Evaluation of tooth-fragment reattachment: a clinical and laboratory study

Evaluation of tooth-fragment reattachment:a clinical and laboratory study

One way to treat fractured tooth due to trauma is toreattach the tooth fragment to its remnant using acomposite resin (1–4). The technique of reattaching atooth fragment was first described by Chosack andEidelman (5) in 1964, and this technique has numerousadvantages over the other techniques: the shape andcolor of the restored tooth are maintained, the patientsuffers no negative social and emotional effects aftertooth restoration, and it is fast, reliable, and cost-effective (2, 3, 6–8).

The reattachment procedure usually involves storageand preparation of the fragment prior to its reattach-ment, and these procedures are important determinantsof the overall clinical outcome. The results of severalstudies have shown that fragment discoloration is due todehydration of dentin in the fragment and decreasedbond strength between the tooth remnant and fragment(9, 10). Accordingly, it recommended that the fragmentbe kept moist in either tap water or physiologic salineuntil its reattachment to prevent the occurrence of theseproblems (9–11). Some investigators (12–14) claim that agood outcome can be achieved without additionalpreparation, such as making an internal enamel groove,

an internal dentin groove, or a V-shaped groove in theexternal enamel of the tooth remnant and/or fragmentprior to the reattachment procedure. Others (3, 7, 15–19)recommend that the tooth remnant or fragment shouldundergo additional preparation before reattaching thefragment. In fact, results from in vitro studies onfragment reattachment have shown that additionalpreparation to the tooth remnant and/or fragmentimproves the bonding between the tooth remnant andfragment (20–22).

In the dental literature, there are only a few studies onthe survival of restored teeth after fragment reattach-ment. Cavalleri and Zerman (23) treated fracturedcrowns using either a composite resin when the fragmentwas not available, or fragment reattachment when thefragment was available. Five years after restoration, theyfound that 100% of the teeth that had been restored byfragment reattachment re-fractured, whereas 40% of theteeth that had been restored using a composite resinre-fractured (23). Andreasen et al. (24) reported theirresults on reattachment after acid etching alone and afteracid etching together with a dentin bonding agent. Therate of survival of restored teeth that had been etched

Dental Traumatology 2010; 26: 308–314; doi: 10.1111/j.1600-9657.2010.00907.x

308 � 2010 John Wiley & Sons A/S

Yucel Yilmaz1, Cigdem Guler2,Hakan Sahin1, Ozge Eyuboglu1

1Department of Pedodontics, Ataturk University,

Faculty of Dentistry, Erzurum, Turkey; 2Depart-

ment of Pedodontics, Inonu University, Faculty

of Dentistry, Malatya, Turkey

Correspondence to: Yucel Yilmaz, AtaturkUniversitesi, Dis Hekimligi Fakultesi,Pedodonti Ana Bilim Dali, Erzurum, TurkeyTel.: +90 442 2311684Fax: +90 442 2360945e-mail: [email protected]

Accepted 26 March, 2010

Abstract – Purpose: To evaluate the restoration of fractured teeth by reattachingtooth fragment to its tooth remnant in a group of children and adolescents, andto compare the results with those of a laboratory study.Materials and Methods: The clinical study was conducted on 43 fracturedincisors: 22 uncomplicated crown fractures (Group A) and 21 complicatedcrown fractures (Group B). The 43 incisal fragments: 23 were kept dry for 47 hand 20 were kept wet for 24 h by the patients before they were reattached. Thefragments were kept in 0.9% saline solution for 30 min before reattachment.The fragments in Group A were reattached using a dentin bonding agent, aflowable and a hybrid resin composite, whereas the fragments in Group B werereattached to the tooth remnant after a pulpotomy was performed. Thelaboratory study was conducted on 56 extracted incisors. Teeth were dividedequally into four groups: Group I – Uncomplicated crown fracture + wetmedium; Group II – Uncomplicated crown fracture + dry medium; Group III –Complicated crown fracture + wet medium, and Group IV – Complicatedcrown fracture + dry medium. The fragments were then reattached in a mannerthat was similar to that used in the clinical study. The restored teeth were thenre-fractured. All data were analyzed statistically.Results: In the clinical study, the restored teeth were followed up for 2 years.Neither the type of trauma nor the storage medium had any significant effect onthe survival, color, and bond strength of the restored teeth when assessed in theclinical and laboratory study. The color disharmony that was encounteredinitially in restored teeth resolved significantly on its own accord within12 months after reattachment of the fragment.Conclusion: Fragment reattachment can be used to treat fractured teethsuccessfully in children and adolescents.

