SINGLE VISIT MTA APEXIFICATION TECHNIQUE FOR FORMATION OF ROOT-END BARRIER IN OPEN APICES- A CASE SERIES

Transcription

1 SINGLE VISIT MTA APEXIFICATION TECHNIQUE FOR FORMATION OF ROOT-END BARRIER IN OPEN APICES- A CASE SERIES Bhumika Kapoor, Osama Adeel Khan Sherwani, Rajendra K Tewari, Surendra K Mishra. 1,2 3,4 Junior Resident, Professor, Department of Conservative Dentistry and Endodontics. Dr. Z. A. Dental College & Hospital, Aligarh Muslim University, Aligarh ABSTRACT: Mineral trioxide aggregate apexification is a viable option for treatment of open apex. MTA forms an apical barrier at the root end against which endodontic treatment can be successfully completed. The multiple advantages of MTA such as its biocompatibility, sealing ability, antimicrobial properties, bioactivity along with single appointment treatment option for open apex is a boon in the field of endodontics. Using calcium hydroxide for root end formation has many disadvantages like decrease in strength of radicular dentin and long follow up visits. Therefore, MTA is material of choice for such cases. However, using calcium hydroxide dressing before MTA placement increases ph of acidic environment and hence maintains hydrated gel like structure of MTA.The following case series represents 4 cases of open apex in which MTA was used for root end barrier formation against which obturation was done successfully. University Journal of Dental Sciences Case Series Keywords : Mineral trioxide aggregate, open apex, apexification. Source of support : Nil Conflict of interest : None INTRODUCTION : Apexification is defined as a method to induce a calcified barrier in a root with an open apex or continued apical development of an incompletely formed root in teeth with necrotic pulp tissue(1). Several materials are used for the management of open apices. The most widely used material until recently was calcium hydroxide that was replaced over intervals for several months, to stimulate calcific barrier formation. Torabinejad and Chivian introduced mineral trioxide aggregate (MTA) as an apical plug and now it is an accepted material for apexification till date. The use of calcium hydroxide affects various mechanical properties of radicular dentin (2). The alkaline ph of calcium hydroxide increases the chances of fracture due to denaturation of dentinal organic proteins. Hence, it is not recommended in teeth with thin dentinal walls. Mineral Trioxide Aggregate is a powder consisting of fine hydrophilic particles of tricalcium silicate, tricalcium aluminate, tricalcium oxide and silicate oxide. It also contains small amounts of other mineral oxides, which modify its chemical and physical properties. Radio opacity is provided by bismuth oxide. The ph of MTA IS 12.5 which imparts it antimicrobial activity(3). MTA has good sealing ability, good biocompatibility, excellent long term prognosis and ability of tissue regeneration. These properties prove it to be a material of choice for cases with high failure rates. The following case series consist of 4 cases with open apex in which single appointment apexification was done with MTA. CASE REPORT 1: An 11 year old boy was referred to Department of Conservative Dentistry and Endodontics, Aligarh Muslim University, Aligarh with the chief complaint of spontaneous pain in upper front teeth. He had a trauma 3 years back but was asymptomatic till recently. Clinical examination revealed fracture of tooth 11. The tooth was tender on percussion and labial mucosa of the concerned tooth showed inflammation. The tooth was painful on palpation. Intraoral radiograph showed incomplete root end formation of 11. The dentinal walls were thick. (Fig1) Fig1: Preoperative radiograph revealed open apex in tooth 11. Pulp testing was done with pulp tester (Parkell inc, USA) and thermal test with heated gutta percha, showed no response in the suspected tooth when compared to adjacent, contralateral tooth. The tooth was diagnosed with pulp necrosis with periradicular periodontitis. 60

