MISS DEBORAH LOUSAN DO NASCIMENTO POUBEL (Orcid ID : 0000-0002-7560-7320)

Accepted Article
Article type : Comprehensive Review

In vitro tooth reattachment techniques: a systematic review

Amanda Pinto Bandeira Rodrigues de Sousaa; Kamilla Françaa; Liliana Vicente Melo de
Lucas Rezendeb; Déborah Lousan do Nascimento Poubelb; Julio César Franco Almeidab;
Isabela Porto de Toledoc; Fernanda Cristina Pimentel Garciab.

a
Undergraduate Student, Department of Dentistry, School of Health Sciences, University of
Brasília, Brasília, Brazil
b
Professor, Department of Dentistry, School of Health Sciences, University of Brasília,
Brasília, Brazil
c
Histopathology Laboratory, School of Health Sciences, University of Brasília, Brasília,
Brazil

Corresponding author:

Fernanda Cristina Pimentel Garcia

University of Brasília – UnB, Department of Dentistry, School of Health Sciences

Brasília, DF, Brazil, CEP 70910-900

Telephone: +55 (61) 3107-1802
Telephone: +55 (61) 98598-4594
Email: deborah.lousan@gmail.com

Conflict of Interest Statement

This manuscript has not been published or presented elsewhere either in part or in its
entirety, and is not under consideration by another journal. We have read and understood
your journal’s policies, and we believe that neither the manuscript nor the study violates
them. There are no conflicts of interest to declare by any author.

This article has been accepted for publication and undergone full peer review but has not
been through the copyediting, typesetting, pagination and proofreading process, which may
lead to differences between this version and the Version of Record. Please cite this article as
doi: 10.1111/edt.12414
This article is protected by copyright. All rights reserved.
 Abstract

Background/Aims: Fragment reattachment is a procedure that offers advantages, such as

Accepted Article
preservation of dental structure and maintenance of color, shape and translucency of the
original tooth. The aim of this study was to analyze the reattachment techniques used to
restore anterior teeth fractured by trauma. Materials and Methods: The PubMed, LILACS,
Web of Science, Cochrane and Scopus databases were searched in October 2016, and the
search was updated in February 2017. A search of the gray literature was performed in
Google Scholar and OpenGrey. Reference lists of eligible studies were evaluated to identify
additional studies. Two authors assessed studies for inclusion, and extracted the data. In vitro
studies that evaluated permanent human teeth fractured by trauma were included. Results:
Twenty-one studies remained after screening. The bond strength between the fragment and
the crown was evaluated in 119 experimental groups. Ten different techniques were
evaluated: no preparation, chamfer, bevel, anchors, overcontour, internal groove, no
preparation associated with chamfer after reattachment, fragment dentin removal associated
with chamfer after reattachment, bevel associated with overcontour, and groove associated
with shoulder. Five different materials were used to reattach the fragment: bonding system,
luting composite resin, flowable composite, microhybrid composite and nanocomposite.
Conclusion: Fragment reattachment using a technique with no preparation and an adhesive
system associated with an intermediate composite with good mechanical properties can
restore part of the resistance of the fractured tooth.

Keywords: crown fracture; dental trauma; treatment; techniques

Introduction

Dental trauma (DT) is considered a public health issue due to its high prevalence.1 DT
usually occur mainly during the growth and development phase of individuals and may
negatively impact the quality of life.1,2

Children and adolescents are considered the leading risk groups in which the main
kinds of DT are uncomplicated crown fractures - that is, without pulp exposure and in the
upper anterior teeth.3 These represent 18-22% of all DT.4 Injuries that affect enamel and
dentin represent 42.7% of all crown fractures, whereas enamel fractures correspond to

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 31.2%.5 Accidents at home or at school are considered the main causes of DT, followed by
accidents caused by sports, violence and motor vehicle collisions.5 Regardless of the cause of
the DT, lack of treatment may cause aesthetic, functional and emotional damage.6
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Several factors may influence DT management and the consequent prognosis – such
as: the affected dental tissue and the amount lost, the type of fracture, the need to perform
endodontic treatment, the presence or absence of dental fragments, and the adaptation of a
possible fragment to the tooth remnant.3,7 Although there is no consensus in the literature
about the ideal technique for dental fragment bonding with different fracture patterns, the
chosen treatment should provide the affected tooth with fracture resistance results similar to
those of the healthy tooth.3,8

