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Journal of Indian Society of Pedodontics and Preventive Dentistry Official publication of Indian Society of Pedodontics and Preventive Dentistry
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Year : 2012  |  Volume : 30  |  Issue : 4  |  Page : 310-316

Comparison of the fracture resistance of reattached incisor tooth fragments using 4 different materials

1 Department of Pedodontics and Preventive Dentistry, PGIDS, Rohtak, Haryana, India
2 Department of Pedodontics and Preventive Dentistry, Government Dental College, Patiala, India

Date of Web Publication19-Mar-2013

Correspondence Address:
R Singhal
Department of Pedodontics and Preventive dentistry, PGIDS, Rohtak, Haryana
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0970-4388.108927

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Aim: To evaluate and compare the fracture resistance of reattached teeth using four different materials. Materials and Methods: 150 extracted human permanent maxillary incisors were randomly divided into five groups of 30 teeth each of one control and four experimental groups. Teeth in experimental groups were sectioned 2.5 mm from incisal edge and reattached using four different materials. The reattached teeth were subjected to evaluate fracture resistance. Results: The mean fracture resistance of reattached teeth using resin modified glass ionomer cement, compomer, composite resin and dual curing resin cement was 8.10 ± 2.34, 11.15 ± 3.36, 17.11 ± 3.99 and 14.13 ± 3.71 kg respectively. Results showed highly significant difference between the groups ( P < 0.001). Conclusion: Fracture resistance of reattached teeth in the different groups varied from 24-51% of that for an intact tooth. Reattachment with composite resin provides highest fracture resistance ( P < 0.05). Reattachment with resin-modified glass ionomer cement was the weakest ( P < 0.05).

Keywords: Anterior crown fracture, fractured tooth, reattachment

How to cite this article:
Singhal R, Pathak A. Comparison of the fracture resistance of reattached incisor tooth fragments using 4 different materials. J Indian Soc Pedod Prev Dent 2012;30:310-6

How to cite this URL:
Singhal R, Pathak A. Comparison of the fracture resistance of reattached incisor tooth fragments using 4 different materials. J Indian Soc Pedod Prev Dent [serial online] 2012 [cited 2021 Jul 31];30:310-6. Available from: https://www.jisppd.com/text.asp?2012/30/4/310/108927

   Introduction Top

Anterior crown fractures are a common form of dental injury that mainly affects children and adolescents. [1] The position of maxillary incisors and their eruptive pattern carries a significant risk for trauma. [1],[2],[3],[4] The incidence of dental trauma is on the rise due to involvement of children and teenagers in contact sports, automobile accidents, outdoors activities and falls. [5] Coronal fracture of permanent incisors represents 18-22% of all traumas to dental hard tissues; of these, 96% involve maxillary incisors (80% central incisors and 16% lateral incisors). [3],[6],[7],[8],[9] Traumatic dental injuries not only cause damage to the dentition, but also have a psychological impact on the child and his parents as well. [7],[10],[11]

Restoration of a fractured crown is important both aesthetically and functionally. Various treatment modalities used to restore the fractured crown include stainless steel crowns, orthodontic bands, pin-retained resin, resin crowns, porcelain jacket crowns, and composite build-up. [11],[12] They may lead to sacrifice of healthy tooth structure. Fractured crowns were commonly restored using composite resin. However, composite resins have the disadvantage of poor abrasion resistance in comparison to enamel, marginal staining, discoloration, and lack of marginal integrity. [11],[12]

A plethora of studies reported that reattachment of fractured fragment to the remaining tooth structure using different adhesive materials and techniques are a suitable alternative, whenever the fractured fragment is available. [4],[10],[12],[13],[14],[15],[16],[17],[18] Reattachment of fragment can provide good and long-lasting aesthetics because the gross anatomic form, color and surface texture of the tooth are maintained. [5],[19],[20] It is more conservative and is a reasonably simple procedure. It restores tooth function and elicits an immediate positive emotional and social response from the child. [11],[15],[19],[21]

The reattached fragments are prone to re-fracture if another traumatic episode occurs or under non-physiological use of the restored teeth. [1],[2],[13] Therefore, most concerns have been directed towards the fracture strength of reattached teeth. A strong, durable and predictable union between the fractured fragment and the remaining tooth is the prime determinant. The purpose of the study is to evaluate the fracture resistance of reattached teeth using four different materials. The fracture resistance determines the bonding ability of the materials to resist re-fracture following fragment reattachment.