2 The patient was discussed with various treatment plans and consent was obtained. Following isolation with a rubber dam, an endodontic access opening was made. Working length was established with the help of intraoral periapical radiograph using 80K file. Minimum instrumentation was done and the walls of canal were circumferentially cleaned with 80K file. The root canal was copiously irrigated with 5.25% sodium hypochlorite and normal saline. Intracanal dressing with calcium hydroxide (Ultradent Products inc, USA) was given for one week and the provisional restoration with Cavit(Cavit GTM) was given. On recall visit, the tooth was asymptomatic. The temporary restoration was removed and canal was irrigated with normal saline and dried with size 80 absorbent paper point(ultradent Products inc, USA). A suitable plugger size that fitted loosely within 2mm of apex was chosen. MTA was mixed with distilled water to a consistency of wet sand and placed in increments in the apical region of the canal using Micro Apical Placement (MAP) system(dentsply Tulsa).Mineral trioxide aggregate was compacted with the plugger previously fitted to the root canal system. Care was taken to prevent extrusion of the material into the periapical area. The final adjustment was done with inverted cut end of gutta percha size 80(Dentsply, USA) with the help of radiograph till a minimum thickness of 5mm. Once the MTA layer is adequately compacted to the working length and confirmed with a radiograph,(fig 2) the excess was removed from the coronal and middle third of the canal with the help of sterile wet fine brush.a moist cotton pellet was placed against it, as the presence of moisture is essential for the material to set.the access cavity was temporized. The patient was recalled after 24 hours. At the next appointment, the MTA felt hard to an endodontic explorer DG-16 (Hu-Friedy International).The remaining part of the root canal was backfilled with injection molded thermoplastic gutta-percha (Obtura III, USA) and sealer (AH 26, Dentsply, Germany). Post obturation radiograph was taken.the patient was asked to report after a week for clinical evaluation and the post endodontic restoration. During recall, the tooth was asymptomatic and post endodontic composite (Tetric Ceram, Ivoclar Vivadent Inc) restoration was placed(fig 3) and patient was recalled after 3,6,12 months for the follow-up. Fig 2: Mineral trioxide aggregate plug Fig 3: Post obturation radiograph CASE REPORT 2: A 14 year old boy was referred to the Department of conservative dentistry and endodntics, AMU Aligarh with the chief complaint of pus discharge from the openings near the root apex of tooth 11. He had trauma 4 years back but was not symptomatic till last 2 months. Clinical examination revealed fractured tooth 11 involving the pulp. Sinus opening was present near the root apex. The tooth was not tender on percussion and there was no pain on palpation. Labial mucosa adjacent to the concerned tooth was inflamed. Intraoral periapical radiograph showed open apex of tooth 11. The dentinal walls were thin.(fig 4) Fig 4: IOPA revealed open apex in tooth 11 Treatment protocols included apexification with calcium hydroxide, single visit MTA apexification and revascularization technique. The patient gave consent for single appointment apexification as he could not report at regular intervals. Following isolation with a rubber dam, an endodontic access opening was made. Working length was established with the help of intraoral periapical radiograph using 80K file. Minimum instrumentation was done and the walls of canal were circumferentially cleaned with 80K file. The root canal was copiously irrigated with 5.25% sodium hypochlorite and normal saline. Intracanal dressing with calcium hydroxide (Ultradent Products inc, USA) was given for one week and access cavity was temporized with Cavit ( Cavit GTM). On recall visit, the tooth was asymptomatic. The temporary restoration was removed and canal was irrigated with normal saline and dried with size 80 absorbent paper point (Ultradent Products inc, USA). A suitable plugger was chosen. MTA was mixed with distilled water to a consistency of wet sand and placed in increments in the apical region of the canal using Micro Apical Placement (MAP) system (DENTSPLYTulsa).Mineral trioxide aggregate was compacted with the help of plugger. Care was taken to prevent extrusion of the material into the periapical area. The 61

3 thickness of MTA was kept 5mm and a moist cotton pellet was placed against it for proper setting(fig 5).Access cavity was given temporary restoration. Patient was recalled next day for obturation. Obturation was done with thermoplastisized technique using Obtura III (Obtura Spartan,Canada). The patient was asked to report after a week for clinical evaluation and the post endodontic restoration (fig 6). During recall, the tooth was asymptomatic and post endodontic composite (Tetric Ceram, Ivoclar Vivadent Inc) restoration was placed and patient was recalled after 3,6,12 months for the follow-up. Fig 5: MTA condensed at the apex Fig 6: Post obturation radiograph CASE REPORT 3: A 21 year old female patient reported to Department of Conservative Dentistry and endodontics, AMU Aligarh. She complained of pain in upper