The development of adhesive dentistry enabled the improvement of minimally

invasive approaches, thereby including aesthetic and functional aspects, which provided
additional benefits to the patient and the clinician.3,7 If a tooth fragment has been preserved,
its bonding to the dental remnant is considered the best choice to restore the fractured tooth,
since this approach reduces the time of clinical care, and restores tooth aesthetics with the
same shape, color, translucency and texture of the original tooth, using an extremely
conservative procedure.3,7,9

However, there are technical variations regarding fragment bonding, such as previous
or late preparation of the remaining tooth, and use of intermediate materials (conventional
resin, flowable resin, luting resin cement and glass ionomer cement),9,10,11 which make
clinical decisions difficult. Based on these issues, the aim of this study was to analyze what
in vitro fragment bonding technique provided the best bond strength results for rehabilitating
anterior teeth fractured by trauma.

Materials and Methods

The present study was a systematic review that was performed according to the
PRISMA checklist12 for systematic reviews and meta-analyses, and it presents a therapeutic
approach with an interventional focus. The null hypothesis was that the preparation
techniques and dental materials have no effect on bonding of reattached.

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 In vitro articles that evaluated human permanent incisors fractured by trauma were
selected. No time restriction was applied. Articles that involved reviews, letters, personal
opinions, book chapters, case reports, articles not written in English, Portuguese or Spanish,
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laboratory studies related to crown fractures in posterior teeth, complex fractures with pulp
involvement of anterior teeth or crown fractures in the primary dentition, and studies in
which tests were performed on animal teeth were excluded.
The search was defined using "mesh" terms and key words based on the following
elements of the PICOS strategy, taking into consideration the research question:
1. Participants (P): Fractured incisors
2. Intervention (I): Dental fragment reattachment
3. Comparison or control (C): Not applicable
4. Outcome measures (O): Types of techniques for crown-fractured anterior teeth
5. Types of studies included (S): In vitro studies

Individual and detailed searches were conducted in different electronic databases:

PubMed, SCOPUS, Web of Science, LILACS, Cochrane. The search in the gray literature
was made using Google Scholar and OpenGrey platforms. The first search was conducted on
5th October 2016, and an update was made on 1st February 2017 (Fig. 1). The articles were
managed by the Rayyan QCRI13 systematic review app. All the references were selected from
the Endnote program (Thomson Reuters, Philadelphia, PA, USA), and the duplicates were
removed. The references of the selected articles were also checked to ascertain if any other
relevant study for the research was neglected during the database search. The search strategy
data is presented in Table 1.
The database search resulted in a total of 408 studies, from which duplicated articles
were excluded (110), leaving 298 studies as part of the selection process for the systematic
review. Article selection for the study was performed in two stages, with two independent
authors (A.P.B.R.S. and K.F.), who took into consideration the pre-established inclusion and
exclusion criteria. The first step consisted of choosing articles according to an analysis of
titles and abstracts. If the article had potential for inclusion in the research, or if the
information presented in the title and abstracts was not enough to obtain a clear decision on
its inclusion, the article was submitted to a second stage selection process. This process
resulted in the exclusion of 262 articles. In the last stage, complete reading of all the selected
articles (36 articles) was performed. One of the 36 selected articles14 did not provide all the
necessary research data. Two attempts were made to contact the author of this article by

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 email, the second of which was carried out a month after the first, both without success, thus
leaving a total of 35 selected articles. Those articles that did not meet the inclusion criteria
were excluded (Figure 1). The remaining articles (21) were chosen to compose the systematic
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review. Whenever there was disagreement between the two evaluators, a third author
(F.C.P.G) was involved, and the final decision was reached through discussions and general
agreement.
The relevant information of the articles selected for the research was standardized and
organized with the help of Microsoft Office Excel software (Microsoft Corporation,
Redmond, WA, USA).

