Journal of Evolution of Medical and Dental Sciences

Bypassing Technique for Managing Separated Instrument - A Case Report

2025-10-25T10:49:54+0530

Fracture of endodontic instruments in the canal is an unfortunate occurrence that may hinder the root canal procedure and negatively impact the treatment outcome. This fragmented instrument present inside the root canal can prevent proper preparation of the root canal space. Overall endodontic prognosis following instrument separation depends on the stage and degree of canal preparation and disinfection at the time of the instrument fracture. Instrument fracture caused by iatrogenic error can occur due to repeated use of instruments, improper technique, lack of lubrication, insufficient knowledge and skills, and use of inappropriate instruments. Management of instrument fracture includes techniques such as bypass or retrieval. This case report describes endodontic bypassing with a separated instrument in a curved canal.

Endodontic treatment aims to clean, shape, and obturate the root canal system to prevent or treat apical periodontitis.^[1] However, procedural errors such as instrument separation can occur, complicating the treatment process and potentially jeopardizing the outcome. The separation of endodontic instruments within the root canal is a common and challenging problem that can hinder adequate canal cleaning and shaping, leading to potential treatment failure.^[2,3]

Instrument separation is frequently attributed to factors such as repeated usage, improper technique, insufficient lubrication, and the intrinsic material characteristics of the instruments themselves. The incidence of separated instruments varies depending on the type of instrument and the clinician’s experience. NiTi (Nickel-titanium) rotary instruments, while highly flexible and efficient, are more prone to fracture compared to stainless steel instruments due to their unique mechanical properties.^[4,5]

When an instrument fractures inside a root canal, it can block access to the apical portion of the canal, preventing thorough cleaning and disinfection. This can lead to persistent infection and failure of the endodontic treatment. The management of separated instruments includes techniques such as bypassing or retrieval. Bypassing involves negotiating a small instrument around the separated fragment to achieve patency and continue with the root canal preparation, whereas retrieval focuses on removing the fragment from the canal entirely.^[6-8]

This case report describes the successful management of a separated endodontic instrument in a curved canal of a maxillary molar using a bypassing technique. The case highlights the importance of clinical skill, appropriate technique, and the use of advanced tools to overcome the challenges posed by instrument separation. Through this report, we aim to provide insights into the practical application of bypassing techniques in endodontic practice and emphasize the need for continuous training and knowledge enhancement among endodontists.^[9]

Endodontic Management with Posterior Indirect Adhesive Restoration by CAD-CAM Procedure - Case Report

2025-10-25T10:49:53+0530

Successful endodontic management depends on knowledge of the anatomy, appropriate modification in the treatment protocol and utilization of a computer-aided design system for final restoration. The residual structure of teeth with endodontic treatment must be preserved and is crucial to long-term survival. The objective of this case report is to describe the clinical treatment steps for endodontic management with PIAR (Posterior Indirect Adhesive Restoration) as the final restoration treatment on the first right mandibular molar using CAD-CAM procedures.

PIAR is very common nowadays in definitive restoration after root canal treatment procedure.^[1] Modern tooth restoration techniques that rely on adhesion are replacing traditional techniques that depend on mechanical retention.^[2] The use of indirect bonded restoration is very frequent in case of extended coronal destruction of a posterior tooth. The primary objective of treating compromised posterior teeth is minimal invasiveness by adhesion, which has led to a total shift in operator strategies toward minimally invasive bonded restorations. Preservation of healthy tissue, which is the main benefit of their restorations, since adhesive restorations do not need extra tooth preparation to achieve resistance and retention form.^[2,3]

The tooth structures to be evaluated include dentin, marginal ridge, pulp chamber and remaining cusp. To improve the strength, the cusp should be covered when required. The main causes of technical failure include leakage margins, excessive wear, and loss of retention.^[4] Modern restorative dentistry is showing a lot of interest in minimally invasive dentistry due to the advancement and development of adhesive bonding procedures. Maintaining the integrity of tooth structure is essential to the durability of teeth and restorations.^[5,6]

Following endodontic therapy, restorative procedures are performed while considering biomechanical and functional aspects such as canine guidance, group function, occlusion type, overjet, overbite, parafunction presence or absence, cavity dimension, occlusal surface, and remaining wall thickness.^[7]The following goals are needed when choosing the best restoration: preventing the infiltration of microorganisms into the root canal system; restoring the tooth's form, stability, and appropriate points of contact with adjacent teeth; restoring function; shielding the remaining tooth structure from additional (carious and non carious) hard tissue loss and fracture; maintaining the health of the marginal periodontal tissues; and maintaining optimal aesthetics.^[8]

