Dental Traumatology 2011; 27: 15–18; doi: 10.1111/j.1600-9657.2010.00951.

Evaluation of the fracture resistance of

reattached incisal fragments using different
materials and techniques

Michelle Chazine, Maurizio Sedda, Abstract – Objectives: When coronal fracture occurs in anterior teeth, fragment
Hani F. Ounsi, Raffaele Paragliola, reattachment can be a valid alternative to a direct restoration. The aim of this
Marco Ferrari, Simone Grandini study was to evaluate the influence of the material and the technique used to
Department of Dental Sciences, University of reattach the fragment. Materials and methods: Eighty sound maxillary and
Siena, Siena, Italy mandibular incisors were selected and randomly divided into eight groups
(n = 10). The incisal third of each tooth was removed using a saw machine. The
fragments in groups 1–4 were reattached using resin-based materials: group 1
adhesive, group 2 flow, group 3 composite, group 4 cement; in groups 5–8, the
same materials mentioned before were used but a bevel was also performed on
Correspondence to: Simone Grandini, both labial and lingual surfaces. Shear bond strength (SBS) was calculated by
Chair of Endodontics and Restorative applying a load incisal to the reattachment line. A two-way Anova was used to
Dentistry, University of Siena, Italy
Tel.: +39 0577 585772
evaluate the influence of materials and techniques on the SBS. Results: The
Fax: +39 0577 233117 technique used was statistically significant (P < 0.001), while the material was
e-mails: grandini@unisi.it, not (P = 0.793). Conclusions: The choice of material seems to have no influence
simogr@gmail.com on the SBS, whereas a bevel performed on the labial and lingual surfaces can
Accepted 4 October, 2010 significantly improve the SBS of the reattached fragment.

Research has shown that fractures of anterior teeth are fracture strength as high as that of sound teeth (including
common among children, particularly those aged be- internal grooves on both tooth and fragment) (19, 20), to
tween 8 and 11 (1). Many techniques have been only approximately 50% (including labial chamfer and
developed to restore uncomplicated fractured crowns, lingual overcontour) (18). Other studies have failed to
such as porcelain veneers (2) or jacket crowns; however, demonstrate statistical differences in fracture strength
such treatments require substantial sacrifice of dental between two and more techniques (21, 22).
structure and sometimes even endodontic treatment (3). The method of obtaining the fragment in the different
The development of resin composite materials has made studies also seems to be relevant. Four studies have
it possible to have a more conservative approach toward reported controversial results regarding the performance
the treatments of these injuries in as much as if the of techniques used for reattachment (19–22) where
fragment of the fractured tooth is available, the reat- distinct methodologies were employed to obtain the
tachment of this fragment is possible (4–11). This fragments. Worthington et al. (22) sectioned the incisal
approach offers several advantages, such as a better edge of the tooth, whereas Reis et al. (19, 23) fractured
and longer lasting esthetic results (4–11), incisal margin the teeth using a universal machine. Both of these
wear that matches that of adjacent teeth and a faster methods were used in other experimental setups (24–28).
procedure. In particular, Loguercio et al. (29) evaluated the effect of
Reattachment of fragments has been performed with fractured or sectioned fragments on the fracture strength
some kind of composite bonding or flow material. The recovery of four techniques used for reattachment and
methods have included bonding without preparation of resin composite buildups. They concluded that the way
the tooth or fragment (12–14). Various preparation fragments are obtained in laboratory tests plays an
techniques have also been attempted, prior to or after important role.
bonding. Regarding the former, these preparation tech- Moreover, the speed applied to cause the trauma
niques have included a v-shaped enamel notch (15, 16) interferes with the results obtained (3, 30), as well as the
both on the fragment and on the tooth; internal groove load application distance to the fracture plane (28).
(9, 17) within the fragment and the remaining tooth; Another variation found among published articles treat-
labial and circumferential bevel (18). These preparation ing this approach was the use of different materials to
techniques have sometimes been combined with a reattach the fragment. These included using bonding
superficial overcontouring with composite over the agents only (3, 20, 21, 24, 31, 32), associating bonding
fracture line, which may be circumferential or lingual agents with flowable resins (30, 33, 34), dual or self-cured
(18). The reported results vary considerably, from luting cements (14, 19), or light-cured luting cements

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16 Chazine et al.

