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Management of coronal fractures of permanent posterior teeth
Management posterior
teeth
S. T. Talim,
M.D.S.,*
of coronal
and
fractures
K. S. Gohil,
of permanent
M.D.%**
Government Dental College and Hospital, Ahmedabad, India
F
ractured posterior teeth have always presented problems in diagnosis and treatment planning. Many incomplete fractures go unnoticed due to the difficulty in diagnosis---the fracture lines usually run along grooves and fissures. Furthermore, the adjoining teeth make it difficult to locate proximal fractures. At times, even the finest probe fails to detect such defects. Unfortunately, scant literature is available regarding classification and treatment of the fractured permanent posterior teeth. Gibbs’ described incomplete fractures without giving many details. Cameron’ also reported on the subject, but most of the teeth he studied either had extensive caries or were restored. This report describes, in detail, the types, signs, and symptoms of and the therapy for fractures of sound posterior teeth. For convenience of discussion and treatment planning of fractured posterior teeth, the following classification is suggested : Class I. Fracture involving enamel a. Horizontal or oblique b. Vertical 1. Complete 2. Incomplete Class II. Fracture involving enamel and dentin without involving pulp a. Horizontal or oblique b. Vertical 1. Complete 2. Incomplete Class III. Fracture of enamel and dentin involving the pulp a. Horizontal b. Vertical 1. Complete *Professor **Lecturer,
172
and Head, Department Department
of Operative
of Operative
Dentistry.
Dentistry.
Management 2. Incomplete Fracture of the roots a. Vertical or oblique 1. Involving the pulp 2. Not involving the pulp b. Horizontal 1. Cervical third 2. Middle third 3. Apical third This classification also applies to fractures
of coronal
fractures
173
Class IV.
of the anterior
teeth.
FACTORS Predisposing factors. The present study shows that fractures of posterior teeth are commonly found in the middle and advanced age groups. The predisposing factors are those which increase the forces acting on the cusps and those which weaken resistance to masticatory forces. Factors which will increase the masticatory load are strong masseter muscles and deep occlusal fissures and grooves. Hypoplastic teeth, a betel nut chewing habit, and sand particles in food cause occlusal wear, thereby reducing the ability of the tooth to resist masticatory forces: The last two are common in this area. The higher percentage of fractures in the advanced age groups may also be due to posteruptive maturation of enamel. Fractured teeth with large cavities and restorations were excluded from the study. Etiologic factors. The tooth may fracture due to trauma or accidental biting on any hard object, such as betel nut, lead shot, cherry stone, bone, or particles of stone. The discomfort or even pain caused by unexpected striking of a small object between the teeth can be explained by the sudden concentration of a force, previously distributed over a number of teeth, on one or two teeth. It seems logical to assume ( 1) that the pain itself is part of a reflex action which stops the contraction of the muscles of mastication and (2) that, during the time required for the reflex action to take place, contraction continues for an appreciable period after contact, thus increasing the discomfort and damage. When it is further considered that the total force is not only suddenly concentrated on one or two teeth but, in the case of a hard small object, to very small areas on these teeth, the fracture of teeth or failure of a restoration can be readily understood.
DISCUSSION Accidental biting on a hard object may lead to periodontitis. The tooth may be only slightly tender and, at times, will make closure of the teeth painful. Relieving the occlusion generally eliminates the discomfort, but when the trauma results in fracture of the tooth, the treatment procedure will depend upon the involvement of the enamel, dentin, or pulp. Fracture of enamel may leave an irregular surface which can be improved by grinding. When the fracture involves the dentin, the surface of the tooth becomes rough and sensitive to both touch and cold. Selective grinding of sharp enamel mar-
174
J. Prosthet. Dent. February, 19i4
Talim and Gohil
Fig. 1. Incom lplete vertical fractures and PUMP (a) and enamel only (b).
