| |

Received: 20 February 2019    Revised: 27 July 2019    Accepted: 30 July 2019

DOI: 10.1111/edt.12506

ORIGINAL ARTICLE

Reattachment of fractured teeth using a multimode adhesive:

Effect of different rewetting solutions and immersion time

Guilherme Brasil Maia | Raquel Vitório Pereira | Déborah Lousan do Nascimento Poubel  |

Júlio César Franco Almeida PHD | Ana Paula Dias Ribeiro | Liliana Vicente Melo de
Lucas Rezende | Fernanda Cristina Pimentel Garcia

Department of Dentistry, Faculty of Health

Sciences, University of Brasília, Brasília,
Brazil
Correspondence
Fernanda Cristina Pimentel Garcia,
Department of Dentistry, School of Health
Sciences, University of Brasília, Brasília,
Brazil.
Email: garciafcp@unb.br
Abstract
Background/Aims: Following coronal tooth fracture, keeping the fragment hydrated
is of the utmost importance in the tooth fragment bonding technique. The aim of this
study was to evaluate the effects of different immersion times in different storage
media on multimode adhesive bonding between reattached fragments and teeth.
Materials and Methods: A total of 195 bovine incisors were fractured and rand‐
omized into the following storage groups (n = 15): G0—control group (sound tooth);
GA—saline solution: for 1 hour (A1) or 24 hours (A2); GB—artificial saliva: for 1 hour
(B1) or 24 hours (B2); GC—coconut water: for 1 hour (C1) or 24 hours (C2); GD—tap
water: for 1 hour (D1) or 24 hours (D2); GE—milk: for 1 hour (E1) or 24 hours (E2);
GF—dry (dehydration): for 1 hour (F1) or 24 hours (F2). Tooth fragments were then re‐
attached using a multimode adhesive in a self‐mode technique with a flowable resin
composite. Fracture resistance was evaluated in a universal testing machine under a
compressive load (1 mm/min). The data were submitted to two‐way analysis of vari‐
ance and the post hoc Tukey test (5%).
Results: The group submitted to the dehydration factor (GF) exhibited a mean value
of 599.1 ± 144.2 N, while those submitted to all hydration protocols (GA, GB, GC, GD,
GE) exhibited a mean value of 751.8 ± 285.4 N. Dehydration significantly affected
the fracture strength values (P = .005). No significant interaction between the rewet‐
ting solutions was observed (P > .05).
Conclusions: Hydration of the tooth fragment increased fracture resistance, regard‐
less of the storage solution and/or immersion time.

KEYWORDS
crown fracture, dental trauma, Fragment reattachment

1 |  I NTRO D U C TI O N traumatic injuries occur mostly in children aged between 9 and
11 years.5
Dental trauma (DT) is considered a public health issue by the World In addition, 33% of adults have reported having had a traumatic
Health Organization due to its high prevalence, which ranges be‐ dental experience before age 19.6 The highest prevalence of DT is
1‒3
tween 7.4% and 58%, and to the negative functional, aesthetic, in the permanent dentition.7 It is considered the most common type
4
and psychological impacts on the life of those affected. These of injury to this dentition,8 with a high occurrence of uncomplicated