The risk of bias for in vitro studies used in this review was adapted from an article by
Sarkis-Onofre et al.15 Article quality was evaluated by describing the following parameters:
randomization of teeth in the different groups, teeth free of caries, restorations and cracks,
use of materials according to the manufacturer’s instructions, calculation of sample size,
inspection method of the fracture performed after fragment bonding, and a clearly expressed
method to determine bond strength between the fragment and the remnant (Table 2).

If the parameter was well defined in the study, it was marked Y (yes) on that specific
topic; if no information could be found on the parameter, it received a N (no). If the data
were not reported clearly enough, the article received an NC (not clear). Based on the amount
of Y’s presented by the article, risk of bias could be classified as high (<49%), moderate (50-
70%), or low (> 70%).

Results

A total of 298 articles were selected (PubMed 135, Cochrane 50, LILACS 5, Web of
Science 23 and Scopus 195); after being fully read, 21 articles were included. The search
results are described in Figure 1 and the risk of bias is described in Table 2, according to the
parameters considered in the analysis.

Of the 21 studies included, a total of 119 in vitro experimental groups that tested the
bond strength of the fragment to the remaining tooth were evaluated (Table 3). These groups
were distinguished according to the technique and materials used, and whether or not the
dental fragment underwent rehydration, according to the different time periods and solutions

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 used. The wide range of methods and materials used in the different studies precluded
performing a meta-analysis of these data.
Accepted Article
Altogether, ten different kinds of preparation techniques on the remnant were
analyzed: no preparation, chamfer, bevel, post anchors, overcontour, internal groove and
variations of these techniques, such as no preparation associated with chamfer after
reattachment, fragment dentin removal associated with chamfer after reattachment, bevel
associated with overcontour, and groove associated with shoulder. Different materials were
used to perform each technique for bonding of the fragment to its remnant. All material
specifications are listed in Table 3.

After bonding, the tooth was subjected to fracture simulation to quantify the bond
strength (BS) value. The force needed to cause the fracture was determined, and the values
were recorded in Kgf, MPa or N. The data were converted to Newton (N) to facilitate
10,21,31
comparison among the studies. Some of the articles precluded this conversion, since
the value of the acting force area has to be known; for this reason, the values were converted
to N/mm2.

In the technique with no preparation of the remnant/fragment, the group18 presenting

the highest BS values (1102.65 N) was that which used a two-step adhesive system
(OptiBond S) associated with a flowable resin (Premise Flowable). The results for this group
were superior to those for the group which combined the no preparation technique with
chamfer after reattachment, and that which used an adhesive system (Single Bond) associated
with a microhybrid composite resin (Filtek Z250) (131.40 N).17 In the preparation technique
with removal of the dentin portion of the fragment associated with chamfer after
reattachment, based on the study by Bhargava et al.,16 the group with the best BS value was
that which associated the chamfer with a microhybrid composite resin (Filtek Z250) (259.58
N), compared with the group that used previous removal of the dentin portion of the fragment
followed by chamfer after reattachment associated with an adhesive system (Single Bond)
and a microhybrid resin (Filtek Z250) (184.36 N).17 In the study by Chazine et al.,10 using the
bevel technique, the group that presented the highest BS was that which associated the bevel
with an adhesive system (Adper Scotchbond IXT) and a nanocomposite (Filtek Supreme),
(13.85 N/mm2). A variation of the latter technique was to use an overcontour with an
adhesive system (Scotchbond 2) associated with a microhybrid composite resin (Filtek
Z250), as evaluated by Stelline et al.,29 and yielding a value of 233.30 N. In the only

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 experimental group in which an anchorage system was performed, the BS found was 599 N;
this system involved mini anchors of prefabricated composites reinforced by glass fibers,
associated with an acid etchant (37% phosphoric acid gel), a primer (ED primer) and a luting
Accepted Article
resin cement (Panavia F).19 In the study by Rajput et al.,34 using the overcontour technique,
the best BS value was associated with an acid etchant (Total Etch), an adhesive system
(Prime and Bond NT dual cure) and a microhybrid composite (Filtek Z100) (307.73 N).34 In
the internal groove technique, the group with the highest BS value associated this technique
with an acid etchant (Total Etch), an adhesive system (Prime and Bond NT dual cure) and a
microhybrid composite (Filtek Z100).34 According to the Vamsi Krishna et al.30 study, the
dentin groove with a shoulder technique presented higher results (305.86 N) when associated
with a luting cement resin (Panavia F 2.0) and a nanohybrid composite (Tetric N-Ceram).