(F)
of a mandibular
first molar involving
Fig. 2. Occlusal view of a mandibular second molar (A) with a mesiodistal the central groove (B) with both fragments separated.
c:namel dentin
fracture
(F) along
gins and application of 33.3 per cent sodium fluoride and kaolin-glycerine paste over the sensitive dentin will prove helpful. Use of desensitizing agents (silver nitrate or zinc chloride) which may further irritate the pulp should be avoided. When the area of involvement is large, onlays, inlay-onlay, or three-quarter crown restorations may serve depending upon the surfaces involved and the required retention. Inlays which do not restore the cusps should be avoided, since they may further increase the susceptibility of the tooth to fracture. Fractures on the non-stressbearing surfaces can be restored with any resinous restorative material with an adequate cement lining. Nearly all the incomplete vertical fractures studied were located along the central groove extending mesially and distally and were difficult to diagnose both clinically and radiographically (Figs. 1 and 2). The vertical fracture of enamel is symptomless and remains unnoticed until it stains with chromogenic material. When the fracture extends into the dentin and the fractured fragments separate slightly, there is severe pain with cold during mastication and with lingual or buccal pressure. The clinical examination of a tooth with a sharp explorer may not reveal the fracture line, but the application of gentian violet in alcohol may help to detect these frac-
Volume 31 Number 2
Management
of coronal
fractures
175
Fig. 3. A proximal view of an incomplete vertical fracture (F) of a maxillary second molar (A) before staining with gentian violet and (B) after staining with gentian violet. A view of a mandibular first molar (C) with two stained fractures (F).
showing proximal
tures in the initial stage (Fig. 3). The application of cold either with ethyl chloride spray or ice will elicit severe pain. With an electric pulp tester, the tooth responds with slightly less current than usual. In such teeth, the occlusion should be corrected first, in order to lessen the masticatory stresses and prevent further injury. A complete cast crown will permanently splint the fractured fragments, One interesting finding was that, in five of the 17 first-molar fractures, similar fractures extending only into the enamel occurred in the contralateral teeth (Fig. 1, B). To prevent further extension of the fracture, such teeth should be restored with an appropriate cast metal restoration. The pain is severe vvhen the pulp is involved. This type of pain is difficult to control even with analgesics. The pain may be less in teeth where the fractured fragments have separated and the pulp is in the process of degeneration. In the initial stage, there is severe pain on the application of cold, which may continue even after its removal. In doubtful teeth, treatment may be postponed for a week or two until definite symptoms are noticed. The threshold of response to electric current may be low in the initial stage or high in the later stage or may even be within the normal limits due to seepage of oral fluids inside the tooth. The test may not be helpful in arriving at the correct diagnosis. The tooth is tender to percussion only when pulpitis is advanced and the periapical region is involved. As the degeneration progresses, the decomposed products of the pulp stain the fragments, and the fracture line becomes visible clinically. The prognosis of the tooth depends upon the involvement of the subpulpal wall. The pulp chamber must be opened to detect the extent of the fracture line. A tooth in which the fracture line has not extended to the subpulpal wall may be endodontically treated and restored with a complete cast crown (Fig. 3, C) . When the fracture involves the subpulpal wall (Fig. 2, A and B) , the tooth must be extracted. Of the 40 teeth treated for coronal fractures, 19 were first molars. This percentage may be due to the maximum masticatory force exerted over these teeth (Table I). Most of the fractures were located toward the lingual side of the occlusal surface because of the steep inclination of the lingual cuspal planes and the placement of
176
Talk
Table
Age
I. Etiology /
J. Prosthet. Dent. Fc~bnmy, 1974
and Gohil
Etiologv
and
treatment i Tooth
of 40 fractured
posterior
Treatment
Classification
/
40
Stone particle
Incomplete vertical pulp exposure Incomplete vertical pulp exposure Incomplete vertical pulp exposure Incomplete vertical pulp exposure Incomplete vertical pulp exposure Incomplete vertical pulp exposure Incomplete vertical pulp exposure Incomplete vertical pulp exposure Complete vertical lingual cusps with exposure Incomplete vertical pulp exposure Incomplete vertical exposure involving wall Incomplete vertical pulp exposure Incomplete vertical pulp exposure Incomplete vertical pulp exposure Incomplete vertical pulp exposure Incomplete vertical pulp exposure Incomplete vertical pulp exposure Complete oblique exposure
29
Stone particle
Complete exposure
38
Stone particle
Incomplete vertical pulp exposure
50
Stone particle
Complete involving
distolingual dentin
36
Stone particle
Complete involving
lingual dentin
45
Stone particle
Complete involving
distolingual dentin
45
Betel nut
45
Betel nut
48
53
Stone particle Stone particle Stone particle Betel nut
53
Betel nut
45
Betel nut
46*
Betel nut
45
Betel nut
50
Stone particle
50
Stone particle Stone particle Stone particle Stone particle Stone particle Betel nut
48 42
26 26 30 55 50
*Pulp became necrotic
with with with
after three months. Tooth
no
Endodontic complete crown Endodontic complete crown Complete crown
with
no
with
no
Endodontic complete crown Endodontic complete crown Complete crown
with
no
Complete
crown
with
no
Complete
crown
of both no pulp
Complete
crown
with
with with pulp subpupal with
no
Endodontic complete crown Endodontic complete crown Complete crown
with with with
pulp
with
pulp
with
complete
Complete
with with
Endodontic crown Extraction
no
with
oblique
teeth
no
cusp
cusp
Endodontic crown Endodontic crown Endodontic crown Endodontic crown
crown
complete complete dowel dowel
Complete
crown
Complete
crown
Desensitization failedcement base and amalgam restoration cusp
was extracted.
