|Year : 2018 | Volume
| Issue : 2 | Page : 117-126
Laboratory and clinical evaluation of uncomplicated fragment reattachment using pinholes
Talat M Beltagy
Department of Pedodontics, Faculty of Dentistry, Kafrelsheikh University, Kafrelsheikh, Egypt
|Date of Submission||04-Mar-2018|
|Date of Acceptance||26-Apr-2018|
|Date of Web Publication||25-Jun-2018|
Talat M Beltagy
Department of Pedodontics, Faculty of Dentistry, Kafrelsheikh University, Kafrelsheikh
Source of Support: None, Conflict of Interest: None
To evaluate laboratory and clinically the uncomplicated fragment reattachment using pinholes.
Materials and Methods
A total of 40 extracted human intact upper permanent central incisors with close similarity were selected and randomly divided into four groups (n = 10) according to the technique of reattachment. The incisal third of 30 specimens were sectioned horizontally. Group I: pinholes, group II: internal dentinal groove, group III: simple reattachment, and group IV (control group): intact teeth. Each fragment was reattached to its sectioned tooth using adhesive bond and resin cement. All specimens were tested for fracture strength under standard conditions in an Instron testing machine. The clinical study was performed on 20 patients, aged 8–16 years, presented with uncomplicated fragments of fractured upper central incisors, and divided into two groups (10 patients each). Group I: pinholes and group II: internal dentinal groove. All patients were followed-up clinically and radiographically at 3, 6, 12, and 18 months. Data were analyzed using one-way analysis of variance and post-hoc test with the significant level P less than 0.05.
The laboratory study showed that the control group recorded the high strength value followed by pinholes, internal groove, and simple reattachment and the difference was statistically significant. However, the clinical results showed no significant differences between the two techniques.
It was concluded that the pinholes technique had only a significant effect on fragment reattachment success in the in-vitro study.
Keywords: coronal tooth fracture, fragment reattachment techniques, tooth fragment
|How to cite this article:|
Beltagy TM. Laboratory and clinical evaluation of uncomplicated fragment reattachment using pinholes. Tanta Dent J 2018;15:117-26
|How to cite this URL:|
Beltagy TM. Laboratory and clinical evaluation of uncomplicated fragment reattachment using pinholes. Tanta Dent J [serial online] 2018 [cited 2018 Oct 19];15:117-26. Available from: http://www.tmj.eg.net/text.asp?2018/15/2/117/235131
| Introduction|| |
The coronal fracture of the anterior teeth is the most frequent form of traumatic dental injury affecting mainly children and adolescents, especially the youngest (8–11 years), and the upper central incisors are the most commonly affected due to their vulnerable situation in the dental arch . Several factors can influence the management of crown fractures, including the extent of the fracture, fracture pattern and tooth restorability, a patient's age, soft tissue condition, absence/presence of tooth fragment, the condition of reattachment, esthetic expectations, occlusion, economics, and prognosis ,.
The coronal fractures are classified according to WHO into uncomplicated crown fractures, such as enamel and dentin fractures and complicated crown fractures that associated with pulp and/or periodontal involvement . The uncomplicated and complicated crown fractures in children's teeth caused by trauma represent ~ 28–44 and 11–15%, respectively .
Various treatment options have been developed to restore the uncomplicated crown fractures, such as veneers , or jacket crowns; however, such treatments are more destructive and harmful to the pulp . The development of resin composite and bonding systems can provide a more conservative approach . Despite the advanced technology in adhesives and restorative techniques, still, no restorative material can reproduce the natural dental structures, functional demands, and esthetic hue . Therefore, when a fractured fragment is available, it is the first restorative option that should be performed immediately ,.
The original fragment reattachment is a vital important technique for restoring coronal fracture. It overcomes the disadvantages of full-coverage or resin restorations . The technique is fast, simple to use, minimally invasive, less time-consuming, and low-cost. It improves the emotional discomforts and incisal function. Likewise, it maintains the original anatomic form of the tooth, the occlusal alignment, natural characteristics of wear, surface texture, translucence, and shape and provides perfect, long-lasting esthetics ,. Therefore, tooth fragment reattachment can be considered the best decision to restore the coronal fracture in patients younger than 18–20 years that overcome any prosthetic replacement .
Several techniques have been proposed for the management of uncomplicated fragment reattachments, such as circumferential bevel , labial chamfer placement ,, internal dentinal groove, v-shaped enamel notch, and a circumferential or lingual composite overcontour ,, the use of dentin pin (biopins) , vertical groove technique , or bonding without additional preparation .