Dental Traumatology. 2020;36:51–57. wileyonlinelibrary.com/journal/edt   © 2019 John Wiley & Sons A/S. |  51
Published by John Wiley & Sons Ltd
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52       BRASIL MAIA et al.
coronal fractures (enamel or enamel and dentin), in which the maxil‐
lary central incisors are the most affected, followed by the maxillary
lateral incisors and mandibular central incisors.9 In the deciduous
teeth, the most common injury is luxation. 2,10,11
A treatment strategy should be based on factors that include
the fracture length, the patient's age, stage of root formation, pos‐
sible pulp and periodontal involvement, aesthetic complications,
and quantity and quality of remaining tooth tissue. The treatment
plan may involve different specialties, thus calling for a multidisci‐
plinary approach. Furthermore, its treatment may be prolonged and
may often have an uncertain prognosis.12 Different methods have
been developed to restore the fractured crown, varying from less
invasive procedures to aesthetic restorations such as resin crowns,
stainless‐steel crowns, ceramic crowns, and direct resin composite
restorations, with or without an intraradicular retainer.6,10 Although
these options can provide full or partial recovery of the mechanical
strength of the tooth, they might be expensive. In addition, they may
require removal of sound tooth structure and lengthy clinical treat‐
ments. Furthermore, replicating the color, shape, surface texture,
and translucency of the natural teeth may be difficult.10,13
In 1964, Chosack and Eidelman14 proposed the restoration of
fractured crowns using the tooth fragment itself. Since then, this
technique has demonstrated high success rates and has become
popular for its advantages such as aesthetic and functional recov‐
ery, use of little restorative material, safety, conservatism, simplicity,
speed, and lower cost, in addition to providing emotional and social
benefits.6,13,15,16 The technique became successful with the advent
of adhesive systems that enable effective attachment of the frag‐
ment to the remaining tooth without requiring additional prepara‐
6,17,18
tion. The fragment bonding procedure recovers between 37%
and 50% of the fracture resistance of the tooth, making it a viable
and safe procedure for long‐term restoration.17,19‒22
Different adhesive systems can be used to reattach the frag‐
ment. The systems are classified according to the number of op‐
erative steps (one, two, or three steps) or the etching mode of the
dental substrate (self‐etching or etch‐and‐rinse). More recently, the
systems have been classified as universal or multimode. In addi‐
tion, the reattachment technique may use an intermediate material
(composite resins, flowable resin composites, resin cements, or glass
ionomer cement).1,17,23 A fundamental aspect of the best prognosis
for attachment of the fragment to the remaining tooth is fragment
hydration, which promotes greater bond strength (BS) than with de‐
hydrated fragments.10,13,16,24,25 A few studies have reported on the
solutions in which the patient can store the tooth fragment such as
saliva, water, saline, milk, and, more recently, coconut water, similar
10,26,27
to the storage of avulsed teeth. However, a consensus on the
best storage solution in which to hydrate the fragment in order to
gain greater BS over time16 is lacking. Moreover, papers evaluating
the use of a multimodal type adhesive system for fragment attach‐
ment are sparse. Thus, the overall objective of the present study was
to compare the influence of the fragment storage condition on the
fracture strength of teeth submitted to bonding. The specific objec‐
tive was to test the following two null hypotheses: Fragment storage
time does not influence fracture resistance, and fragment storage
solution does not influence fracture resistance.
2 | M ATE R I A L S A N D M E TH O DS
This study was performed on 195 bovine mandibular incisors (de‐
void of developmental defects of the crown or caries) selected
according to the dimensions of the crown in order to standardize
the specimens (inciso‐cervical length: 26 ± 1 mm and mesiodistal
width: 15  ±  3  mm). According to CONCEA (Ministério da Ciência,
Tecnologia e Inovação), no ethics committee approval was required.
Tissue remnants (periodontal and endodontic) were removed with
curettes and mechanical prophylaxis. The teeth were stored in dis‐
tilled water until the experiment was carried out.
The following procedure was used to standardize the frag‐
ments: A line was traced on 180 teeth, 5 mm from the incisal edge,
and parallel to it. Then, a diamond disk (Extec Dia. Wafer Blade
102  mm  ×  0.3  mm  ×  12.7  mm, CT, USA) was used to section the
crown by applying a perpendicular force labiolingually. An enamel
and dentin‐deep fracture was then simulated on each tooth, along
the previously traced line, without reaching the pulp. Any tooth dis‐
playing a fracture pattern different from the pre‐established line
was discarded.
The selected teeth were randomized into 13 groups (n = 15),
based on the different hydration solutions and immersion time peri‐
ods as follows: Group 0 (G0)—positive control (sound tooth); Group
A (GA)—storage in saline solution (Needs, LBS, SP, Brazil): A1—sa‐
line for 1  hour (n  =  15), A2—saline for 24  hours (n  =  15); Group B
(GB)—storage in artificial saliva (On Care Spray Oral Hidratant,
Oncosmetic, SP, Brazil): B1—artificial saliva for 1 hour (n = 15), B2—
artificial saliva for 24 hours (n = 15); Group C (GC)—storage in co‐
conut water (Kero Coco, PepsiCo, PE, Brazil): C1—coconut water
for 1 hour (n = 15), C2—coconut water for 24 hours (n = 15); Group
D (GD)—storage in tap water: D1—tap water for 1 hour (n = 15),
D2—tap water for 24 hours (n = 15); Group E (GE)—storage in milk
(LeitBom Integral, Laticínios Bela Vista, GO, Brazil): E1—milk for
1 hour (n = 15), E2—milk for 24 hours (n = 15); Group F (GF)—dry
(dehydration): F1—dry storage for 1 hour (n = 15), F2—dry storage
for 24 hours (n = 15). After the teeth had been sectioned, the rem‐
nants were marked 10 mm from the incisal edge and placed inside
a stainless‐steel cylinder (15 mm in internal diameter and 33 mm in
height) using chemically activated acrylic resin (Vipi Flash, Vipi, SP,
Brazil). The specimens of the positive control group were kept sound
and placed in the cylinder using the same technique as that of the
fractured teeth. All specimens were immersed in distilled water and
kept in an oven at 37°C until use. The dried group specimens were
kept dehydrated in a moisture‐free vessel until the sizing procedure.
After air‐drying with a triple syringe, the following procedural
steps were taken according to the manufacturer's instructions. Single
Bond Universal Adhesive (3M/ESPE, SP, Brazil) was applied to the
fractured surfaces of the fragment and the tooth using a selective
self‐etching mode. The enamel was etched using a 37% phosphoric
BRASIL MAIA et al. |
      53