(25). This illustrates how numerous factors play an Group 2

important role in the fracture strength and longevity of
the reattachment procedure. Only one study has been After applying the adhesive system (Adper Scotchbond
carried out which compares the combination of different 1XT; 3M-ESPE) and light-curing for 20 s both surfaces,
materials and different application techniques (23). This the tooth and the fragment as in group 1, a coat of
study used mandibular molars and concluded that the flowable resin (Filtek Supreme Flowable; 3M-ESPE)
choice of materials had less importance than the tech- was applied. The fragment was reattached to the
nique used. However, the effects of such combinations remaining tooth using hand pressure and the excess
have never been investigated on the anatomically more material on both labial and lingual surfaces was
slender incisor teeth, which are probably less fracture removed using a microbrush. The specimen was then
resistant than the stouter posterior teeth, and where most light-cured as in group 1 while continuing to apply hand
fractures actually occur. pressure.
Therefore, the purpose of this study was to evaluate
the behavior of different materials when used in different Group 3
application techniques to reattach a broken incisor
fragment by studying the shear bond strength (SBS) at The treatment was the same as for group 2 but using a
the fragment–tooth junction. The null hypotheses tested hybrid composite (Filtek Supreme Resin Composite;
in this study were that the SBS is not influenced (i) by the 3M-ESPE) instead of flowable resin.
material nor (ii) by the technique used to reattach the
fragment. Group 4

The treatment was the same of group 2 but using a dual-

Materials and methods
curing cement (RelyX ARC; 3M ESPE) instead of
Eighty sound human maxillary and mandibular incisors, flowable.
extracted for periodontal reasons, were inspected under
optical magnification (2·). The teeth were cleaned from Group 5, 6, 7, and 8
debris and calculus with curettes and ultrasonic tips; only
teeth free from cracks, caries or any other kind of The fragment was reattached as in group 1, 2, 3, and 4,
structural defects were selected and stored in a 0.01% respectively, and then a labial and lingual bevel were
thymol solution until prepared. The teeth were randomly performed on the reattachment line with a 2-mm round
divided into eight groups, each consisting of 10 teeth (five diamond bur (FG200; Intensiv SA, Grancia, Switzer-
maxillary and five mandibular incisors). The teeth were land) mounted on a hand-piece at 34938 g. The 1-mm-
measured on the labial side, from the cervical to the deep bevel was made applying the bur on the fracture
incisal edge, with a digital caliper. This measurement was line equally involving both sides of the fracture line. The
then divided by three after which the tooth was marked bevel on the labial and lingual side was then etched using
at one-third from the incisal edge. Each tooth was 37% orthophosphoric acid (Scotchbond etchant; 3M-
embedded in acrylic resin up to two millimeters from the ESPE) for 30 s. The surfaces were rinsed under running
marker. Specimens were fixed and cut on the mark line, water for 30 s, and excess water was gently removed
perpendicularly to the long axis of the tooth, with a using air flow. The adhesive system was applied to the
water-cooled low-speed diamond saw (IsoMet; Buehler tooth according to the manufacturer’s instructions. First,
Ltd, Lake Bluff, IL, USA). For each tooth, one fragment the primer was applied to the fragment and tooth with a
was obtained, and specimens were then treated as rubbing action (Adper Scotchbond Multi-purpose pri-
follows: mer; 3M-ESPE), and the solvent was allowed to evap-
orate using a gentle air flow. Then, the bonding was
applied to both surfaces (Adper Scotchbond Multi-
Group 1
purpose bonding; 3M-ESPE). The bevel was light-cured
Both the fragment and the tooth were etched using on the labial surface for 20 s and on the lingual surface
37% orthophosphoric acid (Scotchbond etchant; 3M- for another 20 s. Flowable composite resin (Filtek
ESPE, St Paul, MN, USA) selectively for 30 s on the Supreme Flowable; 3M-ESPE) was applied at the
enamel and then 15 s on the dentin. The surfaces of the junction of the two fragments and then light-cured for
fragment and of the remaining tooth were rinsed with 30 s on the lingual surface and on the labial surface. A
water for 30 s, then excess water was gently removed coat of resin composite (Filtek Supreme Resin Compos-
using air flow. The primer solution (Adper Scotchbond ite; 3M-ESPE) was then applied at the same location and
Multi-purpose primer; 3M-ESPE) was applied to the light-cured for 30 s on the lingual and on the labial
fragment and tooth. The solvent was made to evapo- surface.
rate using a gentle air flow for 5 s. The bonding After bonding procedures, the specimens were placed
solution (Adper Scotchbond Multi-purpose bonding; in a Universal Testing Machine (Triax 50 Digital;
3M-ESPE) was applied to both surfaces. The fragment Controls, Milan, Italy). The load was applied on the
was then reattached to the remaining tooth and light- labial surface, perpendicularly to the long axis of the
cured (400 mW cm)2, FreeLight 2; 3M-ESPE) for 20 s tooth, incisal to the reattachment line. A stainless steel
on both labial and lingual surfaces applying hand tip was used at a cross-head speed of 0.75 mm min)1 as
pressure. recommended by ISO Standard (ISO/TS 11405:2003 –