The literature reviews of evidence-based demonstrated that the design and dental materials play a significant role in fracture strength, and the recorded results vary from high strength value, with the use of internal dentinal groove, and composite resin overcontouring ,, while the labial chamfer and lingual overcontour  recorded about 50%. Other investigators have failed to illustrate a significant difference between the other techniques used ,. Many published data reported that both material and technique used for fragments reattachment may have a significant effect on the fracture strength of the restored teeth .
In fact, the in-vitro results from fragment reattachment studies have shown that the additional preparation to the fragment and/or tooth remnant can improve the bonding strength between them ,. Thus, further investigations are required to evaluate the effects of new techniques and adhesives introduced for the clinical use. Therefore, the current study aimed to evaluate laboratory and clinically the uncomplicated fragment reattachment using pinholes. The null-hypotheses suggest that there will be no difference between the effectiveness of different techniques on fragment reattachment.
| Materials and Methods|| |
The current study had two parts (laboratory and clinical parts). The laboratory part evaluated the fracture strength of three different techniques (pinholes, internal dentinal groove, and simple reattachment). The clinical part evaluated the effect of pinholes technique in the fragment reattachment on the survival of the restored tooth.
The study samples comprised 40 intact human maxillary central incisors freshly extracted for therapeutic reasons. The teeth were decontaminated in a buffered aqueous solution of formaldehyde for 2 h and then were cleaned from the calculus and soft tissues with an ultrasonic scaler. Specimens with intact incisal edges and closed apices were selected for close similarity in mesiodistal and buccolingual widths using a digital caliper for the measurement (IOS, USA). Under optical magnification (×4), the teeth were inspected for incipient caries, microcracks, or any other structural defect, then stored in a sterile saline at 4°C and to be used within 3 months of collection ,.
The labial surface of each crown was measured carefully by the digital caliper and divided into three equal horizontal thirds using a marker. The specimens were embedded perpendicular to standard molds of auto-polymerizing acrylic resin, leaving the anatomical crowns exposed [Figure 1]. Specimens were randomly divided into four groups (n = 10/group) according to the technique of reattachment; group I: pinholes, group II: internal dentinal groove, group III: simple reattachment, and group VI (control group): sound teeth.
|Figure 1: The labial surface of a specimens crown was divided into three transversal thirds using a digital caliper (a–c). Acrylic molded specimen within the metallic cylinder (d).|
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The junction of the incisal and middle thirds of the crowns of the three groups was sectioned off horizontally through the long axis of the specimens with a diamond disc under a cooling system, eliciting an Ellis class-II fracture ,,,.
Fragments were cleaned and disinfected using mechanical and chemical techniques. Polishing paste, sodium hypochlorite (NaOCl), and 70% alcohol have been used to remove the protein coating from the fragments. The fragments were kept moist in deionized water for no longer than 48 h before bonding to avoid their dehydration ,,.
Group I: a pinhole (1.5 mm depth and width) was prepared bilaterally within the dentin's fragment, 1 mm away from the dentino-enamel junction using #4 round carbide bur with a high-speed under a cooling system. The pinholes were connected together with a shallow dentinal groove.
Group II: an internal dentinal groove of 1 mm depth and width was prepared within the fragment with #2 round carbide bur with a high-speed handpiece under a cooling system .
Group III: simple fragment reattachment without an additional preparation [Figure 2].
|Figure 2: Incisal fragments showing the used three different reattachment techniques; pinholes (a), the internal dentinal groove (b), and simple fragment reattachment (c).|
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Both surfaces were etched using 37% phosphoric acid gel (Super-etch, SDI) for 30 s, then thoroughly rinsed off and air dried. Two coats of the adhesive resin (Adper Single Bond 2; 3M ESPE) were applied to the etched surfaces and gently air thinned for a 3–5 s without light-activation to avoid the misfit of the bonded parts . A thin coat of self-adhesive resin cement (RelyX Unicem; 3M ESPE) was applied to both surfaces; the fragment was carefully repositioned on the tooth remnant under pressure. The excess cement was removed and light-cured from both aspects for 60 s using curing-light (Demetron Optilux 400; Kerr, USA) while pressing the fragment against the matching specimen part.
Group IV (control group): sound specimens without sectioning.