   Materials and Methods Top

A total of 150 human non carious permanent maxillary incisors extracted for periodontal reasons were collected. In this study, only maxillary incisors were included because these teeth are most prone to trauma. The extracted teeth were kept in 5% sodium hypochlorite solution for 1 h and remaining periodontal tissues were removed with scaler. Then the teeth were stored in normal saline.

The teeth were randomly divided into five groups of 30 teeth each - 1 control group and four experimental groups [Table 1].
Table 1: Grouping of samples

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Tooth in each experimental group was sectioned transversely to the long axis of the tooth, 2.5 mm away from the incisal edge using a diamond disk. 37% phosphoric acid (Tetric N Ceram, Ivoclar Vivadent) was applied along the fractured margins of the tooth and the fragment for 15 s. Then the etched surfaces were rinsed off thoroughly with water and gently air-dried. Bonding agent (Prime and Bond Nano-Technology) was applied with the help of an applicator tip to the etched surfaces of the fractured fragment and the tooth in group III, IV and V. Two consecutive coats were applied, gently air thinned and then light cured for 10 s. The material used for reattachment was then applied on a fractured surface of the tooth as well as the fragment according to manufacturer's instructions [Table 2]. The fractured fragment was then approximated along the fractured tooth margin and light cured for 40 s each on labial and lingual surface. Excess materials on the tooth surface were removed with a scalpel. This procedure was repeated for all the samples in the experimental groups. No additional preparation was made on the fractured margins of the tooth and the fragment either before or after reattachment. All the samples were then thermocycled between two baths, having a temperature differential of 6-60°C for 100 cycles with a dwell time of 30 s in each bath. Each specimen was then embedded in an acrylic resin block such that the long axis of tooth was parallel to the central axis of the block.
Table 2: Materials used in the present study

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All the specimens were then subjected to evaluate the fracture resistance. The specimen mounted in acrylic block was placed in the Universal testing machine. The rod of universal testing machine was held perpendicular to the long axis of the tooth at the incisal third of the crown, parallel and adjacent to the bonding line. The load was applied at cross-head speed of 1 mm/min. The load was increased progressively until the reattached tooth fragment separated. The load at which the reattached fragment de-bonded from the remaining tooth structure was recorded. This load represents the fracture resistance of the reattached tooth. The fracture resistance of all the specimens was recorded in the same manner. The data was compiled and put to statistical analysis.

   Results Top

[Table 3] shows the mean fracture resistance of intact teeth in control group and reattached teeth in four experimental groups. Statistical analysis of the results was performed. [Table 4] shows inter-group comparison of fracture resistance of teeth using Post hoc test.
Table 3: Mean fracture resistance of reattached teeth (in kg) using 4 different materials

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Table 4: Intergroup comparison of fracture resistance of teeth using Post hoc test (Tukey HSD)

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Results of the study showed that specimens in which fragments were reattached using composite resin exhibited highest resistance to fracture (P0 < 0.05). The specimens in which fragments were reattached using resin modified Glass Ionomer Cement (GIC) exhibited least resistance to fracture (P < 0.05). The fracture resistance of reattached teeth in different experimental groups in descending order is composite resin, dual curing resin cement, compomer and resin modified GIC.

   Discussion Top

Liew [22] perhaps best described re-attachment procedure as an excellent short to medium term temporary restoration with potential for indefinite service. Andreasen et al. [13] in a multicenter clinical trial demonstrated a 25% retention rate of reattached coronal fragments at 7 years. Cavalleri and Zerman [23] in another study showed a 90% retention rate at 5 years, outlasting resin composite repairs.

One of the disadvantages of reattachment is the predicted eventual separation of the repair because of progressive breakdown of the bonded junction (cyclic fatigue, hydrolytic degradation). [24] The debonding in many cases are caused by new traumas or non-physiological use of the restored teeth. The modest longevity of such restorations justifies a search for ways to improve the durability of the bond established by the fragment-bonding technique.

The important requirements of reattachment procedure include precise adaptation and a good material to join the two parts. [7],[16] An ideal dental material used for reattachment procedure must possess good mechanical properties to overcome the catastrophic propagation of flaws under an applied stress along with good biocompatibility, minimal gingival irritation and good bond strength.

The differences in the bond strengths between previous studies and the present study may be the result of the different chemical compositions and curing procedures of bonding agents used. It should also be considered that another reason for this difference may be due to the biochemical and histological differences between dental tissues of human and animal teeth. [25]

The studies also differ in the way that tooth fragments are obtained. Some authors have sectioned the incisal edge of teeth (Farik et al., [17],[26],[27] Farik and Munksgaard, [28] Worthington et al.[24] ) Others have placed small notches on the two proximal surfaces and fractured the teeth by using narrow forceps (Munksgaard et al., [29] Andreasen et al.[14] ) or by using a blunt instrument without making any notches (Dean et al.[30] ).