Adhesion of the restorative material to the tooth is facilitated by appropriate bonding methods, which also improve marginal adaptation, prevent microleakage, and make the prepared tooth and the replacement itself more fracture resistant.^[9,10]The interface to the tooth and the interface to the restorative material are two quite different interfaces to take into account. A dual bond-a micromechanical interlocking and a real chemical bond-should be provided by the optimal bonding process to different kinds of indirect restoration.^[9]

Intravascular Laser Fiber Tip Breakage during Endovenous Laser Ablation - A Rare Procedural Complication

2025-10-25T10:49:51+0530

Varicose veins of the lower limbs are a common clinical condition caused by CVI (Chronic Venous Insufficiency). EVLA (Endovenous Laser Ablation) is a widely practiced, minimally invasive treatment modality for managing superficial venous insufficiency and varicosities. Although complications are infrequent, some device-related issues warrant attention due to their potential consequences.

We report a rare case of intravascular fragmentation of the laser fiber tip during EVLA. A 62-year-old male with a 30-year history of bilateral varicose veins presented with left lower limb pain and pigmentation. Clinical examination and venous Doppler revealed SFJ (Saphenofemoral Junction) incompetence and multiple perforator insufficiencies. EVLA of the left GSV (Great Saphenous Vein) was performed. During the procedure, loss of resistance during fiber retraction prompted inspection, which revealed that the laser fiber tip had broken intravascularly. The fragment was localized radiologically and surgically retrieved via targeted wound exploration. The patient had an uneventful postoperative recovery.

Intravascular fragmentation of the laser fiber tip is a rare but recognized device-related complication of EVLA. Adherence to procedural protocols, including fiber inspection before and after ablation, careful energy settings, and continuous intraoperative monitoring, is essential for prevention. This case underscores the importance of prompt recognition and appropriate management to prevent further complications.

Varicose veins of the lower limbs are a prevalent vascular disorder resulting from CVI. This condition arises due to valvular incompetence within the superficial venous system, leading to venous reflux, increased venous pressure, and subsequent vein dilation. It significantly impacts patients’ quality of life by causing symptoms such as pain, heaviness, leg swelling, skin changes, and ulceration, in addition to posing socioeconomic burdens due to reduced productivity and healthcare costs.^[1,2]

Historically, the mainstay of treatment for superficial venous insufficiency was surgical—specifically, high ligation and stripping of the great saphenous vein. In recent years, however, the management landscape has shifted toward minimally invasive endovenous techniques, including EVLA, RFA (Radio-Frequency Ablation), foam sclerotherapy, and cyanoacrylate glue closure. These techniques offer high efficacy, lower morbidity, shorter recovery time, and improved cosmetic outcomes.^[3]

Among these, EVLA has emerged as one of the most commonly performed procedures due to its high vein closure rates and low recurrence and complication profiles. Although EVLA is typically considered safe, there are some rare instances where complications may arise. These include bruising, thrombophlebitis, DVT, skin burns, nerve injury, pigmentation, and more rarely, device-related issues such as laser fiber tip fragmentation.^[4,5]

The case presented in this report is significant because it illustrates a rare but important device-related complication: intravascular fragmentation of the laser fiber tip during EVLA. This type of complication, if not promptly recognized and appropriately managed, can lead to serious outcomes such as thrombosis, embolism, or infection. The case underscores the need for strict procedural protocols, intraoperative vigilance, and post-procedural fiber inspection to ensure patient safety and optimal outcomes.

By documenting this event, the case adds to the limited existing literature on fiber tip fragmentation during EVLA and serves as a practical reminder for vascular surgeons and interventional radiologists to remain alert to this preventable complication during what is otherwise a safe and routine procedure.

A Neonate’s Flutter - A Rare Dance of the Heart

2025-11-18T17:05:18+0530

Atrial flutter is a supraventricular tachyarrhythmia. It is a rare and life-threatening condition during both the fetus and neonatal periods. In severe instances, atrial flutter can compromise circulation and may result in non-immune hydrops fetalis or even fetal demise. Management typically involves the use of antiarrhythmic drugs, transesophageal overdrive pacing, or synchronized direct current cardioversion. Nonetheless, when identified early and treated appropriately, the overall outlook is positive in the majority of cases.

