Title: Comparison of shear bond strengths with different bevel preparations for the re-

attachment of fractured fragments of maxillary central incisors

Arezou Ghoreishizadeh1, Foorough Mohammadi 1, Yashar Rezayi2, Mohammadali

Ghavimi3, Tannaz Pourlak3,4,*.

1. Department of Pediatric, faculty of dentistry, Tabriz University of medical sciences, Tabriz,

Iran.
2. Dental and Periodontal Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
3. Department of Oral and maxillofacial surgery, faculty of dentistry, Tabriz university of
Medical Sciences, Tabriz, Iran.
4. Aging Research Institute, Tabriz University of Medical Sciences, Tabriz, Iran.

*
Correspond author: Dr. Tannaz Pourlak, oral and maxillofacial surgeon, Department of Oral and
maxillofacial surgery, faculty of dentistry, Tabriz university of Medical Sciences, Tabriz, Iran.
Email: tannazpourlak@gmail.com
Phone number: 00989143116175

Acknowledgements

The authors would like to thank Department of Pediatric, faculty of dentistry, Tabriz University of
medical sciences, Tabriz, Iran.

Contribution: Arezou Ghoreishizadeh and Foorough Mohammadi wrote the manuscript and

revised the final version of the manuscript. Yashar Rezayi designed and wrote manuscript and

also drew tables. Mohammadali Ghavimi drew figures and submitted the paper. Tannaz Pourlak

supervised the study and correspondence during the paper submission.

This article has been accepted for publication and undergone full peer review but has
not been through the copyediting, typesetting, pagination and proofreading process,
which may lead to differences between this version and the Version of Record.
Please cite this article as doi: 10.1111/edt.12605
This article is protected by copyright. All rights reserved.
 L3165-6614-0002-AO 0 I iRrO( K LRUOP ZA N DDDD

UcPOrA canA N RUP Ppyr UcPOrA

Title: Comparison of shear bond strengths with different bevel preparations for the re-
attachment of fractured fragments of maxillary central incisors

Running Head: Shear bond strength in reattachment of fractured teeth

Abstract

Background/Aims: Fractures of anterior teeth are a highly prevalent form of dental trauma.
Among the various treatment options, reattachment of the fractured part to the remaining
tooth has a lot of advantages. The aim of this study was to compare different bevel
preparation techniques when reattaching fractured fragments to maxillary central incisors.

Methods: This study was performed on 52 maxillary central incisors that were randomly
divided into 3 experimental groups and 1 control group. In the control group, repair was done
by attaching the fractured fragment using bonding and composite resin without any bevel
preparation. In the second and third groups, the bevel preparation was done to a depth of 0.5
mm before attachment of the fragment on the palatal side of the fracture and on the labial and
palatal sides, respectively. In the fourth group, after tooth preparation, a 0.5 mm composite
veneer was placed on the labial surface. The amount of force needed to re-fracture the tooth
was measured with a universal testing machine and shear bond strength was calculated in
MPa.

Results: Mean and standard deviation (mean±SD) of shear bond strengths in the control
group was 81.48± 8.18 MPa. In the palatal bevel group, it was 97.74± 11.41 MPa, in the
labial and palatal bevel group it was 131.56± 9.25 MPa and in the composite veneer group it
was 104.36± 5.50 MPa. Significant differences were observed between the groups, but there
was no significant difference between the palatal bevel and composite veneer groups.

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Conclusions: Reattachment of the fractured fragments by all three methods increased the
shear bond strength. The highest shear bond strength was obtained when both labial and
palatal bevels were used.

Keywords: Shear bond strength, Palatal, Labial, Bevel preparation, Composite veneer.

1. Introduction

Traumatic dental injuries usually occur in childhood and adolescence.1 Fractures of the
anterior teeth are a common form of dental trauma that affect the primary and permanent
teeth.2 The incisors are most often affected (80% central incisors and 16% lateral incisors).3
Crown fractures represent the majority of dental trauma in the permanent dentition (26–76%
of dental injuries), whereas crown-root fractures account for only 0.3–5%.4 The 7 to 12 years
age group is considered to be the most predisposed age group to any form of dental trauma.5
Numerous epidemiological studies have revealed that approximately one third of all
preschool children, one in six adolescents and one in four adults suffer from a traumatic
dental injury in their lifetime and that most dental injuries include just one tooth, but
differences occur both between and within countries.6,7 The increased number of car
accidents, violence, and sports activities contribute to dental trauma as an emerging public
health problem, and this can have important negative functional, and psychological effects on
children.8,9

