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24 I I case report _ fractured instrument _In a previous case report published in roots 3/10, I demonstrated the possibility of removing a fractured instrument from the root canal.1 In some cases, however, removal of a fractured instrument is impossible or undesirable. Favourable factors for the removalofafracturedinstrumentarestraightcanals, incisors and canines; localisation before the curva- ture; length of fragment of more than 5mm; local- isationinthecoronalormesialthirdoftherootcanal; reamer or lentulo spirals; and hand NiTi K-files.2,3 Ifthecasedoesnotfulfiloneormoreofthesecriteria, removalofthefracturedinstrumentmightbeimpos- sible. Teeth with small roots may also be excluded for instrument removal, since excess removal of dentine willcompromisethelong-termprognosisofthetooth. In these cases, alternatives to instrument removal will have to be sought. Alternatives are leaving the instrument in place, surgical removal, extraction or bypassing the instrument. In the following case report,Iwilldemonstratethemannerinwhichafrac- tured instrument can be bypassed. _Case report A 60-year-old patient was referred to our prac- tice. He had type II diabetes, but no other health problemsandhencewasassignedanAmericanSoci- etyofAnesthesiologistsscoreoftwo.Thepatienthad acutepulpitisontooth#20.Thereferringdentisthad performed a preliminary root-canal treatment but had been unable to pass the curvature. Before starting the treatment, a new diagnostic radiograph was taken (Fig. 1). It showed a fractured instrument in the curvature of the root. The tooth was isolated with a rubber dam and the coronal filling was removed. Straight-line access was estab- lished, as this is imperative to be able to reach and see the fractured instrument. In this case, the frac- tured instrument could not be visualised (Fig. 2). The decision was made to try to bypass the instru- ment rather than try to retrieve it. The key factors for this decision were the impossibility of visualising the instrument, the location of the instrument, the Fig. 1_Diagnostic radiograph showing a separated instrument in the canal at the curvature. roots1_2011 Bypassing a fractured instrument Author_ Dr Rafaël Michiels, Belgium First appointment D-Finder 08 D-Finder 10 K-file 08 K-file 10 PathFile 13 PathFile 16 PathFile 19 Flexile file 20 ProTaper S1 hand file ProTaper S2 hand fileTable I_Shaping sequence of the first appointment. Fig. 1 Table I