Tachycardia in neonates is defined as a persistent increase in heart rate above 180 beats/min. The incidence of arrhythmias for neonatal period is about 1%.^[1] Atrial flutter is an uncommon type of fetal and neonatal arrhythmia. Atrial flutter occurs in approximately 2.1 out of every 100,000 live births, with structural heart defects present in around 36% of these cases.^[2] It constitutes about 32% (nearly one third) of all neonatal cardiac arrhythmias.^[3] The mechanism of atrial flutter in the newborns remains unknown. This type of arrhythmia is often caused by re-entry circuits confined to the right atrium.^[4] It is most commonly seen in children with congenital heart anomalies such as transposition of the great arteries, complex cyanotic heart disease, atrial septal defects, pulmonary stenosis, and abnormalities of the tricuspid valve. Atrial flutter may also arise following surgical procedures involving the atria, particularly after interventions like atrial switch operations for transposition of the great arteries or repair of Tetralogy of Fallot. Although it is relatively rare, atrial flutter can be life-threatening during the fetal and neonatal periods. The condition carries an estimated perinatal mortality rate of around 9%.^[5]

We report a case of a newborn with atrial flutter in the Department of Paediatrics at TRIHMS Hospital, Arunachal Pradesh. The patient’s guardian was duly informed and consent was obtained for publication of case report for medical benefit.

We report a case of a term, large for gestational age neonate who was born via lower segment caesarean section with uneventful antenatal history. His heart rate was persistently between 195-205 beats per minute. An electrocardiogram was performed, which was suggestive of atrial flutter. The atrial flutter was resistant to amiodarone therapy. Synchronised cardioversion was performed and normal sinus rhythm was achieved.

A Rare Case of Pilomatricoma with Osseous Metaplasia

2025-11-18T17:05:17+0530

Pilomatricoma is a benign skin adnexal tumor arising from the matrix cells of hair follicles. Ossifying pilomatricoma is a rare variant characterized by the presence of heterotopic bone formation within the tumor. We report a case of this rare lesion in a 19-year-old female, that was successfully managed. This case highlights the diagnostic challenges, histopathological features, pathogenesis, and treatment outcomes to assist clinicians in the accurate diagnosis and management of this unusual entity.

Interdisciplinary Approach in Endodontic Management with Limited Mouth Opening - A Case Report

2025-11-20T10:41:22+0530

Advances in life expectancy, improved quality of biomaterials used in dentistry, and the rapid development of clinical procedures have led to increasingly complex patient needs and treatment options. Managing such complexities necessitates collaboration among specialists to achieve therapeutic goals and deliver successful treatment for both functional and aesthetic enhancement.

Beginning with a full medical examination, the first stage in treating a patient entails developing a proper treatment plan and gaining a thorough understanding of the patient's condition. After the medical evaluation, x-rays and an objective assessment should be performed in order to identify any variables that may jeopardize the root canal procedure.^[1,2] Subsequently operators can conduct and evaluate diagnostic tests to ascertain a patient's condition and create a comprenshive treatment plan that takes into account their requirements and preferences. Dentists can choose cases according to their expertise, technical proficiency, and comfort level with the aid of proper treatment planning, which also helps practitioners avoid procedural mistakes.^[3,4] As a result, it is crucial to examine and evaluate the elements that contribute to RCT. In the realm of endodontics, these insights are essential for improving education and assisting practitioners in treatment planning and referral decision-making.^[2,4]

The difficulty and success rate of RCT are correlated with patient-derived characteristics like as salivation, gagging, mouth opening constraints, tooth alignment, and occlusal connections.^[5,6] According to a previous study, during an RCT, more than 40% of patients had gag reflexes or mouth-opening limitations.^[4,5] Eating, oral hygiene, access to necessary dental procedures, speech, and facial appearance can all be negatively impacted by this condition . The mouth can normally expand 30 to 50 mm, or about the width of three fingers, for the majority of healthy people. For regular functioning in day-to-day activities, this range of mobility is essential. Interestingly research has indicated that mouth opening may vary by gender, with men often displaying a wider range. A maximum opening limited to 20 mm signifies a condition known as trismus or severely restricted mouth opening, which can pose significant challenges during dental procedures.^[1,5,7]

Long-term dental operations, such as root canal therapy, may result in problems with the temporomandibular joint (TMJ) and its surrounding structures because of trauma or improper posture.^[8] There seems to be a higher chance of developing posterior temporomandibular disorders (TMDs) after molar extraction. Biomechanical, neuromuscular, biopsychosocial, and biochemical factors are all part of the complicated etiology of TMDs.^[9.10] Depending on the underlying cause, TMDs are treated differently. Although TMJ pain and discomfort might worsen after dental procedures, any difficulty opening the jaw the day after should be treated seriously. It is important to schedule an evaluation when a patient complains of minor pain and dysfunction. illness, particularly in the oral cavity, which would guarantee that patients receive more optimal care. The present study aims to bridge the gaps in knowledge following the diagnosis and understanding of the etiology of a disease, especially in the oral cavity, which would ensure the provision of more optimized care for patients. It should also be noted that limited mouth opening or trismus is a condition and is not a disease itself; therefore, it may occur as a sign orsymptom of various diseases.^[7,11]