front left tooth since last 4 months. On examination, tooth 21 had a crown placed on it. The tooth was tender on percussion and there was pain on palpation. Intraoral periapical radiograph revealed open apex of tooth 21. The tooth was not endodontically treated and the crown was placed on it. The dentinal walls were thick (fig 7) Single appointment MTA apexification was planned. On the first appointment the crown was removed using crown removal system(safe crown and bridge removal, Anthogyr) The tooth was isolated by rubber dam and access cavity was made through remaining tooth structure. The working length was established with the help of intraoral radiograph. The canal walls were circumferentially cleaned with 80K file and copious irrigation was done with 5.25% hypochlorite and normal saline. Calcium hydroxide (Ultradent Products inc, USA) dressing was placed for 1 week. The tooth was given temporary restoration with cavit (Cavit GTM3M ESPE, Seefeld, Germany) After 1 week, patient was asymptomatic and tooth was not tender on percussion. The temporary restoration was removed and irrigation with hypochlorite and normal saline was performed to remove calcium hydroxide from the canal. Absorbent paper points (Ultradent Products inc, USA) was used to dry the canal completely. MTA was mixed with distilled water and placed in apical region with help of suitable carrier gun. The material was then condensed to a thickness of 5mm and confirmed radiographically. A wet cotton pellet was placed over cement for proper setting. Patient was recalled further for custom made cast post and crown fabrication (fig 8). The patient was kept on follow up. Fig 7: Preoperative radiograph showing open apex and crown in tooth 21 with no endodontic treatment Fig 8: MTA condensed at the apex. Cast post and crown fabricated CASE REPORT 4: An18 year old female patient reported in department of conservative dentistry and endodontics, AMU Aligarh. She complained of pain in upper front teeth. The patient had trauma 7 years back. On examination, tooth 11 was fractured. There was a sinus tract in relation to tooth 11 and 12 and there was pain on palpation Intra oral radiograph revealed large periapical pathology in relation to tooth 11 and 12. Tooth 11 showed open apex and exposed pulp. (fig 9) Endodontic management of both teeth were decided with single appointment MTA apexification for tooth 11 and root canal treatment for tooth 12.The teeth were isolated by rubber dam and access cavity was made. The working length was established with the help of intraoral radiograph. The canal walls of tooth 11 were circumferentially cleaned with 80K file and copious irrigation was done with 5.25% hypochlorite and normal saline. For tooth 12, chemomechanical preparation was performed with hand K Files (Dentsply, USA).Calcium hydroxide ( Ultradent Products inc, USA) dressing was placed for 1 week. The tooth was given temporary restoration with cavit (Cavit GTM3M ESPE, Seefeld, Germany). After 1 week, the patient was symptomatic, therefore, second calcium hydroxide dressing was placed. On the next appointment, the provisional restoration was removed and irrigation was performed to remove all calcium hydroxide. The canal was dried with paper points and MTA was mixed with distilled water and placed in apical region with help of suitable carrier gun. The material was then condensed to a thickness of 5mm and confirmed radiographically(fig 10). A wet cotton pellet was placed over cement for proper setting. 62

4 Patient was recalled next day for obturation and post endodontic restoration. Tooth 11 was obturated using obtura III and tooth 12 was obturated with lateral condensation (fig 11) Fig 9: Preoperative radiograph showing fractured 12 with open apex Fig 10: MTA apical plug Fig 11: Post obturation radiograph DISCUSSION : Open apices have always been a challenge to an endodontist since it requires an apical barrier against which the canal can be successfully obturated. Premature loss of permanent tooth can lead to various problems such as wide, diverging or parallel canals, inappropriate crown root ratio, thin dentinal walls etc. These problems can pose a threat to successful treatment. Apart from this, fear of dentist of the young individual and discontinuation of any treatment procedure are other risk factors that may not lead to successful treatment. Apexification is the last treatment option of an immature permanent tooth which has lost its pulpal vitality. It causes root end closure by forming an apical plug but does not cause increase in root length and thickness or root end development unlike apexogenesis or revascularization