Clinical and scientific guide to fragment reattachment

Direct anteriors
7 Jul 2016

It is widely known that fractures of anterior teeth are common among children, particularly those aged be- tween 8 and 11. Many techniques and materials are available to restore uncomplicated fractured crowns. Porcelain veneers or jacket crowns require substantial sacrifice of dental structure. Resin composite materials guarantee a more conservative approach, and reattachment of the fragment is nowadays a reality. It is a faster procedure, with a better and longer lasting esthetic results, and an incisal margin wear that matches that of adjacent teeth.
The purpose of this article is to make a critical appraisal, based on scientific and clinical evidence, of the optimal technique to reattach a fragment.

Different materials (mainly dentin bonding agents, flowable composites, regular composites and dual curing resin cement), and different techniques (bevel before vs after reattachment, silicone guides vs no silicone guides) have been used for the purpose.

In this article an ex-vivo study will be shown and discussed in details to understand which is the best procedure to be used in cases where a fragment is available for reattachment.
Different methods and preparations have been proposed: bonding without preparation of the tooth/fragment, a V-shaped enamel notch both on the fragment and on the tooth; internal groove within the fragment and the remaining tooth; labial and circumferential bevel. These preparation techniques have sometimes been combined with a superficial overcontouring with composite over the fracture line, which may be circumferential or lingual. The reported results vary considerably, from fracture strength as high as that of sound teeth to only approximately 50% .

Fig. 1

Img. 1 – The purpose of this study by Chazine et al (2011) was to use a “Shear Bond Strength” (SBS) test to see if any difference could be detected when using 4 different materials and 2 different techniques for fragment reattachment.

Fig. 2

Img. 2 – 80 freshly extracted incisors were selected, measured and cut with an Isomet Saw.

Fig. 3

Img. 3 – Adhesive (group 1), flowable resin composite (group 2), resin composite (group 3), dual curing resin cement (group 4) were used for the purpose. in these first four groups no post reattachment bevel was performed.

Fig. 4

Img. 4 – In groups 5,6,7 and 8 an additional post reattachment procedure was performed using a round bur to create a “double bevel” both on the tooth and on the fragment. The preparation was then filled with composite (flow then regular).

Fig. 5

Img. 5 – All samples were then tested and fractured.

Fig. 6

Img. 6 – The results clearly show that when a post reattachment technique is used, higher SBS values can be obtained.

Fig. 7

Img. 7 – The picture shows the difference in fracture mode. No post reattachment technique leads to a detachment. When a post reattachment technique is used, the fracture is very similar to that of a natural tooth.

Fig. 8

Img. 8 – The ex vivo study is a support to our clinical work. The technique shown guarantees a nice marginal integration together with a high strength to the reattached fragment.

Fig. 9

Img. 9 – This technique was used in the article we presented last February.

 

Conclusions

Conclusions

This ex-vivo study supports the following conclusions: the type of material used for re-attaccment did not influence the fracture resistance, while the technique used for reattachment (post reattaccment bevel) positively influenced the fracture resistance.

Bibliography

References

  1. Grandini R, Pagni L, Pagavino G, De Fraia E. Using the ?coronal fragment for the repair of anterior tooth fracture. Quintessence Int Dent Dig 1985;10:839–45 and 925–33.
  2. Chazine M, Sedda M, Ounsi HF, Paragliola R, Ferrari M, Grandini S. Evaluation of the fracture resistance of reattached incisal fragments using different materials and techniques. Dent Traumatol. 2011 Feb;27(1):15-8.
  3. Rappelli G, Massaccesi C, Putignano A. Clinical procedures for the immediate reattachment of a tooth fragment. Dent Trau- ?matol 2002;18:281–4.
  4. ?

  5. Davis MJ, Roth J, Levi M. Marginal integrity of adhesive ?fracture restorations: chamfer versus bevel. Quintessence Int ?1983;14:1135–46.
  6. ?

  7. Pusman E, Cehreli ZC, Altay N, Unver B, Saracbasi O, Ozgun ?G. Fracture resistance of tooth fragment reattachment: effects of different preparation techniques and adhesive materials. Dent Traumatol 2010;26:9–15.
  8. Yilmaz Y, Zehir C, Eyuboglu O, Belduz N. Evaluation of ?success in the reattachment of coronal fractures. Dent Trau- ?matol 2008;24:151–8.
  9. Reis A, Francci C, Loquercio AD, Carrilho MR, Rodrigues Filho LE. Reattachment of anterior fractured teeth: fracture strength using different techniques. Oper Dent 2001;26:287–94.
  10. Demarco FF, Fay R-M, Pinzon LM, Powers JM. Fracture resistance of re-attached coronal fragments: influence of different adhesive materials and bevel preparation. Dent Traumatol 2004;20:157–63.
  11. Munksgaard EC, Hojtved L, Jorgensen EH, Andreasen JO, Andreasen FM. Enamel-dentin crown fractures bonded with various bonding agents. Endod Dent Traumatol 1991;7:73–7.
  12. Worthington RB, Murchison DF, Vandewalle KS. Incisal edge reattachment: the effect of preparation utilization and design. Quintessence Int 1999;30:637–43.
  13. Reis A, Kraul A, Francci C, de Assis TG, Crivelli DD, Oda M et al. Re-attachment of anterior fractured teeth: fracture strength using different materials. Oper Dent 2002;27:621–7.
  14. Loguercio AD, Mengarda J, Amaral R, Kraul A, Reis A. Effect of fractured or sectioned fragments on the fracture strength of different reattachment techniques. Oper Dent 2004;29:295–300.
  15. Badami AA, Dunne SM, Scheer B. An in vitro investigation into the shear bond strengths of two dentin-bonding agents used in the reattachment of incisal edge fragments. Endod Dent Traumatol 1995;11:129–35.
  16. Farik B, Munksgaard EC, Andreasen JO. Impact strength of teeth restored by fragment-bonding. Endod Dent Traumatol 2000;16:151–3.
  17. Farik B, Munksgaard EC, Andreasen JO, Kreiborg S. Fractured teeth bonded with dentine adhesives with and without unfilled resin. Dent Traumatol 2002;18:66–9.