Use of ribbond and panavia F cement in reattaching fractured tooth fragments of vital maxillary anterior teeth
A 16-year-old female patient reported to the Department of Conservative Dentistry and Endodontics with a history of an automobile accident and injury to the upper front teeth. The patient had reported to the department within half an hour after injury. Initial examination revealed an oblique fracture on permanent maxillary right central incisor (MRCI) and permanent maxillary left lateral incisor (MLLI) involving three-fourths of the clinical crown with associated exposure of the pulp []. Diagnosis of Ellis's class 3 fractures on both tooth were made. Maxillary left central incisor (MLCI) had a 3-year-old composite restoration. On clinical examination, the fracture line extended from labial to lingual in an apical direction. Radiographic examination revealed an oblique fracture with MRCI and MLLI []. While MRCI exhibited fracture line extending 2 mm above the bony crest, the MLCI exhibited some periapical changes. The treatment options presented to the patient and to her legal guardians were: (1) Crown build-up restoration with a resin based composite, (2) reattachment of the tooth fragment (3) root canal therapy, post and core and lastly, the least desired (4) extraction. After some deliberation about the advantages, disadvantages, prognosis, and cost of each treatment option, the patient opted to have the tooth fragment reattached. It is important to note that the reattachment option was presented only after confirming that the fragment was in good condition and that it fit reasonably well on the fractured tooth.\nThe fragments of MRCI and MLLI were still attached by a soft-tissue junction at the palatal aspect []. After local anesthesia, the coronal fragments were separated with minimum force [Figure and ] and was stored in saline to prevent dehydration. Since the pulpal exposure was fresh, the exposed site was disinfected with chlorhexidine and saline and direct pulp capping was done with mineral trioxide aggregate (MTA) (Dentsply, Tulsa Dental, Tulsa, OK, USA) [Figure and ]. Glass ionomer cement (Fuji IX GC Corporation Tokyo, Japan) was placed as the final restoration. After 2 weeks orthodontic extrusion was planned with MRCI to expose the fractured site supragingivally, using a custom-made appliance []. Vitality test was performed to check for the vitality of the teeth after 6 weeks. Both MRCI and MLLI tested positive for vitality, but MLCI showed delayed response. The procedure of reattachment of fragment was carried out.\nThe pulp chamber of the respective fragments (MRCI and MLLI), which were stored in saline and anti-fungal agent thymol for 8 weeks, were debrided of pulp and a groove was made with a long flat ended tapered fissure bur to act as a retentive area (Mani, Japan) []. Etching (37% phosphoric acid gel, Prime Dent, New Delhi, India) and bonding (Bond I, Pentron Technologies LLC, Wallingford, CT, US) of the MRCI and MLLI and the respective fragments were done. A small pre-measured piece (2 mm) of ribbond (Ribbond Inc., Seattle, WA, USA) was selected, bonding agent applied (Bond I, Pentron Technologies LLC) and cured for 20 s. The ribbond was placed vertically in the groove prepared in the fractured fragments along with panavia F dual cure cement (Kuraray, Osaka, Japan) []. The fragments were then verified for a fit with the teeth surface to ensure proper adaptation. Excess cement was removed and light cured from both buccal and palatal side.\nThe occlusion was carefully adjusted and the patient was instructed to avoid exerting heavy function on the reattached teeth. Patient was recalled after 6 months, vitality test was done with electric and cold test. The MRCI and MLLI responded positively but MLCI showed no response. Root canal therapy was done with MLCI. An 18-month recall showed good esthetics and function of the reattached teeth and vitality of both MRCI and MLLI was confirmed [Figure and ].