technique. Apexogenesis is treatment to preserve vital pulp tissue in the apical part of a root canal in order to complete formation of root apex(4).therefore, apexogenesis is only possible when some vital pulp is remaining. It was not possible in our cases as all of them had necrotic pulp. Revascularization technique has an added advantage of complete formation of pulp dentin complex. The defense mechanisms of pulp dentin complex is also completely established by regenerative techniques. However, long term follow up and uncertainty of the results are disadvantages of revascularization protocol. Also, till date only case reports and case series have been reported for regeneration technique. The randomized controlled trails are still lacking for a definite evidence. Open apices are usually seen in young individuals and hence surgery is not a desirable treatment for this. The thin, fragile dentinal walls poses a threat to fracture on compaction of root end filling material. Also, patent dentinal tubules of young dentin cannot be sealed completely by root end filling material. Many materials have been reported to induce calcific barrier formation. The use of non setting calcium hydroxide was done by Kaiser in 1964(5) and later Frank(6) brought this to a higher level. Coviello and Brilliant in 1979 introduced tricalcium phosphate(7)later, Schumache and Rutledge in 1993 suggested calcium hydroxide as a permanent apical barrier (8). The Frank's technique of placing calcium hydroxide sometimes provides inconsistent results like: 1) The periapex closes with a definite (though minimal) recession of the root canal. The apical aspect continues to develop with a seemingly obliterated apex. 2) The obliterated apex develops without any change in the root canal space. 3) A thin, calcific bridge that is not radiographically discernable develops. 4) A calcific bridge forms just coronal to the apex and can be determined radiographically. One of the major drawbacks of calcium hydroxide is that it is a multiple visit procedure. In this procedure, the calcium hydroxide dressing is replaced every three months until a barrier is formed, which may require up to 24 months. So, such repetitive procedures are difficult to maintain. The long term and short term of calcium hydroxide can affect the mechanical properties of radicular dentin.(9,10,11) The ph of calcium hydroxide is 11.8 which is highly alkaline. Some authors have proposed that the alkaline ph of Ca(OH)2 may lead to neutralization and denaturation of dentin organic proteins. This may cause collagen degradation leaving the root more prone to fracture(2,12) Infection control is an upmost factor for any successful procedure. Similar, is the case with apexification where presence of infection can cause delay in root end closure(12,13). However, some authors have claimed that there is no significant difference in apexification time when infection is present(14,15,16) The long term procedures also exposes the risk of loss of coronal seal. This further can increase the duration of procedure as infection free environment cannot be maintained. Thus, keeping all facts in mind a single appointment, non surgical approach to open apex is best treatment plan. A desirable material which can form an apical plug is required 63

5 for this procedure. To, the best of our knowledge Mineral trioxide aggregate (MTA) is material of choice for single appointment apexification and till date no material has been at par with MTA. Torabinejad et al discovered orginal form of MTA which was gray MTA(17) The main constituents are calcium silicate(casio 4), bismuth oxide(bi2o 3), calcium carbonate(caco 3), calcium sulfate(caso 4), Calcium Aluminate(CaAl2O 4). MTA cement contains a hydrophilic powder that reacts with water and produces a calcium hydroxide and calcium silicate hydrated gel. A major advantage of MTA is its biocompatibility (18,19,20,21) and hard tissue formation. This hard tissue formation is because of ability of MTA to induce c e m e n t o b l a s t i c c e l l s ( 2 2 ) S c a n n i n g e l e c t r o n microscope(sem) analysis has shown that cementoblasts have ability to attach and grow on MTA. MTAforms a biologic barrier at the apical end which prevents regress of microorganisms(23) It causes deposition of new cementum and periodontal regeneration. MTA has longest setting time of 2 hours and 45 minutes. The compressive strength is low 40MPa but it increases to 67MPa in 21 days. The initial ph is 10.2 which rises to 12.5 in 3 hours after mixing. Gray MTA had a disadvantage of discoloration which was solved by discovery of white MTA in 2002.The composition of both varieties is similar and a difference of less than 6 % is seen in any one of the component. The radioopacity of both kinds is similar and it is 3.04mm of aluminum. However, placing gray MTA at the apex is not unaesthetic in anyway. The use of MTA as an apical barrier was first reported in 1996.