Fig. 1

Careful examination of pre-operative X-Ray to determine the degree of difficulty:

  1. GP perforating the mesial root of the tooth (denoting cleaning and shaping of bone and obturating it with GP).
  2. Short mesial filling by 3-4 mm denoting either ledge or blockage.
  3. Broken Rotary file at middle to apical junction of distal root.
  4. Metallic filling over mesial root and inside the orifice of distal root.
  5. Non visible canals space beyond broken file and beyond short mesial filling denoting dystrophic calcification or very tight canal space.
Fig. 2

Here is after removal of temporary filling, metallic filling covering mesial root and inside the orifice and canal of distal root (black arrow).

Careful inspection using ultrasonics and Endodontic probe DG16 to remove all of this and to uncover the GP inside the bone and differentiate it from the GP inside the root.

Fig. 3

Here is after careful removal of all coronal obstructions

GP inside the bone (red arrow )

GP inside the Mesial Canal (small white arrow)

Distal Root after removing all metallic filling (large white arrow)

Fig. 4

Atraumatic removal of broken file from distal canal.

Enlargement above it using modified 25 Taper 6% rotary file and ET25 Ultrasonic Tip.

P.S I removed the file before removing GP from the perforation Site and from Mesial canal in order for it not the jump from distal root to any other place.

Fig. 5

After complete cleaning and shaping of mesial root and distal root, I removed GP from perforation side using H Files to grab it.

Due to severe bleeding of granulation tissues removed, I temporized the case using calcium hydroxide to neutralize the acidity of perforation site before placing MTA

Here you find the Mesial and Distal Canal obturated and Perforation site closed by MTA.

Fig. 6

Post operative X-rays show:

  1. Closure of perforation site with no voids and closing every discrepancy.
  2. GP removed from bone with no leftovers.
  3. No loss in dentin while removing broken file distal.
  4. Fixing short mesial root ledge and reaching apex.
  5. Coronal seal via final bonded restoration.
Fig. 7

About the Author:

Dr Khaled Khalifa

B.D.S. Misr International University

Endodontic Specialist

Course Director “The Endo Formula”

Endodontic Consultant in multiple private clinics

Member of The Royal College of Surgeons England (MJDF)

Member of The American Association Of Endodontics (AAE)

Member of British Association Of Endodontics (BES)

Practice limited to Endodontics


Retreatments are very challenging. Careful inspection of preoperative X-ray allows you to put a strategy on how to fix the tooth.

Operator must have enough knowledge, skills and tools before going through such treatments in order not to complicate the case more than this.

Our prime goal is to restore function and health of tooth structure with minimal loss of tissues.


Prognostic Factors and Primary Healing on Root Perforation Repaired with MTA: A 14-year Longitudinal Study

Fabio G. Gorni, DDS  Andrei C. Ionescu, DDS, PhD 

Federico Ambrogi, MSc, PhD Eugenio Brambilla, DDS  Massimo M. Gagliani, MD, DDS 

Published:June 14, 2022DOI:

Contemporary Endodontic Retreatments: An Analysis based on Clinical Treatment Findings

Michael M. Hoen, DDS  Frank E. Pink, DDS, MS 


Postoperative Pain after Endodontic Retreatment Using Rotary or Reciprocating Instruments: A Randomized Clinical Trial

Daniel Comparin, DDS, MSc Edson Jorge Lima Moreira, DDS, MSc, PhD Erick M. Souza, DDS, MSc, PhD Gustavo De-Deus, DDS, MSc, PhD  Ana Arias, DDS, MSc, PhD  Emmanuel João Nogueira Leal Silva, DDS, MSc, PhD 

Published:May 03, 2017DOI:

Flare-ups after Endodontic Treatment: A Meta-analysis of Literature

Igor Tsesis, DMD Vadim Faivishevsky, DMD Zvi Fuss, DMD Ofer Zukerman, DMD 

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