All specimens were restored for 2 weeks at 100% humidity and at 37°C and then were placed in separate mesh bags and thermocycled together in distilled water for 1000 cycles between 5 and 55°C at a dwell and transfer time of 15 and 10 s, respectively . The specimens were positioned in the jig adapted in an Instron testing device (Instron, High Wycombe, UK) at Department of Dental Biomaterials, Faculty of Dentistry, Tanta University (Tanta, Egypt). Force was applied in a labio-palatal direction using a 0.5 mm thick stainless steel rod at 90° angle in the center of the incisal third of the specimen with a crosshead speed of 0.5 mm/min ,, [Figure 3]. The load required to detach each specimen's fragment was recorded in kilogram forcing units (kgf) .
|Figure 3: Metal assembly used to hold a specimen at an angle of 90° (a). A mounted specimen ready for testing of fragment strength in an Instron testing machine (b).|
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A clinical prospective study was performed between 2012 and 2016 on 20 children patients of both sexes aged 8–16 years (mean: 12.6 ± 2.3 years) who presented at the Department of Pedodontics, Faculty of Dentistry, Tanta University with uncomplicated fragments of fractured upper central incisors following a traumatic dental injury.
All children' parents were thoroughly informed about the purpose and procedures of the study, and written consents were obtained, in addition to the ascents obtained from the children above 8 years. The protocol of this study was approved by the Research Ethics Committee, Faculty of Dentistry, Tanta University.
The inclusion criteria were that the patient (i) had uncomplicated fractured crown that involved enamel and dentin (Ellis class II); (ii) did not have any systemic disease, periodontal pathology, and caries of the tooth remnant; (iii) had no previous restoration to a fractured tooth or history of tooth fractured; and (iv) was able to come back for regular recall examinations .
All fractured teeth were checked for vitality tests (Parkell Products Inc., Farmingdale, New York, USA), pulp exposure, and any periodontal changes following the dental trauma. The fractured tooth, fragment margins, and condition were examined by trans-illumination to rule out the presence of enamel cracks. For each patient, a preoperative periapical radiograph was taken to evaluate the root fracture, apex maturation, and periapical area. The patients were divided randomly into two study groups (n=10) according to the reattachment technique.
Group I: pinholes group
The fragment was cleaned, disinfected, and placed in deionized water for 30 min before reattachment procedure. It was assembled to check the close fit and to detect any missing parts. The pinholes with the connecting shallow dentinal groove were prepared, as discussed in the in-vitro study. Each patient was treated under local anesthesia and cotton rolls isolation. The fractured tooth was separated from the adjacent teeth with a celluloid strip during the reattachment procedure. The technical steps of reattachment were similar to the group I in the in-vitro study [Figure 4], [Figure 5], [Figure 6]. The restored tooth was finished, polished with rubber abrasive and a series of Soflex discs (3M ESPE Dental Products, St. Paul, Minnesota, USA). The occlusion was carefully checked and granulated fine and extra-fine diamond burs (Heico Switzerland Products) were used for any occlusal adjustments. All patients were instructed to maintain good oral hygiene and recalled for clinical and radiographic evaluation at 3, 6, 12, and 18 months.
|Figure 4: Preoperative photograph showing the uncomplicated coronal fracture of upper permanent incisors (a and b). The pinholes with a shallow connecting groove were prepared in the fragment of upper right central incisor (c). The tooth after fragment reattachment and composite restoration of left central incisor (d and e).|
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|Figure 5: Uncomplicated coronal fracture of traumatized upper right central incisor (a). The fragment with pinholes preparation (b). The case after reattachment procedure (c).|
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|Figure 6: Frontal view uncomplicated coronal fractures of upper right central incisor (a). The fractured fragment with pinholes preparation (b, c). The case after reattachment procedure (d).|
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Group II: internal dentinal groove
An internal dentinal groove of 1-mm depth and width was prepared within the fragment as mentioned before. All technical steps of reattachment were similar to group II in the in-vitro study [Figure 7].
|Figure 7: Preoperative photograph showing uncomplicated coronal fractures of upper central incisors (a). The right central was endodontically treated and the fragment repositioned but not included in the study (b, c). The internal dentinal groove was prepared in the other fragment (e, f). The patient after fragment reattachment (g).|
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All teeth were examined for fragment stability, the presence of abscess, gingival swelling, tooth mobility, sinus tract formation/fistula, sensitivity to percussion and pulp vitality test . The pulp test was carried out at the recall time after treatment . The color harmony between the fragment and the tooth remnant was evaluated using Cvar and Ryge's  modified rating system which has three scores: (i) α: there is no color mismatch, shade and/or translucency between the restoration and the adjacent tooth (ii) Bravo: there is a slight color mismatch, shade and/or translucency, and (iii) Charlie: there is an obvious color mismatch, shade, and/or translucency. Color harmony immediately scored postreattachment and during recall time and it was scored on images that were obtained using an 18-MP digital camera (EOS 600D, Canon, Tokyo, Japan) at an illumination of 5000K ± 10% .