with acid only was 50% at 1 year, whereas that of teethrestored with acid etching and a dentin bonding agentwas 50% at 3 years. Spinas (25) reported that all teeththat had been restored by fragment reattachment neededto be replaced completely 7 years after restoration. Inview of the paucity of data on the overall clinicaloutcome of tooth restoration by fragment reattachment,we undertook a clinical and a laboratory study aimed atevaluating the effect of trauma type and the storagemedium on the survival, color, and bond strength ofrestored teeth after fragment reattachment.

Materials and methods

Study design

The study consisted of two parts: a clinical and alaboratory study. The clinical study evaluated the effectsof trauma type and the type of storage medium of thefragment on the survival of the restored tooth. To thisend, we (i) compared the color harmony between toothremnant and fragment, and (ii) determined the rate ofpulpal survival in the restored tooth. The laboratorystudy compared the effects of trauma type and the typeof storage medium on the bond strength between thetooth remnant and the reattached fragment.

Clinical study

A prospective clinical study was performed between 2003and 2007 in the Pedodontics Department, School ofDentistry, Ataturk University, Erzurum, Turkey. Thestudy involved children aged from 6 to 15 years (mean10.4 ± 2.6) who presented at the Pedodontics Depart-ment with fragments of broken teeth following trauma.

The inclusion criteria for the study were that thepatient (i) did not have an ongoing medical problem,periodontal disease, and caries of the tooth remnant;(ii) had no previous history of fractured teeth due totrauma and had not undergone a previous restoration toa fractured tooth by either fragment restoration or othermethods; and (iii) was able to return for regular follow-up examinations.

Group A consisted of 22 incisors from patients whopresented at our clinic 35 h (average) after trauma withan uncomplicated crown fracture that involved enameland dentin. Group B consisted of 21 incisors frompatients who presented at our clinic 38 h (average) aftertrauma with a complicated crown fracture that involvedthe enamel, dentin, and exposure of the pulp. Of the 43incisal fragments, 23 were kept dry for 47 h and 20fragments were kept in tap water for 24 h by the patientbefore reattachment. Thirteen of the 22 incisal fragmentsin Group A, and ten of the 21 incisal fragments in GroupB were kept dry by the patient before reattachment. Theremaining incisal fragments in the two groups were keptin tap water before they were reattached.

Treatment protocols

On arrival at the clinic, all the incisal fragments fromGroups A and B were placed in 0.9% saline solution

( _I.E. Ulagay, Istanbul, Turkey) for 30 min. Each patientwas treated under local anesthesia (Ultracaine DS;Aventis, Istanbul, Turkey), and a rubber dam wasplaced to isolate the fractured tooth.

In Group A, the dentin was not covered with linercement before the reattachment procedure. No pre-reattachment preparations were carried out on eitherthe tooth remnant or the incisal fragment of thefractured tooth. Prior to reattachment, the incisalfragment was removed from the saline solution, driedgently with an air spray, and then was fastened to apiece of adhesive wax for ease of handling. The toothremnant was separated from the mesial and distal teethby a celluloid band during the reattachment procedure.The tooth remnant and incisal fragment were etchedwith 35% phosphoric acid using the total-etch tech-nique. The acid was removed using a water spray.Then, the surfaces were dried using polyurethane pellets(Pele Tim; Voco, Cuxhaven, Germany). Dentin bondingagent (Prime & Bond NT�; Dentisplay, Konstanz,Germany) was then applied according to the manufac-turer’s instructions. After 20 s, the bonding agent wasspread using an air spray for 3–5-s, and then curedunder a visible light source for 10 s. In Group B,pulpotomy was performed on the tooth remnant byplacing calcium hydroxide (Life Fast Set; Kerr, Salerno,Italy) directly onto the exposed pulpal tissue. Theremnants of the pulpal tissue in the incisal fragmentswere removed using a slowly rotating round bur(S1-012-RA; NTI, Kahla, Germany). The cavities ofthe tooth remnant and the incisal fragment were filledwith a flowable resin composite (Tetric Flow, IvoclarVivadent, Schaan, Liechtenstein). Care was taken toensure that the cavities were not over-filled with theresin composite. The resin was then cured under avisible light source for 20 s. Before reattaching thefragment, flowable resin composite was applied to thebroken tooth surfaces. When reattaching the fragment,the operator made every effort to ensure that the fitbetween the tooth remnant and the incisal fragment wasas good as possible.