(24) Shabahanget al compared MTA, osteogenic protein- 1 and Calcium hydroxide for apexification in dogs(25) and found that MTA induced hard-tissue formation more often than any other test materials. Thus, MTA was suitable for use as an apical barrier for apexification in immature roots. In 2007, Simon et al used MTA on 57 teeth had showed successful results(26).he concluded that that use of MTA reduces root fracture risk, had better patient compliance and showed early results. Before placement of MTA it is advocated to place calcium hydroxide in the canal for 1 week interval for disinfection of canal. The acidic ph raises which reduces inflammation of periapical tissues. After one week interval if the tooth is free from symptoms then the tooth is isolated with the help of rubber dam and calcium hydroxide is washed away. After drying of canal by paper points MTA is placed in increments by using MTA carrier or amalgam carrier and condensed with suitable pluggers and cut end of inverted GP cone no. 80. It is placed 4 to 5mm in thickness(27). The adequacy of material is verified radiographically. As the setting time of MTA is long and it needs moisture during setting procedure a moist cotton is placed in the canal. While, placing the cotton it is kept in mind that cotton is not directly placed above MTA as cotton fibers may get entrapped in the material. The tooth is then given suitable provisional restoration with tight coronal seal and canal is usually condensed with obturating material in the next appointment keeping in mind it's long setting time. It is difficult to prevent extrusion of material from blunderbuss canals. Hence, placement of MTA is done with caution and it is placed 1 to 3mm short of root end. While, condensing MTA any voids should be avoided and it should be condensed in a single plane. Any excess MTA sticking on the walls should be removed by scrubbing wet cotton or brush against canal walls. MTA is also not affected by blood contamination(28). Holland et al theorized that the tricalcium oxide in MTA reacts with tissue fluids to form calcium hydroxide, resulting in an apical barrier (29).Since, apexification is done in necrotic pulp it is important to create an environment free from microbes. This further renders the need of a material with antibacterial properties. MTA is proved to possess some antibacterial properties. Torabinejad et al tested MTA, amalgam, ZOE and SuperEBA against nine facultative bacteria and seven strict anaerobes(3). Mineral trioxide aggregate was found to have an antibacterial effect on five of nine facultative bacteria but no effect on any of the strict anaerobes. The other materials had similar effects. It was concluded that none of the test materials had all of the antibacterial effects desired for a root-end filling material. Hachmeister et al emphasized that the apical plug thickness may only have a significant impact on displacement resistance(30) while in the present case the thickness of apical plug of MTA was 5 mm and the remaining part of the root canal was back-filled with injection molded thermoplastic gutta-percha (ObturaIII, USA) and sealer (AH 26, Dentsply, Germany). CONCLUSION : The development of MTA is a milestone in field of dentistry. The properties of MTA like its bioactivity, sealing ability and biocompatibility prove it to be an excellent tool for cases that have poor prognosis. Many advantages of this material along with single appointment apical closure 64

6 outweigh any disadvantage of MTA. As discussed previously single appointment is better than multiple appointments. Therefore, MTA apexification can be a feasible and effective treatment option for open apices. ACKNOWLEDGMENT: The authors are grateful to Professor Ashok Kumar (Department of Conservative Dentistry and Endodontics, Dr. Ziauddin Ahmad Dental College, AMU, Aligarh) for his support and guidance in the above cases. REFERENCES: 1. American Association of Endodontists: Glossary of Endodontic Terms, ed 7, Chicago, IL, 2003, American Association of Endodontists 2. Andreasen JO, Farik B, Munksgaard EC. Long-term calcium hydroxide as a root canal dressing may increase risk of root fracture. Dent Traumatol Jun;18(3): Torabinejad M, Hong CU, Pitt Ford TR, Kettering JD: Antibacterial effects of some root end filling materials. J Endod, 1995;21(8): Heasman P, McCracken