A periapical radiograph was used to examine: Pulp canal obliteration, intactness of the lamina dura, fracture of the root or the alveolar bone, external root resorption, ankylosis, and apical pathology for each tooth . The restored teeth were scored according to the stage of root development using the method of Moorrees et al.  which was modified by the formula of Andreasen and Pedersen : R (1/4 − 3/4): root length (1/4, 1/2, or 3/4), Rc: root length complete, A (1/2): apex half-closed, and Ac: apical closure complete.
Statistical analysis was performed using SPSS software, version 19 (IBM, Chicago, Illinois, USA). The fracture strength was presented as the range, mean, and SD. The mean values of fracture strength for the tested groups were compared using one-way analysis of variance, and the least significant difference test was used as post-hoc test to compare between each two groups. The level of significance was adopted at P less than 0.05.
| Results|| |
[Table 1] showed that control sound group recorded the highest fracture strength value followed by pinholes, the internal dentinal groove, and simple reattachment group and the differences were significant (P < 0.05).
All restored teeth with fragment reattachment were assessed clinically and radiographically for 18 months. In both groups, none of the signs and symptoms of sensitivity to percussion, loss of pulp vitality, abscess/swelling, draining sinus/fistula, and mobility were reported.
Radiographically, pulp canal obliteration, loss of lamina dura, pathologic root resorption, ankylosis, failure of the formation of a closed apex, and apical changes were not observed in both groups [Figure 8], [Figure 9], [Figure 10]. All patients had 100% success. Fragment stability showed that refracturing of the fragment in one (10%) patient of pinholes group at 18 months follow-up and two (20%) patients in internal groove group; one of them was refractured at 12 months and another at 18 months of follow-up [Table 2]. The difference was not statistically significant (P > 0.05).
α Scores for color harmony were recorded 50 and 60% at the baseline for pinholes and internal group, respectively, which increased to 100% at 9 months. Charlie score was not observed [Table 3] and [Figure 11] and [Figure 12].
|Figure 8: Postoperative periapical radiograph showing fragments reattachment of upper central incisors; one with pinholes (right) and the other with the internal groove, 3/4 roots length were formed with the apices halves-closed (A/2) (a). Root lengths (Rc) and the apical closure (Ac) were completed during the recall time (b and c).|
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|Figure 9: Preoperative radiograph showing the uncomplicated coronal fracture of upper right central and uncomplicated fracture of the other central (a). Endodontic treatment with fragment reattachment of left central (b) not included in the study, and fragment reattachment with internal groove of right central (c).|
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|Figure 10: Preoperative periapical radiograph showing the uncomplicated coronal fracture of upper right central incisor (a); fragment reattachment with pinholes (b).|
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| Discussion|| |
In-vitro results of the current study support rejection of the null hypothesis that there was no difference between the tooth fragment reattachment techniques.
The uncomplicated coronal fracture is most common among children and teenagers resulting from accidental trauma or sports injuries. When the fractured fragment is still available, repositioning, and bonding it immediately to the tooth remains is the first restorative option that should be performed ,.
Tooth fragment reattachment should be considered, especially in children having teeth with uncompleted roots because the vital dental tissues were preserved during dental development ,. Although this method is convenient and very simple, the treated tooth will still be more susceptible and vulnerable to repeated trauma. Therefore, it requires maintaining a clean and dry field, good selection of proper techniques, high-quality adhesive systems, and materials for the respective clinical situation .
Several factors play an important role in the survival of the reattached fragment. Among these factors are the fragment stored media, type adhesive material used, use of materials to protect the dentin-pulp complex, flow of cement or resin composite, and the technique used for the fragment reattachment ,,. However, some of the studies have recorded that the resin materials have no positive influence on the fracture resistance of the reattached fragment ,.
One of the important factors that have a significant influence on fragment reattachment strength is the preparation design. Some of the studies reported that the fragment reattachment strength was lower than that of the sound tooth, and additional preparations to the tooth remnant and/or fragment were recommended , as they improve the bonding strength between them. Various techniques have been proposed, but the most commonly used one is the internal dentinal groove that restores about 97.2% of the fractured fragment . So this technique in this study was used for comparison in the clinical part.
