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36 I I case report _ instrument removal according to his referral letter—while performing root-canal treatment on tooth #4. The root-canal treatment was necessary because of a trauma that the patient suffered. The buccal cusp had fractured and the pulp was exposed. A new diagnostic radiograph (Fig. 8) was taken, whichshowedthefragmentapprox.5mmfromthe apex. The tooth was isolated with a rubber dam and access was gained through the temporary restora- tion, which was placed by the referring dentist. After opening, the remnants of calcium hydrox- ide paste were removed with 10% citric acid and passive ultrasonics. The fractured instrument could bevisualisedimmediately(Fig.9),becausethecanal was very large in the middle and coronal part. This allowed a very conservative and tissue-saving ap- proach. Given the position in the canal and the shape of the canal, a deep apical split of the canal was suspected. After probing with small K-files, a patent palatal was confirmed. Theinstrumentwasfracturedinthebuccalcanal. A titanium ProUltra tip #8 (DENTSPLY Maillefer) wasusedtoloosentheinstrument.Inthemeantime, copious irrigation with 5% sodium hypochlorite was performed. The fractured instrument was retrieved (Fig. 10) and after determining working length (Fig. 11), shaping with rotary nickel-titanium instruments (TwistedFiles,SybronEndo)wasstarted.Bothcanals were shaped to a size 25.08 Twisted File. The master apical file was kept small due to the deep split (Fig. 12) and the tension felt while shaping, thus minimising new instrument fracture. Apical finish- ing was carried out with size 25 K-flexofiles. Smear-layer removal was performed with a rinse of 10 % citric acid. A final wash of the canal was carriedoutwithsterilesaline.Taperedgutta-percha coneswerethenfittedandtug-backwasconfirmed (Fig. 13). Topseal was used as a root-canal sealer. Both canals were obturated according to the con- tinuous wave of condensation technique with the ElementsObturationUnit.Afterobturation(Figs.14 & 15), a temporary restoration in glass-ionomer cement was placed together with a cotton pellet, which was soaked in an alcohol and chlorhexidine mixture first and then air-dried after it had been placed in the access cavity. Final radiographs (Figs. 16 & 17) were taken, both parallel and angled. The prognosis of this case was good and the patient was referred to his general dentist for a definitive coronal restoration. _Conclusion In the end, removal of a fractured instrument can be very difficult and it may take a long time to accomplish. Dr Marga Ree once said on the ROOTS forum that she was being taught that endodontics is all about the three Ps: Passion, Persistence and Patience.Thishitsthenailrightontheheadasfaras instrument retrieval is concerned._ Editorial note: A list of references is available from the publisher. Fig. 14_Apical obturation with gutta-percha. Fig. 15_The pulp chamber after complete obturation with gutta-percha. Fig. 16_Final radiograph (parallel). Fig. 17_Final radiograph (angled). roots3_2010 DrRafaëlMichiels graduatedfromtheDepart- mentofDentistryatGhent University,Belgium,in2006. In2009,hecompletedthe three-yearpostgraduate programmeinEndodontics attheUniversityofGhent.He worksintwoprivateprac- ticeslimitedtoEndodonticsinBelgium.Hecanbe contactedatrafael.michiels@gmail.comandviahis websitewww.ontzenuwen.be. _about the author roots Fig. 16 Fig. 17 Fig. 14 Fig. 15

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