After the incisal fragment had been reattached in itsoriginal place, the excess resin composite was removedusing a dental probe. The resin composite on each toothsurface (buccal and lingual) was light-cured for 20 s. Toachieve optimal function and esthetics, the tooth wasbandaged using a hybrid resin composite (Valux Plus,3M ESPE, Seefeld, Germany) that was the same color asthe resin composite. The fracture lines on the buccal andlingual surface were double-chamfered using a rounddiamond bur (FG010010; HRC101, Berlin, Germany).The double chamfer was etched with 35% phosphoricacid for 60 s after which the acid was removed using awater spray and the surface of the tooth was dried withpolyurethane pellets. The dentin bonding agent was thenapplied as previously described. The selected hybridcomposite resin was applied and cured under a visiblelight source for 40 s. The tooth was finished andpolished using Sof-Lex� polishing discs (3M ESPE).The rubber dental dam was removed and occlusion waschecked. All the patients were given instructions on oralhygiene.

Tooth-fragment reattachment 309

� 2010 John Wiley & Sons A/S

Follow-up examinations

The clinical follow ups were conducted at 3-monthintervals during the first year, at 6-month intervalsduring the second year, and at 12-month intervals insubsequent years. At each clinical follow-up examina-tion, the following were evaluated: fragment position,fragment stability, gingival swelling, and presence ofabscess, sinus tract formation, sensitivity to percussion,and the response to the pulp test. Furthermore, the colorharmony between the tooth remnant and incisal frag-ment, and between the adjacent healthy teeth and therestored tooth was evaluated using Cvar and Ryge’s (26)modified rating system which has three scores: (i) Alpha:there is no mismatch in color, shade and/or translucencybetween the restoration and the adjacent tooth (ii)Bravo: there is a mismatch in color, shade and/ortranslucency between the restoration and the adjacenttooth, and (iii) Charlie: there is a mismatch between therestoration and the adjacent tooth outside the normalrange of tooth color, shade and/or translucency. Colorharmony was scored on images that were obtained usinga 10.1 mega pixel digital camera (Panasonic LumixDMC-FZ50; Matsushita Electric Industrial Co, Ltd,Kadoma Osaka, Japan) at illumination of 5000 K ±10% (Fuji Film Macro Ring Light TT-MED; Fuji PhotoFilm Co., Ltd., Tokyo, Japan).

Radiological follow-up examinations were conductedat 6-month intervals during the first year and at 12-month intervals in subsequent years. In these examina-tions, the following were assessed: pulp canal oblitera-tion, intactness of the lamina dura, extent of breakdownof marginal bone, external inflammatory resorption,replacement root resorption, apical radiolucency, andformation of a dentinal bridge in the teeth that hadundergone pulpotomy. In addition, the restored teethwere scored according to the stage of root developmentusing the method that was described initially by Moor-rees et al. (27) and modified later by Andreasen et al.(28) using the following formula:

R1/4–3/4: Root length 1/4–3/4,Rc: Root length complete,A1/2: Apex half-closed, andAc: Apical closure complete.