Although the laboratory part of the study may help in the prediction of clinical outcomes and behavior of the restoration, the in-vitro results cannot be extrapolated and may be affected, as they always lack the clinical environmental condition that the restoration could be subjected to a long time. Therefore, in this study, both laboratory and clinical evaluation of pinholes technique in fragment reattachment would be the true judgmental tests .
To simulate the uncomplicated Ellis class II coronal fracture in this study, one-third of each specimen was sectioned horizontally, and the fragments were kept moist in deionized water before reattachment to maintain a proper hydration, superior bond strength ,, and inhibit the fragment discoloration . The labial aspect of each specimen was selected for force application to simulate the real traumatic hard objects. The center of the incisal thirds was the point for force application which was very carefully controlled to maintain the same distance of fulcrum to all specimens .
In the current study, the control sound group had the highest fracture strength followed by pinholes and internal dentinal group, while simple reattachment was the lowest, and the difference was significant.
Placement of pinholes with a connecting shallow groove may provide high fracture strength than the internal dentinal groove. This may be explained by the increase in surface area of adhesion, as the fracture strength is directly proportional to the surface area . Also, the greater the involvement of internal resins within preparation is, the better the retention and fracture strength, and the distribution of force are ,. The horizontal resin bar with the vertical resin slots in pinholes design act as an opponent to the labial compressive force, while in simple reattachment, the stress always concentrated on the fracture line . The results of the current study were in close agreement with the studies of Srilatha et al. , Loguercio et al. , Kumer et al. , and Abdulkhayum et al.  who concluded that the fragments reattachment with internal groove technique showed high fracture strength than simple reattachment which was in accordance with the findings of the current study.
The clinical evaluation of this study reported that the restorations success rate was 90% and 80% for pinholes and internal groove group, respectively, while the radiographic evaluation showed 100% for both groups.
Electric pulp test was carried out at the recall time after treatment to exclude any false response of the chocked traumatized tooth . In this study, all restored teeth had no clinical signs and symptoms during the recall time. At the last follow-up period, the survival rate of the restored teeth with pinholes and internal grooves techniques were 90.0 and 80.0%, respectively, and the difference was not significant. As children have restricted control of incisive function, more were exposed to repeated trauma and traumatic situations and misuse of physiologic tooth function; therefore, the risk of the fragment debonding is high. This may explain the fragment refractured in both groups of the clinical study ,.
In this study, bravo color disharmony may be due to the fragments kept dry with the patients for about 2–3 days before reattachment ,. α score was dramatically increased from 50 and 60% baseline to 100% at 9 months for pinholes and internal groove group, respectively, as most of the coronal fragments retrieve occurs at the time of trauma. This finding is in agreement with the findings of Simonsen , Toshihiro and Rintaro , and Yilmaz et al.  who demonstrate that the fractured fragment may regain some of the translucency and original color as a result of the intraoral water absorption.
In both groups, the restored teeth had no clinical signs or symptoms during the recall time. These findings are in agreement with previous results of Simonsen , Diangelis et al. , Chu et al. , and Rappelli et al. .
Radiographically, there was no delay in root development was observed in the treated teeth having open apices. This agrees with the previous results of Robertson et al.  and Yalmez et al.  who observed complete root development in restoring teeth having open apices, but without concomitant luxation injury.
This indicated that the uncomplicated fragment reattachment using proper design, acid etchant, and a high-quality adhesive system with resin cement may provide pulpal protection against the infection, thus avoiding any pulpal or pathological complications , demonstrating satisfactory clinical and radiographical results.
There were some limitations for this study including; possible debonding of the fragment, color mismatch for a period of time  because of incomplete fragment rehydration with breakdown of the collagen fibers , and demarcated fracture line was noticed in few cases .
Although the use of this technique in fragment reattachment is reasonably simple, fast and conservative approach with good function and esthetic results, further research is highly recommended in both the in-vitro test and for evaluating the long-term clinical success of reattached fragment.
| Conclusion|| |
The in-vitro results concluded that pinholes technique showed the highest fragment strength as compared to the other used technique. The in-vivo results demonstrated a good esthetic and functional performance technique. Therefore, pinholes design can be considered an acceptable alternative technique in tooth fragment reattachment of uncomplicated coronal fracture.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12]
[Table 1], [Table 2], [Table 3]