Complete
crown
Volume 31 Number 2
Table Age 24 48 45 ‘5 ‘P 55 35 35 25 48 18 18 18 18
18 18 18
Management
of coronal
fractures
177
I-Cont’d 1
Etiology
stone particle Stone particle stone particle Stone particle Stone particle Unknown Stone particle Stone particle Bone Unknown Accidental fall Accidental fall Accidental fall Accidental fall Accidental fall Accidental fall Accidental fall
1 Tooth
)
Classification
Treatment
Complete palatal cusp with pulp exposure Complete enamel
Endodontic dowel crown Judicious grinding
Complete mesiobuccal cuspenamel only Complete horizontal with no pulp exposure Complete lingual cusp with no pulp exposure Incomplete vertical distolingual cusp with pulp exposure Complete enamel of lingual cusp Complete enamel of distolingual cusp Complete enamel and dentin of mesiolingual cusp Incomplete enamel and dentin Complete oblique lingual cusp with pulp exposure Complete oblique mesiolingual cusp with pulp exposure Complete oblique buccal cusp involving enamel and dentin Complete oblique distobuccal and lingual cusps involving enamel and dentin Complete oblique buccal cusp involving enamel and dentin Complete oblique lingual cusp involving enamel and dentin Incomplete vertical involving enamel and dentin
Selective grinding for occlusal relief Endodontic dowel crown with cuspid anatomy Partial veneer crown with cuspid anatomy Old fracture-severe pain-tooth extracted Judicious grinding Judicious
grinding
Complete
crown
Complete crown Endodontic dowel crown with cuspid anatomy Endodontic complete crown Complete crown Complete
crown
Complete
crown
Complete
crown
Complete
crown
the central groove toward the lingual aspect of the tooth. Treatment of complete oblique fractures of premolars involving enamel and dentin or enamel, dentin, and pulp of either cusp needs special consideration. These teeth are difficult to restore, since the support needed to restore the cusp is inadequate because of the constriction at the cervical region. The masticatory load can be minimized by restoring the tooth in the manner for a canine, using a partial veneer crown with or without a dowel when the pulp is involved. The extension of the occlusal portion of the partial veneer crown toward the buccal surface will give additional protection and support to the cusp. A complete horizontal fracture usually involves the pulp and can be treated with root-canal therapy, followed by construction of a dowel and cast or amalgam core and a complete cast crown.
178
.I. Prosthet. Dent. F&r-uaw, 1974
Talim and Go&l
A thorough history, careful examination, correct diagnosis. planning will help to restore these teeth to normal function.