acid gel (Condac, FGM, SC, Brazil). The acid gel was applied to the TA B L E 1   Means and standard deviations of fracture resistance
enamel for 30 seconds, rinsed for 30 seconds, and then dried for (N) of sound and reattached teeth submitted to testing bonding
technique according to different storage protocols
10 seconds. The universal adhesive was then applied for 20 seconds.
The surfaces were dried for 5 seconds using an air syringe to allow Groups Description Mean (standard deviation)
the solvent to evaporate. The adhesive was light polymerized for
G0 Sound 1243.2 (257.9)a
10 seconds on the mesial wall and 10 seconds on the distal wall using
GA1 Saline 1 h 724.9 (272.7)b
Bluephase Ivoclar Vivadent (Schaan, Liechtenstein) with 1200 mW/
GA2 Saline 24 h 824.8 (290.9)b
cm2 irradiance. A flowable composite, Filtek Z350 XT Flow of color
GB1 Artificial saliva 1 h 723.1 (201.7)b
A3 (3M/ESPE, SP, Brazil), was then applied to the fractured surface
GB2 Artificial saliva 24 h 733.4 (275.2)b
of the tooth, and the fragment was positioned by direct bonding.
The fragment was adapted with hemostatic tweezers, and a GC1 Coconut water 1 h 727.7 (338.7)b

brush (Tigre, SC, Brazil) was used to remove the excess composite. GC2 Coconut water 24 h 887.2 (257.9)b