In an attempt to obtain an equal amount of area exposed, all of the teeth were cut at the same distance from the incisor margin (2.5 mm) in the present study. By this method, we tried to reduce to a minimum the variation in resistance to fracture resulting from the thickness of the layers of enamel and dentin present. [12] However, the anatomy of the surface produced by the cut is certainly different from the surface resulting from the fracture. With the cut, a smear layer is produced that is otherwise not found on a fractured surface. A fractured surface tends to be parallel to the direction of the enamel prisms, while the orientation of the surface exposed by cutting is dictated by the direction of the cut. [31] In the end, our choice was dictated by the fact that the cut establishes a repeatable condition absolutely necessary for an in vitro study, although it does not exactly simulate an accidental fracture. Sengun et al., [32] Badami et al. [12] and Worthington et al. [24] used the cut to study fragment bonding. The micro mechanical interlocking between the fragments and the respective remnant is very important for fracture strength recovery of the technique employed. [31] The fit between the fragment and the remaining teeth is lost by sectioning, and strength of the reattached teeth relies only on the bonding of the material to the sectioned interfaces and the mechanical properties of the materials employed. [18]

Another important factor is the maintenance of adequate hydration while the fragment is outside the mouth. [15] Hydration maintains the vitality and original aesthetic appearance of the tooth. The hydrophilic characteristic of adhesive systems also means that hydration acts to ensure adequate bond strength. The strength of the final restoration is dependent on correct hydration of the dentin fragment. [15]

The fractured surfaces of the tooth and the fragment were etched with 37% phosphoric acid for 15 s. Acid conditioning produced a significant increase in surface roughness and porosity in enamel and enlarged tubular openings in dentin. The resin entrapped within such pores would serve to improve bond strength. [33],[34] Etching for 15 s resulted in equal or even an enhanced etching pattern as compared to the pattern obtained with 60 s of etching according to the study conducted by Thosar et al. [35]

The choice of materials varies among case reports. The development of more effective adhesive systems has encouraged clinicians to use only these materials to reattach fragments to the remnant (Munksgaard et al., [29] Badami et al., [12] Andreasen et al., [14] Kanca et al., [36] Liebenberg, [37] Pagliarini et al. [8] ). Otherwise, other clinicians prefer to associate adhesive systems with other materials such as flowable composites (Small, [38] Farik and Munksgaard, [28] Farik et al., [17] Farik et al., [25] Liebenberg [37] ), dual or chemically cured resin cements (Dickerson, [39] Reis et al. [4] ) and its light cured version (Dean et al.[30] ). The use of viscous materials have been suggested where adhesive systems are used, along with hybrid and micro-filled light-cured resin composites (Martens et al., [40] Simonsen, [41] Burke, [21] Diangelis and Jungbluth, [42] Baratieri et al. [43] ), as well as chemically cured resin composites (Dean et al. [30] ).

As noted, many combinations of materials are reported in the literature and so far, only a few studies have evaluated their performance in terms of reattaching fragments to the remnant.

The results of this study demonstrated that the different materials were not able to attain the fracture resistance obtained from intact teeth, which is in accordance with previous findings in literature. [12],[14],[24],[29]

Among the experimental groups, teeth reattached with composite resin (Esthet X, Dentsply) showed highest resistance to fracture. This could be attributed to the following reasons.

It is a micro-hybrid composite resin, which has superior mechanical properties due to higher inorganic filler content. [34],[44],[45] The total filler content of Esthet X (Dentsply) is about 77% by weight (60% by volume). [46] In addition, the barium alumino-fluoro-boro silicate glass filler particles range in size from 0.02 microns to 2.5 microns (with an average of 0.6-0.8 m) while the silicon dioxide particles range from 10 nm to 20 nm. This unique particle distribution pattern provides superior strength and high fracture toughness. [46] The adhesive layer applied to the etched dentin penetrates the intertubular dentin, forming a resin-dentin inter diffusion zone, or "hybrid layer." They also penetrate and polymerize in the open dentinal tubules, forming resin tags. These tags harden after polymerization and provide micro-mechanical retention. [45] In addition; the adhesive layer increases the surface-free energy of dentin that is required for adequate interfacial contact. [45]

Farik et al. [20] verified that most of 5 th generation bonding agents increased the fracture resistance of reattached coronal fragments when used in conjunction with an unfilled resin. In a study conducted by Reis et al., [18] teeth reattached with hybrid resin composite showed higher fracture strength as compared to other materials used in the study. Farik et al. [20] showed in a study that the fracture strength of reattached teeth was significantly improved when adhesives were used in conjunction with resin for reattachment of the fractured fragment. The results of the present study are in accordance with these studies.