and sound treatment
SUMMARY
Forty fractured posterior teeth were studied, and a classification for the convenience of discussion and treatment has been suggested. Signs, symptoms, and treatment procedure for the restoration and prevention of fractures of the permanent posterior teeth v,‘ere discussed. References 1. Gibbs, J. W.: Cuspal Fracture Odontaigia, Dent. Dig. 60: 158-160, 1954. 2. Cameron, C. E.: Cracked-Tooth Syndrome, J. Am. Dent. Assoc. 68: 405-411, 1964. 3. Gabel, A. B.: The American Textbook of Operative Dentistry, ed. 9, Philadelphia, Lea & Febiger, Publishers, p. 163. GOVERNMENT AHMEDARAD
DENTAL
16, INDIA
COLLEGE
AND HOSPITAL
1954,
teeth
S. T. Talim,
M.D.S.,*
of coronal
and
fractures
K. S. Gohil,
of permanent
M.D.%**
Government Dental College and Hospital, Ahmedabad, India
F
ractured posterior teeth have always presented problems in diagnosis and treatment planning. Many incomplete fractures go unnoticed due to the difficulty in diagnosis---the fracture lines usually run along grooves and fissures. Furthermore, the adjoining teeth make it difficult to locate proximal fractures. At times, even the finest probe fails to detect such defects. Unfortunately, scant literature is available regarding classification and treatment of the fractured permanent posterior teeth. Gibbs’ described incomplete fractures without giving many details. Cameron’ also reported on the subject, but most of the teeth he studied either had extensive caries or were restored. This report describes, in detail, the types, signs, and symptoms of and the therapy for fractures of sound posterior teeth. For convenience of discussion and treatment planning of fractured posterior teeth, the following classification is suggested : Class I. Fracture involving enamel a. Horizontal or oblique b. Vertical 1. Complete 2. Incomplete Class II. Fracture involving enamel and dentin without involving pulp a. Horizontal or oblique b. Vertical 1. Complete 2. Incomplete Class III. Fracture of enamel and dentin involving the pulp a. Horizontal b. Vertical 1. Complete *Professor **Lecturer,
172
and Head, Department Department
of Operative
of Operative
Dentistry.
Dentistry.
Management 2. Incomplete Fracture of the roots a. Vertical or oblique 1. Involving the pulp 2. Not involving the pulp b. Horizontal 1. Cervical third 2. Middle third 3. Apical third This classification also applies to fractures
of coronal
fractures
173
Class IV.
of the anterior
teeth.
FACTORS Predisposing factors. The present study shows that fractures of posterior teeth are commonly found in the middle and advanced age groups. The predisposing factors are those which increase the forces acting on the cusps and those which weaken resistance to masticatory forces. Factors which will increase the masticatory load are strong masseter muscles and deep occlusal fissures and grooves. Hypoplastic teeth, a betel nut chewing habit, and sand particles in food cause occlusal wear, thereby reducing the ability of the tooth to resist masticatory forces: The last two are common in this area. The higher percentage of fractures in the advanced age groups may also be due to posteruptive maturation of enamel. Fractured teeth with large cavities and restorations were excluded from the study. Etiologic factors. The tooth may fracture due to trauma or accidental biting on any hard object, such as betel nut, lead shot, cherry stone, bone, or particles of stone. The discomfort or even pain caused by unexpected striking of a small object between the teeth can be explained by the sudden concentration of a force, previously distributed over a number of teeth, on one or two teeth. It seems logical to assume ( 1) that the pain itself is part of a reflex action which stops the contraction of the muscles of mastication and (2) that, during the time required for the reflex action to take place, contraction continues for an appreciable period after contact, thus increasing the discomfort and damage. When it is further considered that the total force is not only suddenly concentrated on one or two teeth but, in the case of a hard small object, to very small areas on these teeth, the fracture of teeth or failure of a restoration can be readily understood.
DISCUSSION Accidental biting on a hard object may lead to periodontitis. The tooth may be only slightly tender and, at times, will make closure of the teeth painful. Relieving the occlusion generally eliminates the discomfort, but when the trauma results in fracture of the tooth, the treatment procedure will depend upon the involvement of the enamel, dentin, or pulp. Fracture of enamel may leave an irregular surface which can be improved by grinding. When the fracture involves the dentin, the surface of the tooth becomes rough and sensitive to both touch and cold. Selective grinding of sharp enamel mar-
174
J. Prosthet. Dent. February, 19i4
Talim and Gohil
Fig. 1. Incom lplete vertical fractures and PUMP (a) and enamel only (b).