Afterward, the reattached surfaces were light cured for 40  sec‐ GD1 Tap water 1 h 749.5 (238.8)b
onds in four stages: 10 seconds on the mesial wall, 10 seconds on GD2 Tap water24 h 670.3 (274.7)b
the distal wall, 10 seconds on the labial wall, and 10 seconds on the GE1 Milk 1 h 680.7 (213.7)b
lingual wall. GE2 Milk 24 h 796.7 (488.6)b
The reattached specimens and the sound teeth were mounted GF1 Dry (dehydration) 1 h 633 (176.7)b
in a universal testing machine (MTS Landmark 370.10, MN, USA) to
GF2 Dry (dehydration) 24 h 562.8 (91.9)b
evaluate resistance to impact. The cylinders were positioned in a
Note: Means followed by same superscript letters do not differ statisti‐
stainless‐steel device 70 mm in height, with a square base of 70 mm
cally (Tukey, P > .05).
and a 45° inclined plane with a central hole (21 mm in diameter and
33 mm in depth). The teeth were then subjected to a tangential load
TA B L E 2   Means (N) and standard deviations of fracture
at 1 mm/min crosshead speed. The load cell used was 5 kN (500 kgF). resistance of experimental groups submitted to dehydration and
The antagonistic metal device was fixed to the universal testing ma‐ hydration protocols
chine and positioned 2 mm from the incisal edge of the labial sur‐
Mean (standard
faces of the teeth. The load required to fracture the specimens was
Groups Description deviation)
recorded (N), and the data were submitted to descriptive statistical
Dehydrated Dehydrated for 1 or 24 h 599.1 (144.2)a
analysis (mean and dispersion), followed by analytical analysis using
Hydrated Hydrated in different solutions 751.8 (285.4)b
two‐way analysis of variance (ANOVA) and the Tukey post hoc test
at 5% significance. One‐way ANOVA was performed to compare the Note: Means followed by same superscript letters do not differ statisti‐
hydration protocols. The fracture modes were analyzed using a ste‐ cally (Tukey, P > .05).

reomicroscope at ×16 magnification. Fracture modes were classified

as cohesive in dentin (substrate or material failure), adhesive (inter‐
facial failure between substrate and restorative), or mixed (combina‐
tion of adhesion and cohesion failures). Representative descriptive
analyses (%) were used to describe the fracture mode. Statistical
significance was accepted as P < .05. The data were expressed as
mean ± standard deviation.
3 | R E S U LT S
The data obtained were initially analyzed by comparing the experi‐
mental groups (reattached tooth) with the control group (sound
tooth) by one‐criterion variance analysis (experimental groups),
complemented by the Tukey test. The control group (G0) presented
higher mean fracture resistance values than those of the other ex‐
perimental groups (P < .05) (Table 1).
The group submitted to the dehydration factor (GF) was then
compared and analyzed with those submitted to the hydration factor
in all the other solutions (GA to GE). The dehydration significantly
affected fracture strength values (P = .005, t test) (Table 2 and
Figure 1).
With the two‐way ANOVA, the purpose was to identify possible
differences between the hydration periods, 1 hour or 24 hours, and
the different hydration solutions (saline, saliva, coconut water, tap
water, and milk). No significant differences were found for the time
periods or the solutions or even for the interaction between these
factors (P > .05) (Table 3).
The fracture pattern presented by the healthy teeth (G0) was
different from that presented by the teeth submitted to fragment
reattachment (GA to GF). All the specimens from the control group
presented fractures in the cervical (cohesive) region, whereas the
specimens submitted to fragment reattachment presented fractures
of the adhesive, mixed, or cohesive types (near the fracture line)
(Figure 2).
4 | D I S CU S S I O N
In the present study, the influence of both the storage medium
used to hydrate the fragment and the hydration time was evalu‐
ated to determine the fracture resistance of teeth submitted to
bonding. The null hypotheses were accepted, since no difference
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54       BRASIL MAIA et al.