In relation to the dental fragment rehydration process, the Capp et al.17 study showed
that BS could be recovered in a tooth whose fragment was dehydrated for a period of 48 h, if
the fragment was rehydrated with distilled water for 30 min prior to reattachment, resulting in
a BS value equivalent to 167.59 N. The same study showed that the value of the BS was
higher if the fragment was kept hydrated, attaining 184.36 N.17 Shirani et al.25 showed that
teeth rehydrated with distilled water for a period of 24 hours (h) presented higher BS values
than those rehydrated for 30 min prior to the reattachment. However, when the fragment was
dehydrated for a period of 30 min or less, rehydration with distilled water 30 min before
reattachment can promote recovery of part of the BS.25 By using the same rehydration time
(24 h) for all groups analyzed, the Shirani et al.26 study showed that teeth with the highest BS
values were those that used milk (374.20 N) or saliva (328.6 N) as a moisturizing solution for
the dental fragment, whereas a later Sharmin et al.24 study showed that the group presenting
the highest BS values was rehydrated in saline for a period of 24 h (75.91 N).

Discussion

Many of the studies analyzed9,10,18,20,21,23-27,29,30,32-34 used anterior teeth extracted for

periodontal reasons, since they sought teeth that were free from fractures, cracks, caries,
restorations or any type of structural defect, to minimize the risk of bias. On the other hand,
some of them9,10,16,18,20-28,31,33,34 did not make it clear whether the chosen teeth had similar
dimensions in relation to such variables as size of the outer crown, pulp size and thickness of
the dental tissues, factors which could lead to risk of bias. Although trauma is more frequent

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 in upper anterior teeth, some studies9,20,21,25,26 have chosen to use only lower anterior teeth,
since they were easier to obtain due to periodontal diseases.23
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In the studies evaluated, the intentional fracture of the healthy tooth was performed by
sectioning (produced by disks, saws and surgical blades), or produced by a universal testing
machine. It is important to note that the structural loss and the contact surface can change
according to the technique used to simulate the trauma in the healthy tooth.6 When trauma
occurs by fracture, the fragment fits more easily into the remnant, because it tends to occur
on a parallel plane, following the orientation of the enamel prisms.3,9,10,20,22 This does not
occur when the injury is reproduced by sectioning; in this case, the fragment cannot be
adapted perfectly due to the loss of tooth structure.4,6,9-11,16,20,22 The advantage of using the
sectioning technique is that a more faithful reproduction may be obtained in all the study
teeth, thus facilitating standardization.4,6

Another factor influencing the final BS results is maintaining adequate hydration or

even rehydration of a dehydrated tooth fragment before the restorative procedure, which both
favors maintaining the original color of the fragment and influences the BS values.5,29 Capp
et al.17 reported that the BS could be partially recovered if the dental fragment was rehydrated
for only 30 min prior to reattachment, a procedure conducive to better clinical management.
In contrast with the results found by Capp et al.,17 Shirani et al.25 considered rehydration for
30 min unsatisfactory in comparison with 24 h, a period of time that could be considered
satisfactory if the fragment were reattached a second time. In an in vitro study with bovine
teeth, Poubel et al.8 reported that the fracture strength of a tooth, whose reattachment was
performed with a dehydrated fragment is inferior to that of a tooth kept hydrated or
rehydrated for 15 min or 24 h. Since there was no statistical difference between both periods,
rehydration for only 15 min would be preferred, thus not only favoring clinical management,
but also partially restoring lost resistance. The BS values observed in the studies17,25 where
the fragment was subjected to different dehydration variables were lower, a finding that could
compromise the technical analysis, because it generates bias. The Shirani et al.25 and Shirani
et al.26 studies used fragment reattachment associated with the no preparation technique, an
adhesive system and a fluid composite, altering only the rehydration solution or the
rehydration time of the dental fragment. They showed that groups in which the teeth were

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 rehydrated for 24 h in distilled water, milk or saliva, presented higher BS values than the
study group reported by Reis et al.,9 which used the same type of technique and intermediate
material, but which did not focus on analyzing the influence of rehydration and dehydration
Accepted Article
of the fragment on the BS values.