(F)
of a mandibular
first molar involving
Fig. 2. Occlusal view of a mandibular second molar (A) with a mesiodistal the central groove (B) with both fragments separated.
c:namel dentin
fracture
(F) along
gins and application of 33.3 per cent sodium fluoride and kaolin-glycerine paste over the sensitive dentin will prove helpful. Use of desensitizing agents (silver nitrate or zinc chloride) which may further irritate the pulp should be avoided. When the area of involvement is large, onlays, inlay-onlay, or three-quarter crown restorations may serve depending upon the surfaces involved and the required retention. Inlays which do not restore the cusps should be avoided, since they may further increase the susceptibility of the tooth to fracture. Fractures on the non-stressbearing surfaces can be restored with any resinous restorative material with an adequate cement lining. Nearly all the incomplete vertical fractures studied were located along the central groove extending mesially and distally and were difficult to diagnose both clinically and radiographically (Figs. 1 and 2). The vertical fracture of enamel is symptomless and remains unnoticed until it stains with chromogenic material. When the fracture extends into the dentin and the fractured fragments separate slightly, there is severe pain with cold during mastication and with lingual or buccal pressure. The clinical examination of a tooth with a sharp explorer may not reveal the fracture line, but the application of gentian violet in alcohol may help to detect these frac-
Volume 31 Number 2
Management
of coronal
fractures
175
Fig. 3. A proximal view of an incomplete vertical fracture (F) of a maxillary second molar (A) before staining with gentian violet and (B) after staining with gentian violet. A view of a mandibular first molar (C) with two stained fractures (F).
showing proximal
tures in the initial stage (Fig. 3). The application of cold either with ethyl chloride spray or ice will elicit severe pain. With an electric pulp tester, the tooth responds with slightly less current than usual. In such teeth, the occlusion should be corrected first, in order to lessen the masticatory stresses and prevent further injury. A complete cast crown will permanently splint the fractured fragments, One interesting finding was that, in five of the 17 first-molar fractures, similar fractures extending only into the enamel occurred in the contralateral teeth (Fig. 1, B). To prevent further extension of the fracture, such teeth should be restored with an appropriate cast metal restoration. The pain is severe vvhen the pulp is involved. This type of pain is difficult to control even with analgesics. The pain may be less in teeth where the fractured fragments have separated and the pulp is in the process of degeneration. In the initial stage, there is severe pain on the application of cold, which may continue even after its removal. In doubtful teeth, treatment may be postponed for a week or two until definite symptoms are noticed. The threshold of response to electric current may be low in the initial stage or high in the later stage or may even be within the normal limits due to seepage of oral fluids inside the tooth. The test may not be helpful in arriving at the correct diagnosis. The tooth is tender to percussion only when pulpitis is advanced and the periapical region is involved. As the degeneration progresses, the decomposed products of the pulp stain the fragments, and the fracture line becomes visible clinically. The prognosis of the tooth depends upon the involvement of the subpulpal wall. The pulp chamber must be opened to detect the extent of the fracture line. A tooth in which the fracture line has not extended to the subpulpal wall may be endodontically treated and restored with a complete cast crown (Fig. 3, C) . When the fracture involves the subpulpal wall (Fig. 2, A and B) , the tooth must be extracted. Of the 40 teeth treated for coronal fractures, 19 were first molars. This percentage may be due to the maximum masticatory force exerted over these teeth (Table I). Most of the fractures were located toward the lingual side of the occlusal surface because of the steep inclination of the lingual cuspal planes and the placement of
176
Talk
Table
Age
I. Etiology /
J. Prosthet. Dent. Fc~bnmy, 1974
and Gohil
Etiologv
and
treatment i Tooth
of 40 fractured
posterior
Treatment
Classification
/
40
Stone particle
Incomplete vertical pulp exposure Incomplete vertical pulp exposure Incomplete vertical pulp exposure Incomplete vertical pulp exposure Incomplete vertical pulp exposure Incomplete vertical pulp exposure Incomplete vertical pulp exposure Incomplete vertical pulp exposure Complete vertical lingual cusps with exposure Incomplete vertical pulp exposure Incomplete vertical exposure involving wall Incomplete vertical pulp exposure Incomplete vertical pulp exposure Incomplete vertical pulp exposure Incomplete vertical pulp exposure Incomplete vertical pulp exposure Incomplete vertical pulp exposure Complete oblique exposure
29
Stone particle
Complete exposure
38
Stone particle
Incomplete vertical pulp exposure
50
Stone particle
Complete involving
distolingual dentin
36
Stone particle
Complete involving
lingual dentin
45
Stone particle
Complete involving
distolingual dentin
45
Betel nut
45
Betel nut
48
53
Stone particle Stone particle Stone particle Betel nut
53
Betel nut
45
Betel nut
46*
Betel nut
45
Betel nut
50
Stone particle
50
Stone particle Stone particle Stone particle Stone particle Stone particle Betel nut
48 42
26 26 30 55 50
*Pulp became necrotic
with with with
after three months. Tooth
no
Endodontic complete crown Endodontic complete crown Complete crown
with
no
with
no
Endodontic complete crown Endodontic complete crown Complete crown
with
no
Complete
crown
with
no
Complete
crown
of both no pulp
Complete
crown
with
with with pulp subpupal with
no
Endodontic complete crown Endodontic complete crown Complete crown
with with with
pulp
with
pulp
with
complete
Complete
with with
Endodontic crown Extraction
no
with
oblique
teeth
no
cusp
cusp
Endodontic crown Endodontic crown Endodontic crown Endodontic crown
crown
complete complete dowel dowel
Complete
crown
Complete
crown
Desensitization failedcement base and amalgam restoration cusp
was extracted.
