal from sulcus by rinsing.

Dispenser tips can bent- improves intraoral access.

Disadvantages

Expensive

Effective under limited conditions.

Disposable metal dispenser tips are too large

causes difficulty to express

Thickness makes it difficult to express

Precautions

Thorough cleaning is mandatory to prevent

interference in polymerization of poly vinyl

siloxane materials

Contraindications

Presence of periodontal pocket and furcation

Known allergy to aluminum chloride

Inclined to be near the

edge of the marginal

gingiva

Tip of canula Pushed against the

tooth surface

Placement of metal dispenser

Magic foam

Developed by Prof Dr. Dumfahrt

Non-hemostatic gingival retraction system (Coltène/ Whaledent)

First expanding vinyl polysiloxane material designed for retraction of the gingival sulcus

Mechanism

• Expansion of silicon foam

Limitation

Limited clinical indications

Less hemostatic

No improvement in speed/quality compared

to cord

Less effective on sub gingival margin

Components of magic foam

• Foam

• Cartridges

• Mixing and intraoral tips

• Comprecaps

60 subjects who required metal ceramic restoration

Mean vertical displacement

• Expasyl -0.72 mm

• Medicated retraction cord-0.49 mm

• Magic foam-0.38 mm

Mean gingival retraction width

• Expasyl -0.37 mm

• Medicated retraction cord- 0.29 mm

• Magic foam- 0.26 mm

Rao et al; Comparative evaluation of gingival displacement using expasyl,

magic foam cord and medicated retraction cord-An vivo study, TPDI ,January

2012, Vol.3,No.1

Gingitrac (Centrix co)

Mild natural astringent gel

Utilizes patient s bite pressure to push material into sulcus and retract gingiva

Consists of

Mixing gun

Gingitrac cartridge

Gingitrac matrix cartridge

Mixing nozzle

Dispensing tips

Gingicap

Advantages

Less traumatic to tissues than retraction cord

Color of foam makes it easy to see during use

Easy to remove material from preparation and

sulcus

Adequate working time

Disadvantages

Limited clinical indications

No hemostasis provided

Relatively expensive compared with retraction cord

No improvement in speed or quality of retraction compared with cord

Less effective on sub-gingival margins

Intraoral tips may be too large to adequately inject material into sulcus

Merocel strips

• Marco Ferrari et al in 1996 found Merocel

• Synthetic material that is biocompatible polymer

(hydroxylate polyvinyl acetate)

Mechanism of action

• Expands by absorption of oral fluids and exerts

pressure on surrounding tissue

Method

About 2 mm of merocel retraction strip

Provisional crown inserted

Maintain pressure on crown for 10-15 min

Advantages

Easily shaped and adapted around tooth

Highly effective in absorption of oral fluids

Chemically pure- no post surgical complications

Non abrasive

• 14 maxillary tooth requiring complete metal ceramic

restoration

• Retraction was done using merocel and

conventional method

Mean vertical retraction of gingival cord - 2.02

Mean vertical retraction of retraction strips - 2.78

Shivashakthy M, Comparative study on the efficacy of gingival retraction using

polyvinyl acetate strips and conventional retraction cord - An in vivo study ,

Journal of clinical and diagnostic research, 2013 Oct Vol-7(10)

Stay put retraction cord

Fine metal filament reinforced displacement cord

impregnated or non impregnated

Consist of braided retraction cord and ultrafine

copper filaments

Remains in shape and does not deform

Traxodent

• Syringe-dispensed 15% aluminum chloride,hemostatic paste

• Ergonomic syringe

• Easy to use

• Disposable and flexible tips

• Each syringe can be repacked for maximum freshness

• Paste with a malleable consistency

Gingival displacement in digital impressions

15% aluminum chloride in an injectable matrix

Cords avoided to prevent artifacts on digital

impression

Retraction Capsule

• Astringent retraction paste supplied in a single-use

capsule

• The retraction paste contains 15% aluminum chloride

and can be used alone or in conjunction with retraction

cord for all indications requiring temporary deflection of

marginal gingival

Aim : to investigate the pressures generated by 4 different cordless

gingival displacement materials.

A chamber with a dimension of 5x5x2 mm was made from Type IV stone

and silicone material to simulate a rigid and elastic environment. A

pressure gauge was embedded into the wall of the chamber

The pressure generated by cordless systems is more than 10 times less

than with displacement cord, and this could result in inadequate

displacement

The median post injection pressures generated by Expasyl (142.2 kPa)

and Expasyl New (127.6 kPa)

3M ESPE Astringent Retraction Paste (58.8 kPa) and Magic Foam Cord

(32.8 kPa).

Bennani .V etal Comparison of pressure generated by cordless gingival displacement

materials J Prosthet Dent 2014;112:163-167

Gingival retraction in implants

Indicated only in rare situations

• Fabrication of custom abutment

Only injectable matrix technique used

Chang YSM etal Effect of a cordless retraction paste material on implant surfaces:

an in vitro study,Braz Oral Res. 2011 Nov-Dec;25(6):492-9

G-Cuff

• G-Cuff Non-Invasive Tissue management

• Provides immediate tissue displacement for transfer

emergence profile modeling as a recipient for the resin

• For clean cementation as a cement barrier

Polymerization time compatibility index of polyvinyl siloxane

impression materials

The study comprised 10 gingival displacement agents

5 conventional astringents:

(10%, 20%, and 25% aluminum chloride, 25% aluminum sulfate,15.5% ferric sulfate)

5 experimental adrenergics:

(0.1% and 0.01% HCl-epinephrine, 0.05% HCl-tetrahydrozoline, 0.05% HCl-

oxymetazoline, and 10% HCl-phenylephrine).

It is important to avoid or minimize the direct contact of chemical displacement

agents with PVS during gingival displacement and impression procedures.

15.5% ferric sulfate from CDA group and 0.01% HCl-epinephrine and 0.05% HCl

tetrahydrozoline from the EDA group were identified in this study as optimal under

clinical conditions.

Nowakowska et al, Polymerization time compatibility index of polyvinyl siloxane

impression materials with conventional and experimental gingival margin

displacement agents J Prosthet Dent 2014;112:168-175)

References

Shillingburg HT; Fundamentals of FixedProsthodontics; 2012; 4th edition ; Quintessencepublications; USA; pp: 257-279

Rosenstiel SF; Contemporary FixedProsthodontics; 2014; 4th edition; India; pp: 431-465

Livaditis et al, Comparison of the new matrixsystem with traditional fixed prosthodonticimpression procedures, J Prosthet Dent1998;79:200-7

Shah M J et al; Gingival retraction methods in fixedprosthodontics –A systematic review, Journal of dentalsciences;2008, Vol 3(1):4-10

Thomas MS et al, Nonsurgical gingival displacement inrestorative dentistry, June 2011, Vol32(5),27-39

Shivashakthy M, Comparative study on the efficacy ofgingival retraction using polyvinyl acetate strips andconventional retraction cord - An in vivo study , Journalof clinical and diagnostic research, 2013 Oct Vol-7(10):8-11

Priyanka Bawane, Library dissertation, Fluid controland soft tissue management