G: Harthy's dental dictionary, 3rd Edition, London, 2007, Chuchill Livingstone Elsevier 5. Kaiser JH: Management of wide- open canals with calcium hydroxide. Paper presented at the meeting of the American Association of Endodontics, Washington, DC April 17,1964. Cited by Steiner JC, Dow PR, Cathey GM: Inducing root end closure of nonvital permanent teeth. J Dent Child 35:47, Frank AL: Therapy for the divergent pulpless tooth by continued apical formation. J Am Dent Assoc 72:87, Coviello J, Brilliant JD. A preliminary clinical study on the use of tricalcium phosphate as an apical barrier. J Endod Jan;5(1): Schumacher JW, Rutledge RE. An alternative to apexification. J Endod Oct;19(10): Twati WA, Wood DJ, Liskiewicz TW, et al. An evaluation of the effect of non-setting calcium hydroxide on human dentine: a pilot study. Eur Arch Paediatr Dent 2009;10:104 9.filling materials. J Endod, 21: , Kettering JD, Torabinejad M. Investigation of Mutagenicity of Mineral Trioxide Aggregate and other commonly used Root end Sahebi S, Moazami F, Abbott P. The effects of short-term calcium hydroxide application on the strength of dentine. Dent Traumatol 2010;26: Marending M, Stark WJ, Brunner TJ, et al. Comparative assessment of time-related bioactive glass and calcium hydroxide effects on mechanical properties of human root dentin. Dent Traumatol 2009;25: Cvek M: Treatment of non-vital permanent incisors with calcium hydroxide. I. Follow-up of periapical repair and apical closure of immature roots. Odontol Rev, 1972;23(1): Kleier D J, Barr ES: A study of endodontically apexified teeth. Endodont Dent Traumatol, 1991;7(3): Yates JA: Barrier formation time in non-vital teeth with open apices. Int Endodont J, 1988;21(5): Mackie IC: UK National Clinical Guidelines in Pediatric Dentistry. Management and root canal treatment of nonvital immature permanent incisor teeth. Int J Paed Dent, 1998;8(4): Ghose L J, Baghdady VS, Hikmat YM: Apexification of immature apices of pulpless permanent anterior teeth with calcium hydroxide. J Endod, 1987;13(6): Torabinejad M, Watson TF, Pitt Ford TR. Sealing ability of a mineral trioxide aggregate when used as a root end filling material J Endod, 19: , Torabinejad M, Hong CU, Pitt Ford TR, Kettering JD:Cytotoxicity of four root-end filling materials. J Endod, 1995;21(10): Torabinejad M, Hong CU, Pitt Ford TR, Kariyawasam SP: Tissue reaction to implanted Super-EBA and mineral trioxide aggregate in the mandible of guinea pigs: a preliminary report. J Endod, 1995;21(11): Torabinejad M, Pitt Ford TR, Abedi HR, Tang HM: Tibia and mandible reactions to implanted root-end filling materials (abstract 56). J Endod, 1997;23(4): Torabinejad M, Pitt Ford TR, Abedi HR, Kariyawasam SP, Tang HM: Tissue reaction to implanted root-end filling materials in the tibia and mandible of guinea pigs. J Endod, 1998;24(7): Thomson TS, Berry JE, Somerman MJ, Kirkwood KL:Cementoblasts maintain expression of osteocalcin in the presence of mineral trioxide aggregate. J Endod 29:407, Andreasen JO, Munksgaard EC, Fredebo L, Rud J: Periodontal tissue regeneration including 65

7 cementogenesis adjacent to dentin-bonded retrograde composite fillings in humans. J Endod 19:151, Tittle KW, Farley J, Linkhardt M, Torabinejad M:Apical closure induction using bone growth factors andmineral trioxide aggregate. J Endod 22:198, 1996 (abstract#41). 25. Shabahang S, Boyne PJ, Abcdi HR, McMillan P, Torabinejad M: Apexification in immature dog teeth using osteogenic protein- 1, mineral trioxide aggregate, and calcium hydroxide (abstract 65). J Endod, 1997;23(4): Simon S, Rilliard F, Berdal A, Machtou P: The use of mineral trioxide aggregate in one-visit apexification treatment: a prospective study. Int Endod J 40:186, Valois CR, Costa ED, Jr: Influence of the thickness ofmineral trioxide aggregate on scaling ability of rootendfillings in vitro. Oral Surg Oral Med Oral Pathol Oral RadiolEndod 97:108, Torabinejad M, Higa RK, McKendry D J, Pitt-Ford TR: Dye leakage of four root-end filling materials: Effects ofblood contamination. J Endod, 1994;20(4): Holland R, de Souza V, Nery M J, Otoboni Filho JA,Bernabe PF, Dezan E: Reaction of rat connective tissueto implanted dentin tubes filled with mineral trioxideaggregate or calcium hydroxide. J Endod, 1999;25(3): Hachmeister DR, Schindler WG, Walker WA (3rd)Thomas DD: the sealing ability and retention of mineral trioxide aggregate in a model of apexifecation. J Endod, 2002;28(5): CORRESPONDENCE : Dr. Bhumika Kapoor, Department of Conservative Dentistry and Endodontics, Dr. Z. A. Dental College & Hospital, Aligarh Muslim University, Aligarh, India bhumika.kapoor88@gmail.com 66