Laboratory study

The laboratory study was performed on 56 permanentupper incisor teeth that had been extracted recently frompatients because of periodontal problems and had nodevelopmental defects of the crown, caries, and arestoration of any type. The tissue remnants on the rootsurfaces of the teeth were removed using a dental scaler.The mesiodistal and buccolingual widths of all the teethwere measured using calipers (Dentaurum, Inspringen,Germany). Using an independent two-sample t-test, wedetermined that the sizes of the teeth in the two groupswere not significantly different from each other. Theteeth were divided randomly into two groups of 28 teeth;a group in which an uncomplicated coronal fracture wascreated, and a second group in which a complicated

coronal fracture was created. For these purposes, thepulp horn line of each tooth was identified radiograph-ically and then marked on the vestibular enamel surface.All the teeth were then embedded in an acrylic resinblock. For those teeth in the first group, the acrylic resinsurface was 1 mm above the pulp horn line, and for thoseteeth in the second group, the acrylic resin surface was2 mm below the pulp horn line. Each specimen was thenplaced in an Insitron testing device (Hounsfield, Roydan,UK) in such a manner that the angle between thevestibular surface of the tooth and horizontal plane was180 degrees. A force was then applied to the vestibularenamel surface of the embedded tooth, 4 mm from itsedge at a 90� angle using a 0.5 mm thick stainless steelrod. The crosshead speed of the testing device was0.5 mm min)1 (Fig. 1). The force required to fractureeach tooth was recorded in Newtons. Both the toothremnant and incisal fragment of each tooth were thennumbered to ensure that each remnant could be matchedcorrectly to its fragment at the time of fragmentreattachment. Each test group was then subdivided intotwo groups. In one group, the tooth remnant and itsincisal fragment were kept at room temperature in tapwater for 24 h prior to reattachment (wet medium). Inthe other group, the remnant and fragment were kept atroom temperature for 47 h prior to reattachment (drymedium). The experimental groups were as follows:

0.5 mm min–1

Pulp horn line

0.5 mm min–1

Pulp horn line

90°

90°

1 mm

2 mm

Acrylic resin block

Acrylic resin block

(a)

(b)

Fig. 1. Diagram explaining the creation of (a) an uncompli-cated crown fracture and (b) a complicated crown fracture inthe laboratory study.

310 Yilmaz et al.


Group I: Uncomplicated crown fracture + wet med-iumGroup II: Uncomplicated crown fracture + drymediumGroup III: Complicated crown fracture + wet med-iumGroup IV: Complicated crown fracture + dry med-iumAll incisal fragments were placed in 0.9% saline

solution for 30 min before reattachment. The method ofreattachment for all fragments was the same as thatdescribed for the clinical study. The restored teeth werethen thermocycled for 250 cycles between 5 and 55�Cand then stored in tap water for 24 h at 37�C prior tofurther testing. The restored teeth were then re-fracturedby applying a force to the identical surface of therestored tooth using the Instron testing device at acrosshead speed of 0.5 mm min)1. The force required torefracture each restored tooth was recorded in Newtons.

Statistical analysis of the data

Clinical studyThe Wilcoxon signed rank sum test was used to analyzethe results of the study parameters namely, the effects oftrauma type, and the type of storage medium of thefragment on the rate of survival of the restored teeth.

Laboratory studyAn independent two-sample t-test was used to comparethe forces that were required to cause uncomplicated andcomplicated fractures (fracture resistance forces) beforeand after the fragments were reattached. The effects ofthe storage medium on the bond strengths of the restoredteeth were compared by a univariate analysis of variance.The bond strengths and baseline fracture resistanceforces of those teeth in which the tooth fragment hadbeen kept in either the wet or dry storage medium werecompared using a paired Student’s t-test. All the statis-tical analyses were performed using a computerizedstatistical program (spss 15.0, SPSS Inc., Chicago, IL,USA). The level of significance was set at 5%.

Results

Clinical study

Table 1 presents the time points at which follow-upexaminations were made on the restored teeth in theclinical study. All restored teeth were evaluated. Therestored teeth were followed for 2 years (mean24.6 ± 14.4 months). Three (7.0%) of the 43 restored

teeth had re-fractured due to another traumatic injury.One of these teeth was from Group A (in the 24thmonth, wet medium) and the other two were from GroupB (one in the 24th month, wet medium and the other inthe 35th month, dry medium). The remaining 40 teeth(93.0%) were still intact and completely functional at thelast follow-up examination. None of the patients was lostduring the follow-up period.