Complete
crown
Volume 31 Number 2
Table Age 24 48 45 ‘5 ‘P 55 35 35 25 48 18 18 18 18
18 18 18
Management
of coronal
fractures
177
I-Cont’d 1
Etiology
stone particle Stone particle stone particle Stone particle Stone particle Unknown Stone particle Stone particle Bone Unknown Accidental fall Accidental fall Accidental fall Accidental fall Accidental fall Accidental fall Accidental fall
1 Tooth
)
Classification
Treatment
Complete palatal cusp with pulp exposure Complete enamel
Endodontic dowel crown Judicious grinding
Complete mesiobuccal cuspenamel only Complete horizontal with no pulp exposure Complete lingual cusp with no pulp exposure Incomplete vertical distolingual cusp with pulp exposure Complete enamel of lingual cusp Complete enamel of distolingual cusp Complete enamel and dentin of mesiolingual cusp Incomplete enamel and dentin Complete oblique lingual cusp with pulp exposure Complete oblique mesiolingual cusp with pulp exposure Complete oblique buccal cusp involving enamel and dentin Complete oblique distobuccal and lingual cusps involving enamel and dentin Complete oblique buccal cusp involving enamel and dentin Complete oblique lingual cusp involving enamel and dentin Incomplete vertical involving enamel and dentin
Selective grinding for occlusal relief Endodontic dowel crown with cuspid anatomy Partial veneer crown with cuspid anatomy Old fracture-severe pain-tooth extracted Judicious grinding Judicious
grinding
Complete
crown
Complete crown Endodontic dowel crown with cuspid anatomy Endodontic complete crown Complete crown Complete
crown
Complete
crown
Complete
crown
Complete
crown
the central groove toward the lingual aspect of the tooth. Treatment of complete oblique fractures of premolars involving enamel and dentin or enamel, dentin, and pulp of either cusp needs special consideration. These teeth are difficult to restore, since the support needed to restore the cusp is inadequate because of the constriction at the cervical region. The masticatory load can be minimized by restoring the tooth in the manner for a canine, using a partial veneer crown with or without a dowel when the pulp is involved. The extension of the occlusal portion of the partial veneer crown toward the buccal surface will give additional protection and support to the cusp. A complete horizontal fracture usually involves the pulp and can be treated with root-canal therapy, followed by construction of a dowel and cast or amalgam core and a complete cast crown.
178
.I. Prosthet. Dent. F&r-uaw, 1974
Talim and Go&l
A thorough history, careful examination, correct diagnosis. planning will help to restore these teeth to normal function.
and sound treatment
SUMMARY
Forty fractured posterior teeth were studied, and a classification for the convenience of discussion and treatment has been suggested. Signs, symptoms, and treatment procedure for the restoration and prevention of fractures of the permanent posterior teeth v,‘ere discussed. References 1. Gibbs, J. W.: Cuspal Fracture Odontaigia, Dent. Dig. 60: 158-160, 1954. 2. Cameron, C. E.: Cracked-Tooth Syndrome, J. Am. Dent. Assoc. 68: 405-411, 1964. 3. Gabel, A. B.: The American Textbook of Operative Dentistry, ed. 9, Philadelphia, Lea & Febiger, Publishers, p. 163. GOVERNMENT AHMEDARAD
DENTAL
16, INDIA
COLLEGE
AND HOSPITAL
1954,