The null hypothesis proposed was rejected because either preparation technique or
dental material influenced bonding reattached fragments to teeth.

The choice of materials and techniques varies according to the studies.3 Some have
shown that the associations of materials used for reattachment did not influence the BS of the
fractured tooth.9,10 With other authors, the material was less influential than the technique
used at the time of reattachment.16,35 Some studies have considered both the material and the
technique used in the reattachment process as the primary associated factor for establishing
the BS between the fragment and its remnant.22,34,36 According to Reis et al.,9 the use of an
adhesive system associated with other intermediate materials, such as composite resin flow,
resin cements and other composites, tends to have BS results similar to those for situations in
which no further preparation is performed.3 The study by Bhargava et al.16 analyzed BS using
the simple and the bevel techniques associated with three different intermediate materials
(adhesive system, luting cement resin and nanoparticulate resin) and showed that
nanocomposites presented greater resistance to fracture in both techniques, because they have
better mechanical properties. The same study demonstrated that luting cement resin would be
the second-best material.16 Reis et al.9 reported that the association of the adhesive system
with a hybrid resin promoted higher BS values than flowable resins and luting cement resins,
because of better mechanical properties due to the greater amount of inorganic load.
Flowable composites are indicated in situations where the fragment is of reduced size, since
their ability to flow allows good adaptation between the fragment and the remaining
tooth.9,18,37

The technique employed depends on the type of fracture and whether there is good or
poor adaptation between the parts of the tooth.20 When the fragment is reattached to its
remnant with no preparation technique, it recovers 50% of the fracture resistance, in relation
to the healthy tooth.17,20 According to Reis et al.,35 when an additional preparation is
performed at the fracture line (beveling), the bond obtained is superior to that of a bonded
tooth without any further preparation, increasing 60% in its strength. The creation of a bevel,
overcontour or internal groove, or the removal of the dentin portion prior to reattachment,

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 increases the bond between the tooth parts, since these techniques provide greater contact
area and adhesion.3,17,20,35 In the study by Srilatha et al.,28 the overcontour technique
promoted a 91.4% recovery of its fracture resistance, compared with the healthy tooth,
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because this technique allows greater distribution of the material on the tooth surface, thus
promoting better propagation of tensions in the enamel, unlike the simple technique, in which
tension propagates along the fracture line. In the same study, the technique of making internal
grooves in the teeth prior to reattachment was able to recover 89.2% of their resistance,
because the resin that occupies the region of the internal groove promotes an antagonistic
force when a compression load is applied to the tooth.28 However this technique is not
compatible with the principle of minimal intervention, because it requires additional
preparation compared with the simple technique.21 Furthermore, techniques involving
composite resin exposure in the oral cavity tend to suffer aesthetic loss over time due to the
discoloration and abrasion process that may occur with composites.9 Worthington et al.38
reported that teeth with some type of additional preparation do not present better bond
strength than teeth reattached with the no preparation technique.

One disadvantage of fragment reattachment is the possible debonding of the remnant

due to progressive degradation of the adhesive interface, a new trauma episode or
parafunctional habits involving the restored tooth.27,38 Nevertheless, fragment reattachment to
its remnant, when feasible and well adapted, is considered the best choice in the case of
coronal fracture, since it favors the practice of minimal intervention and restores resistance
and aesthetics satisfactorily.

Conclusion
Based on the in vitro articles analyzed, the tooth fragment reattachment technique
without further preparation, using an adhesive system associated with an intermediate
composite with good mechanical properties, is indicated and adequate to recover some of the
strength lost in the fractured tooth.

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Accepted Article
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Accepted Article

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