was found between the values for the storage times (1 hour or
24 hours) or for the hydration solutions used. However, the de‐
hydration of the fragment led to significantly lower fracture re‐
sistance values. Hydrating the fragment increased the fracture
resistance of the tooth by 25.4% compared with bonding a dehy‐
drated fragment.
F I G U R E 1   Mean fracture resistance (N) of experimental groups
submitted to dehydration and hydration
TA B L E 3   Two‐way ANOVA results for fracture resistance
according to different experimental protocols for hydration
The use of bovine teeth in this study was supported by Nogueira
et al, 28 who stated that bovine teeth present morphology, micro‐
hardness, and mineral composition similar to human teeth and are
also easier to obtain. Regarding the methodology, the tooth frag‐
ments were obtained by sectioning with a diamond disk instead of
fracturing. Badami et al29 and Reis et al19 stated that the surface of a
sectioned tooth is different from that of a fractured tooth: In a frac‐
tured region, the fracture line tends to run parallel to the direction of
enamel prisms, whereas the direction in a sectioned tooth is dictated
by the position of the disk.30 However, this direction does not faith‐
fully represent the actual situation of the trauma, since it does not
always occur linearly or with perfect adaptation. 2,23 Nevertheless,
fracture simulation with a cutting disk allowed the standardization
of the fragments required to reduce confounding bias.
The 1 mm/min compression stress applied to the specimens in
the universal test machine was another limitation of the present
study, since it did not simulate the clinical failure mode.31 In addition,
spontaneous fracture most often occurs quickly and with an imme‐
diate overload on the tooth. In contrast, the intentional fracture
performed in the study was at a slow and steady speed and with a
load that increased progressively as the contact of the machine with
the tooth increased. However, dental trauma does not always result
from high energy impact. Malocclusion and parafunctions such as
bruxism can expose the teeth to constant overload, which can result
in coronal fracture.

Degrees of Previous studies have evaluated hydration of the fragment be‐

Factors freedom MS F P fore reattachment to ensure a better long‐term prognosis.10 In this

Time 1 127541.5 1.54 .216

study, both the hydration periods and solutions were based on the
clinical routine (representing the time intervals between the time
Solution 4 41877.1 0.51 .731
the DT occurred and the time the patient reached the dental office)
Time × solution 4 63556.75 0.77 .547
and the ease of access of the general population to clinician‐based