 2011 John Wiley & Sons A/S

 Fragment reattachment 17

Dental Materials-Testing of adhesion to tooth structure). Including maxillary and mandibular teeth in the groups
The fracture load was recorded in N. was carried out for practical reasons as collecting 80
The fracture surfaces of the teeth were photographed intact central incisors of each kind is difficult. Neverthe-
with a digital reflex camera (Nikon D70s; Nikon Corp., less, this could represent a source for bias, and care was
Tokyo, Japan) at a magnification of 1:1 (Micro-Nikkor taken to include the same number of maxillary and
105 mm f/2.8 AF-D; Nikon Corp.). The surface area was mandibular teeth in each group. The results obtained in
measured with a dedicated software (ImageJ 1.39u; this study showed no statistically significant difference in
National Institutes of Health, Bethesda, MD, USA) the SBS for the first 4 groups thus leading to the
and used to allow expressing SBS values in MPa. acceptance of the first null hypothesis. This is also
The statistical analysis was performed with spss 12 confirming the results obtained by Loguercio et al. (29);
(spss Inc., Chicago, IL, USA). The Kolmogorov– in contrast, Farik et al. (36) have reported differences in
Smirnov test was applied to verify the normal distribu- SBS between filled and unfilled resins, stating that all the
tion of data. A two-way anova was used to establish the adhesives used for their test, except the adhesive Excite
influence of the material (adhesive, flowable, composite, (Ivoclar Vivadent, Schaan, Liechtenstein) should be used
cement) and the technique used (standard, bevel) in with an unfilled resin when restoring fractured teeth by
fragment reattachment on the SBS. The significance level reattachment.
was set at P < 0.05. Observing the fracture surfaces, it was noted that in
groups 1 to 4, all of the specimens failed at their weakest
point, which in this case proved to be the reattachment
Results
line, more precisely the interface between the tooth and
The obtained results are shown in Table 1. The two-way the repairing material. Considering the fact that the
anova showed that the variable ‘technique’ was statis- samples could be thought of as a three-layer system, the
tically significant (P < 0.001), while the variable ‘mate- fact that the repair failed at the tooth material interface
rial’ was not (P = 0.793). The interaction between could be explained by the fact that one layer (the tooth)
‘material’ and ‘technique’ was also statistically significant was immobilized in the holders of the testing machine
(P = 0.018). and that the two other layers (repair material/fragment)
were free. Another possible explanation for this type of
failure is not having a perfect fitting: a discrepancy
Discussion
between the fragment and the tooth will act as a stress
In the present study, the specimens were sectioned with a raiser (35). A third possibility would be that, having the
saw rather than fractured. Badami and Reis (29, 31) have force applied incisal to the reattachment line, the weakest
shown that the surface of a sectioned tooth is different point would be the interface.
from a naturally occurring fractured one, as the fracture On the other hand, statistically significant higher SBS
produces fragments with a good fitting. A fractured was found when a postreattachment bevel was per-
surface also tends to run parallel to the main direction of formed forcing us to reject the second null hypothesis.
the enamel prisms, whereas the orientation of the Reis et al. (19) and Stellini et al. (18) had already
sectioned surface is dictated by the alignment of the highlighted that the resistance of reattached fragments
diamond saw used to section the incisal edge. Therefore, with an additional preparation, such as the chamfer
the fitting in this study, between the tooth and the technique or bevel combined with an overcontouring
fragment, was not perfect and sometimes even presented have given values as high as 60% of the intact tooth.
a gap. Hence, the results obtained in this study should be Other studies (20, 23) had also shown that a preparation
an underestimation of what could be achieved clinically postreattachment, such as a bevel or a chamfer, has a
using these techniques. However, using a saw resulted in positive effect on fracture resistance. In a recent study,
smooth surfaces, which is an advantage as the number of Stellini et al. (18) fractured cattle incisors and repaired
defects in the adhesive interface is lower (35) and it them with different preparations postreattachment. He
allowed to standardize the mode of ‘fracture’ that would concluded that the overcontouring or the combination of
have been otherwise random. Furthermore, the teeth a vestibular and lingual chamfer gave the tooth a
used for the experiment were teeth extracted for peri- fracture resistance 50% superior to that of an intact
odontal reasons, which are usually teeth of older people, tooth.
whereas trauma happens usually in younger patients. In the groups where the bevel was performed on the
labial and lingual side, the mode of failure changed. In
Table 1. Means and standard deviation for the different groups many cases, the fracture propagated as far as the root
and caused the whole crown to fracture. A possible
Group Technique Material Mean (MPa) SD (MPa)
explanation for this type of failure could be that the
1 Standard Adhesive 9.78 2.11 interface created allowed stress transfer further down the
2 Standard Flowable 8.89 3.18 restored structure sometimes even to the enamel–cement
3 Standard Composite 7.55 2.50 junction.
4 Standard Cement 7.86 1.12 From a clinical standpoint, the use of this fragment
5 Bevel Adhesive + Bevel 12.04 3.27 reattachment technique is in accordance with the min-
6 Bevel Flow + Bevel 12.55 3.13
imal intervention concept (37). It reduces to the mini-
7 Bevel Composite + Bevel 13.85 3.36
8 Bevel Cement + Bevel 12.05 3.76 mum the quantity of enamel and dentin lost and
guarantees a complete restitutio ad integrum of the tooth.

 2011 John Wiley & Sons A/S

18 Chazine et al.

Conclusions 18. Stellini E, Stomaci D, Stomaci M, Petrone N, Favero L.

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 2011 John Wiley & Sons A/S