The teeth reattached with dual curing resin cement (Calibra Esthetic Resin Cement, Dentsply) showed fracture resistance lower than teeth reattached with composite resin (Esthet X, Dentsply). It could be attributed to the lower filler content of dual curing resin cement (60-65%) as compared to composite resin. [47] Lower the filler content, inferior is the bond strength of the resin. [45] Dual curing resin cement requires mixing of two pastes (base paste and catalyst paste) that may lead to air incorporation. It reduces the mechanical properties significantly. [1],[18] This correlates with the study by Demarco et al. [16] where dual cured resin cement showed fracture resistance lower than that of light-cured composite resin.

The teeth reattached with compomer (Dyract, Dentsply) showed fracture resistance higher as compared to the fracture resistance of teeth reattached with resin modified glass ionomer cement (GC Fuji II LC, GC Fuji Corporation). It could be due to the resin content of compomer which is about 70% as compared to 30% in resin modified GIC. [9] Higher the resin content better would be the mechanical properties of the material. In addition, an adhesive was applied over the etched surfaces in teeth reattached with compomer (Dyract, Dentsply). [9] This adhesive layer favors good adherence to the substrate as they penetrate the micro-porosities created by etching. [44],[48] In teeth reattached with resin modified GIC (GC Fuji II LC, GC Fuji Corporation), no adhesive was used.

Almuammar et al. [48] in their study observed that compomers showed higher bond strength than resin modified GIC, but less than composite resin. The results of the present study are in accordance with this study. Andreasen et al. [13] in their study concluded that use of dentinal bonding in combination with acid etching improves the fracture strength as well as a retention rate of the reattached fragment.

Teeth reattached with resin modified GIC (GC Fuji II LC, GC Fuji Corporation) showed least resistance to fracture. Resin modified GIC is mainly a glass ionomer with addition of small quantity of resin component such as hydroxyl-ethyl-methacrylate or Bisphenol-A-glycidyl dimethacrylate. It mainly relies on chemical bond through ion-exchange between the material and the tooth substrate rather than mechanical bond. [45],[48] It may be the reason for least fracture resistance of teeth reattached with resin modified GIC.

Different methodologies have been employed in laboratory articles. For instance, among several sources of variation found in these methodologies, it has been demonstrated that the crosshead speed might alter the results obtained. The mean fracture strength of fragment-bonded teeth decreases with increasing cross-head speed. [14] This phenomenon can be explained by an increasing brittleness of the methacrylate polymer with increasing load speed. [26] Prior in vitro studies of incisal edge reattachment have employed crosshead speeds ranging from 0.5 mm/min to 1.0 mm/min. [10],[12],[29],[30] Andreasen et al. [14] investigated the effect of loading fragments bonded with Scotchbond Multi-Purpose at 1, 5, 50,100 and 500 mm/min and noted that fracture strength decreased exponentially with loading speed.

In the case of reattachment, many authors sustain the necessity of the use of additional preparations to augment the retention of the re-bonded fragment, while others confide in the improvement of consolidated techniques of dentinal bonding that offer a resistance equal to that which is offered by the enamel. [49] Preparationless incisal edge reattachment with a modern adhesive approach is compelling, because most incisal fractures occur with minimal or no net loss of tooth structure. [24] Ideally, it would seem that the restorative procedure should require minimal tooth preparation in order to decrease manipulative trauma to the tooth and chair time.

The loss of tooth structure during sectioning with diamond disk, the speed at which repeat trauma actually occurs in vivo, and the inability to adequately reproduce actual intraoral forces in a laboratory simulation are notable limitations to the external validity of the present findings. Clinical trials should be conducted to confirm the hypothesis presented by laboratory investigations.

   Conclusion Top

Within the limits of the present investigation, the following can be concluded from the present study: (1) Fracture resistance of reattached teeth in different groups varied from 24 to 51% of that for an intact tooth. (2) Reattachment with composite resin provides the highest fracture resistance ( P < 0.05).(3) Reattachment with resin-modified glass ionomer cement was the weakest (P < 0.05).

However, long-term clinical trials as well as in-vitro studies on larger number of samples and at larger scale need to be undertaken, before drawing any definitive conclusion.

   References Top

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  [Table 1], [Table 2], [Table 3], [Table 4]

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