F I G U R E 2   Distribution of fracture
pattern for test of fracture resistance of
sound or reattached teeth using different
storage protocols
BRASIL MAIA et al.
information, based on previous studies.10,25,26,31 Between 67.6%
and 88% of trauma‐derived fractures reach only the enamel or
the enamel and dentin, without pulp involvement (uncomplicated
crown fractures).3,4 For these patients, a self‐etching system may be
the preferred choice to avoid pulp damage and dentin sensitivity,
24
avoiding the use of phosphoric acid directly on the dentin. These
systems are recommended since demineralization and infiltration
of resin monomers occur simultaneously.13,32 However, the acidity
(pH 2.5) of most self‐etching adhesives is insufficient to promote de‐
mineralization of the enamel to the extent achieved by phosphoric
acid.32 Therefore, the selective application of phosphoric acid to the
enamel surface has been recommended based on in vitro studies,3,13
since acid etching of the enamel promotes dissolution of the prisms,
thus increasing porosity and surface energy, in order to obtain ad‐
hesive penetration, and enabling the formation of a uniform hybrid
layer.13 The proposed technique for fragment reattachment was se‐
lective etching in enamel, followed by active application of Single
Bond Universal (3M/ESPE, SP, Brazil) as a self‐etching adhesive.
The intermediate material of choice was Filtek Z350 XT flowable
composite resin (3M ESPE, SP, Brazil) because its lower viscosity
provided better remnant‐fragment adaptation compared with con‐
ventional composite resins and because its inorganic filler content
33
was higher compared with resin and ionomeric cements. According
to Garcia et al18 and de Souza et al,34 fragment reattachment using
a technique with no preparation and an adhesive system associated
with an intermediate resin composite with good mechanical prop‐
erties can restore part of the resistance of the fractured tooth. The
protocol for this study followed that of the study by Poubel et al, 25
where bovine teeth were also used and the fragment was bonded to
the remnant with a multimode adhesive in the self‐etching mode and
with a flowable composite resin.
The statistically significant difference between the dehydrated
group and the other experimental groups corroborates the findings
10,16,35,36
of previous studies, where dehydration of the fragment led
to lower fracture resistance values. Once the fragment was kept de‐
hydrated for 1 hour or 24 hours, the collagen fibers collapsed, 24,37
thus preventing penetration of the resin monomers between the
collagen fibrils.35,37 This accounts for the lower fracture resistance
values in the tested groups and the higher prevalence of the mixed
fracture type.
A consensus regarding the best solution for hydration of the
10,26,32 26
fragment is lacking. Prabhakar et al reported a statistically
significant difference between the hydrated solutions and the dehy‐
drated group and obtained the highest values for milk and coconut
water, which were not statistically different, as in the present study.
Those authors suggested that the isotonicity of milk with high water
content and the high osmolarity of coconut water allowed adequate
remodeling of the dentinal tubules to prevent collapse of the col‐
lagen fibrils.10 Shirani et al32 reported a statistically significant dif‐
ference between the solutions, with the highest mean values being
obtained for milk and saliva.
O’Donnell et al38 and Oshiro et al39 reported that saliva and milk
components, such as calcium and phosphate, can strengthen the
|
      55
surface layer of the demineralized dentin, thus modifying the sur‐
face topography and affecting the degree of dissolution during acid
etching. This results in a higher bond strength of the adhesive during
the adhesion process. However, these characteristics were not able
to boost fracture resistance in a statistically significant manner com‐
pared with the other hydrated groups (coconut water, saline solu‐
tion, and tap water). The adhesive technique used (selective enamel
acid etching with a multimode adhesive) in the enamel and dentin
surface treatment may have removed the interference that the solu‐
tions may have caused in all the groups. This reinforces the idea that
hydration is the primary factor promoting the partial restoration of
adhesive strength. This finding is contingent upon the correct man‐
agement of the dental fragment by the patient after the trauma,
since a similar positive outcome will ensue, regardless of the storage
solution. In contrast, the lack of statistical difference between the
solutions can be supported by the theory that the use of phosphoric
acid in the enamel, to increase adhesion may have masked possible
differences in the influence of the solution used. The longevity could
show statistical difference between the hydrated groups as a func‐
tion of the properties of each solution.
The lack of statistical difference between the hydration periods
of 1 hour and 24 hours, as supported by the literature, 24,25 lies in the
more favorable, shorter clinical routine and the patient's expectation
regarding the resolvability of the damage, seeing that the fragment
may be bonded in the same clinical session, giving the patient back
oral function, aesthetics, and self‐esteem. 25
According to the analysis and interpretation of the results, all of
the storage media (saline, tap water, artificial saliva, coconut water,
or milk) increased fracture resistance in comparison with dehydra‐
tion, but with no statistical difference between the tested media.
No difference was found between the hydration time points (1 hour
or 24 hours) in relation to the fracture strength of the tooth after
fragment reattachment. Further clinical studies should address the
longevity of fractured crown restorations using the tooth fragment
stored in different media and for different periods to create consis‐
tent clinical protocols.
5 | CO N C LU S I O N S
The solution used to hydrate the fragment, as well as the immersion
time, did not interfere with fracture strength after fragment bond‐
ing. A 1 hour hydration time in any media was sufficient to assure
similar bond strength values of the fragment to the remaining tooth
structure compared with 24 hours hydration using a multimodal ad‐
hesive system associated with a flowable resin composite, reinforc‐
ing the importance of hydration for the viability and success of the
technique.
AC K N OW L E D G E M E N T
The authors would like to thank Maurício Jesus Gonzales from
Physical department of University of Brasília.
 |
56       BRASIL MAIA et al.
C O N FL I C T O F I N T E R E S T
There are no conflicts of interest to declare by any author.
ORCID
Déborah Lousan do Nascimento Poubel  https://orcid.
org/0000-0002-7560-7320
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