The rates of survival of the restored teeth foruncomplicated and complicated fractures at the lastfollow-up examination were 95.7% and 90.0%, respec-tively. These rates were not significantly different fromeach other (P > 0.05).

When the effect of wet and dry storage medium wascompared, the rates of survival of the restored teeth atthe last follow-up examination were 90.0% and 95.7%,respectively. Again, these rates were not significantlydifferent from each other (P > 0.05).

The rate of survival of the pulp in the tooth remnantat the last follow-up examination was 100% for uncom-plicated tooth fractures and 95% for complicated toothfractures, respectively. These rates were not significantlydifferent from each other (P > 0.05).

At the clinical follow-up examinations, we did not findany problems in fragment position and stability. Wefound also no gingival swelling, abscess, or sinus tractformation and response to pulp testing in both groups.However, we did find that one tooth in Group B wassensitive to percussion.

Data on color harmony between the tooth remnantand its incisal fragment and between the restored toothand the adjacent healthy teeth were as follows. At thetime of reattachment, 19 (44%) of the 43 teeth had Alphascores, 18/43 teeth (42%) had Bravo scores, and 6/43teeth (14%) had Charlie scores. After 12 months, thenumber of teeth with Alpha scores increased, and therewere no teeth with Charlie scores: 36/43 teeth (84%) hadAlpha scores and the remaining seven teeth (16%) hadBravo scores. These seven teeth that had Bravo scores at12 months had Bravo scores at the time of fragmentreattachment.

There was no clinical and radiological evidence of (i)pulp canal obliteration, (ii) breakdown of marginal bone,(iii) external inflammatory resorption, and (iv) rootresorption in the restored teeth irrespective of whetherthe type of tooth fracture was uncomplicated or compli-cated. However, in Group B, we found that one toothhad an intact lamina dura and apical radiolucency, andthere was formation of a dentin bridge in 11 teeth. Thescores for root formation and apical closure of the 43restored teeth were R1/4 = 1, R1/2 = 4, R3/4 = 3,Rc = 5, A1/2 = 1, and Ac = 29. At the last follow-up

Table 1. Time points at which follow-up examinations were made on the restored teeth in the clinical study

Groups

Follow up (months)

Mean duration ± SD6–8 9–11 12–17 18–23 24–35 36–47 48+

Group A 4 2 5 – 4 7 – 23.2 ± 14.1

Group B 4 1 2 1 7 4 2 26.1 ± 14.9

Mean duration 7.3 9.0 13.0 23.0 28.5 39.6 55.0 24.6 ± 14.4



examination (55 months), these scores were R1/4 = 0,R1/2 = 0, R3/4 = 2, Rc = 1, A1/2 = 5, and Ac = 35.

The mean kappa value for intra-examiner repeatabil-ity for clinical assessment, color harmony, and radio-graphic evaluation was 0.85.

Laboratory study

Table 2 summarizes the fracture resistance forces of theoriginal and restored teeth. There were no statisticallysignificant differences between the fracture resistanceforces that were required to cause either an uncompli-cated fracture or a complicated fracture. When thefracture resistance forces were compared with respect toeither the fracture type (uncomplicated or complicated)or the environment in which the teeth were kept (wet ordry) prior to their reattachment, no statistically signif-icant differences were found. However, statisticallysignificant differences were found when the fractureresistance forces of the original teeth were compared withthose of the restored teeth with respect to either fracturetype or the pre-reattachment environment. The fractureresistance forces of the restored teeth ranged from16.2% to 29.7% of those of the original teeth, and thesevalues were statistically significantly different (P < 0.05;Power = 1).

Discussion

Although it has been argued that the results of in vitrostudies cannot be extrapolated to the in vivo condition, ithas been claimed that they may help to predict theoutcome of clinical applications (29). Therefore, we feltthat it was important that this study has both a clinicaland a laboratory-based component to examine theoverall clinical outcome after fragment reattachment,particularly with respect to the survival of the restoredteeth.

We found that neither the type of trauma nor thestorage medium had any effect on the survival ofrestored teeth after reattachment. Of the 43 restoredteeth, three had re-fractured because of a second trauma.Some authors (3, 7, 15–19) have proposed that restoredteeth with reattached fragments are less likely to refrac-ture when the either the tooth remnant and/or incisalfragment is prepared prior to the reattachment proce-dure. Therefore, it could be argued that there would havebeen fewer re-fractures if the tooth remnant and/orfragment had been prepared prior to reattachment.However, we considered that additional preparation to

either the tooth remnant and/or its fragment would becounterproductive to the protective nature of the reat-tachment procedure. The outcome of the remaining 40restored teeth was clinical success. Contributory factorsto this high success rate may be the bond strength of thebonding agent, and the type of flowable resin compositeand hybrid resin composite that were used in thereattachment procedure. The dentin bonding agent thatwas used in this study, namely Prime Bond & NT� is anacetone-based resin. Hence, we suggest that the water-chasing ability of acetone effectively displaced waterfrom the dentin surface, resulting in optimal resininfiltration into the collagen network (30). In addition,the bonding agent contains nano-sized filler particles.Although controversial, it is claimed that these nano-sized particles increase the bond strength of the materialdue to their capacity to penetrate the spaces between thecollagen microfibrils, thereby providing ‘nano-retention’(31, 32). The strength of the resin bond after hardening is193 N, which is considerably higher than the estimatedbite strengths (155 N) (33) of children who participatedin this study.

It has been reported that the strength of the bondbetween the tooth fragment and tooth remnant isreduced when the fragment is kept in a dry environmentfor more than 1 h prior to its reattachment (10). Fariket al. (10) recommended that fragments that wereinitially kept in a dry environment should be kept moist(in water) for at least 24 h prior to their reattachment.The results of our study are not in agreement with thoseof Farik et al. (10). In the laboratory study, we foundthat the fracture resistance forces of tooth fragments andremnants that were kept in a dry environment for 47 hfollowed by 30 min in 0.9% saline were not significantlydifferent from those for teeth that had been kept in tapwater for 24 h prior to their reattachment. These findingswere the same as the results that were obtained from theclinical study. In our clinical study, we found nodifferences in the rates of survival of restored teeth,regardless of whether the fragments were kept either dryor moist prior to reattachment. Lee et al. (34) reportedthat the residual chlorine from saline solutions that areused to store tooth fragments can negatively influencebond strengths. They found that the bond strength oftooth fragments that were kept in 0.9% saline solutionprior to reattachment was significantly lower than thosethat was in distilled water prior to reattachment. We didnot keep the incisal fragments in distilled water prior totheir reattachment. Therefore, it could be argued that ifwe had used distilled water to store the fragments prior

Table 2. Fracture resistance forces of the original and restored teeth that were measured in the laboratory study according to the typeof trauma (uncomplicated or complicated) and the environment of the tooth fragment prior to reattachment (wet or dry)

Groups n

The force required to

fracture each tooth

(±SD) (Newton)

The force required to

fracture reattached teeth

(±SD) (Newton)

% Change

(decrease)

Group I (uncomplicated crown fracture + wet medium) 14 961 ± 308 194 ± 55 79.8

Group II (uncomplicated crown fracture + dry medium) 14 727 ± 272 191 ± 67 73.7

Group III (complicated crown fracture + wet medium) 14 768 ± 117 228 ± 116 83.8

Group IV (complicated crown fracture + dry medium) 14 1008 ± 281 163 ± 65 70.3

312 Yilmaz et al.


to their reattachment, we could expect higher bondstrength and a more successful clinic outcome than thatreported in the clinical study. Therefore, we suggest thatthere is a need for further studies to determine the idealstorage solution for tooth fragments before their reat-tachment.

It has also been reported that color disharmony canoccur between the tooth fragment and tooth remnantwhen the fragment is kept in a dry environment prior toits reattachment (3). Furthermore, some investigatorsreported that the color disharmony may disappearwithin 12 months because of water absorption by thefragment after its reattachment (3, 11, 35). In addition,Capp et al. (36) reported that fracture strength of a tooththat had been kept in a dry environment for 48 h couldbe restored when restored after only 30 min rehydration,and this may be promising for conserving the originalcolor of the tooth. At the time of reattachment in ourclinical study, 19 of 43 teeth had Alpha scores and of theremaining 24 teeth, 17 had Alpha scores after 12 months.From these results, we believe that 12 months is notalways long enough to achieve color harmony whenfragment reattachment is used to restore fractured teeth.This finding is not in agreement with the results of arecently published study of Yilmaz et al. (11). One likelyreason for this difference is the time between the toothfracture and the reattachment of the tooth fragment. Inthis study, all teeth were reattached after approximately36 h, whereas this time was 18 h in the previouslypublished Yilmaz et al. (11) study.

Andreasen and Andreasen (9) proposed that discol-oration of the fracture line may be due mainly to the useof chemically cured composite resins as the bondingagent. To overcome this problem, they recommended thecombined use of light-cured composite resin and doublechamfering of the fracture line. In our clinical study, nodiscoloration was noted on the reattachment line whenwe followed this recommendation.

Prior to the fragment reattachment procedure, 21teeth had complicated crown fractures. These teeth weretreated endodontically by a pulpotomy. Pulpotomy wasthe preferred treatment because of the increased poten-tial for contamination due to the size of the pulpexposure (>2 mm) and the prolonged exposure time(average 38 h) (37).

Robertson et al. (38) proposed that postproceduralcomplications with pulp involvement in restored teethafter fragment reattachment are related to the injuryitself rather than the treatment. Furthermore, they notedthat obliteration of the pulp canal and pulpal necrosisoccurs rarely in coronal fractures, even when the pulp isexposed (38). However, they did comment that luxationinjuries that occurred concomitantly with crown frac-tures have a significant deleterious effect on pulpalprognosis with respect to pulpal necrosis and obliterationof the pulp canal (38). We noted that none of the 43fractured teeth suffered from a luxation injury orobliterated pulp canal. Only one of the 43 teeth devel-oped pulpal necrosis. The tooth in which this occurredhad a complicated crown fracture initially and wastreated endodontically by a pulpotomy. At the 24-monthfollow-up examination of this tooth, no pathologies were

observed clinically or radiologically, and a dentin bridgehad formed. At the 36-month follow-up examination,this tooth re-fractured in the 35th month due to a secondtrauma. Thus, pulpal necrosis may have developed dueto loss of protective barrier function of the restorationand the late presentation of the patient after the secondtrauma. The dentinal bridge is not a good protectivebarrier, because it contains cellular elements and multi-ple wide-tunnel defects (39–43). Cox et al. (39) havereported an association between tunnel defects in thedentinal bridge and necrosis due to inflammation.Therefore, we are of the opinion that the pulpal necrosiswhich occurred in one tooth in our clinical study mightbe associated with tunnel defects in the dentin bridge.

In our clinical study, no delay was noted in the rootdevelopment of the restored teeth with complicated oruncomplicated crown fractures and open apices. This isin agreement with the previous findings. Robertson et al.(38) found that root development continued in teeth withcrown fractures and open apices when there was noconcomitant luxation injury.

All three forms of pathologic root resorption (surface,inflammatory, and replacement) have been reported tooccur after luxation injuries with displacement or rootfractures (9). In our study, none of the fractured teethhad a concomitant luxation injury or root fracture, and itis probably for this reason that we did not find anypathological root resorption in the restored teeth afterfragment reattachment.

Conclusions

1 The type of trauma that causes coronal fractures orstorage medium in which the fragment is kept prior toits reattachment has no effect on the survival, color,and bond strength of restored teeth after fragmentreattachment. In addition, fragments can be reattachedto fractured tooth remnants successfully without addi-tional preparation of the tooth remnant and/or frag-ment after coronal fractures.

2 Although the color disharmony that is encounteredinitially in restored teeth after fragment reattachmentresolves significantly on its own accord within12 months, this length of time may not always be longenough to achieve full color harmony in all cases offragment reattachment.

3 Based on the results from our laboratory study, thefracture resistance force of restored teeth after frag-ment reattachment is significantly lower than that ofun-restored natural teeth.

Clinical relevance

Fragment reattachment can be used to treat fracturedteeth successfully following trauma in children andadolescents.

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Evaluation of tooth-fragment reattachment: a clinical and laboratory study