The site of the fracture, size of the fractured fragments, pulp involvement, periodontal status,
root maturation, occlusion, and time are factors which influence the management of tooth
fractures.10 Several techniques can be used to restore fractured crowns, ranging from original
tooth fragment reattachment to full-coverage crown restorations. Early techniques consisted
of stainless steel crowns, pin-retained resin, porcelain bonded crowns and composite resin.11
Reattachment should be the first choice of treatment when the fractured fragment is
available.12 The benefits of this treatment include maintaining the color and size of the
original tooth, it will bear in a similar manner to nearby teeth, it will provide positive
psychological reactions to the patient and it is economical.13 Various techniques and adhesive
materials have been reported for reattachment of the fractured part of the tooth, but there is

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no consensus on the best method and best material. Bond strength is the initial mechanical
load to fracture divided by the simple, geometrically defined, cross-sectional area of the
bond.14

According to various studies, the technique of tooth preparation is the main factor in
increasing shear bond strength (SBS) and the type of bonding system used is considered to be
secondary factor. The SBS is described as the maximum stress that a material can bear before
failure with shear loading.15 Previous studies have shown that the choice of material has no
effect on the SBS, while a bevel preparation on the labial and palatal surfaces can
considerably improve the SBS of the reattached fragment.16

Overall, these findings put emphasis on the requirement for additional studies regarding the
effects of new adhesive techniques that are being constantly developed and presented for
clinical use. Consequently the aim of this study was to compare different bevel preparation
techniques used to reattach fractured fragments of maxillary central incisors by studying the
shear bond strength (SBS).

2. Material and Methods

This study was an ex-vivo study. The study protocol was accepted by the Ethics Committee
of Tabriz University of Medical Sciences (IR.TBZMED.REC.1398.302). Inclusion criteria
were maxillary central permanent incisors with healthy crown structure that could be
mounted in acrylic. Exclusion criteria were teeth with any fracture, decay, filling, restoration,
caries, any other kind of structural defects and hypoplastic lesions.

Fifty-two, human maxillary permanent central incisors which had been extracted due to
periodontal disease or dental prosthetic needs were used. After extraction, the teeth were
rinsed with water to remove the blood and the remaining tissues. They were then stored in
0.1% thymol solution for 48 hours for disinfection. Subsequently the specimens were stored
in 0.9% normal saline solution during the study and incubated at 37°C to simulate the oral
environment. Then they were randomly divided into 4 groups of 13 teeth (3 experimental and
1 control group).

The specimens were transversely sectioned 3 mm from the incisal edge. To make the same
fracture pattern in each study group, cutting was performed with a thin diamond disc (Figure
1A). Because dehydration of tooth surfaces (especially dentin) may affect attachment and
bonding of the adhesive fragment, the teeth and fractured fragments were stored in 0.9%

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normal saline solution until repaired. The specimens were mounted in acrylic resin blocks in
which the edge of the acrylic was 1 mm away from the tooth, before restoration.

In the control group, the fragment and the teeth were etched with 37% orthophosphoric acid
(Scotchbond etchant; 3MESPE, MN, USA) selectively for 20 s and then the surfaces of the
fragment and the tooth were washed with water for 20 s, and extra water was gradually
removed by air flow. Then both surfaces were impregnated with 5th generation Solobond M
bonding (Voco, Cuxhaven, Germany). After using a light air flow, a second layer was
applied and light cured for 20 s. Then Grandio Flow nano-hybrid composite (Voco,
Cuxhaven, Germany) was used to attach the fractured piece to the tooth (carefully matched
between the two pieces) and light cured (400 mW cm2, Free Light 2; 3M-ESPE) for 20 s on
both the labial and palatal sides.

In group 2, after using the adhesive method and light-curing for 20 s on the tooth and the
fragment as in group 1, a round diamond bur was used to create a 0.5 mm deep bevel
preparation along the fracture line on both the fractured fragment and remaining tooth on the
palatal side. After etching and bonding, Polofil Supra micro-hybrid was applied to repair the
beveled area (Figure 1B).

In group 3, all procedures were the same as for group 2, except that the bevel preparation was
performed on the labial surface in addition to the palatal surface (Figure 1C).

In group 4, after bonding the fragment to the tooth, a 0.5 mm composite veneer was placed on
the labial surface using Polofil Supra (Voco, Cuxhaven, Germany). The finish line of the
veneer was located 0.5 mm above the cementoenamel junction (CEJ). Finishing and polishing
were performed on all specimens to remove any excess composite resin.

After the bonding procedures, the specimens were placed in a Universal Testing Machine
(Triax 50 Digital; Controls, Milan, Italy). The load was applied on the palatal surface, vertical
to the long axis of the tooth and incisal to the reattachment line. The surface area was
measured with a software program (ImageJ 1.39u; National Institutes of Health, Bethesda,
MD, USA) and this was used to express SBS values in MPa.

Results were expressed as mean ± SD. The Kolmogorov– Smirnov test was used to verify the
normal distribution of data. Levene's test was applied to evaluate the equality of variances for
a variable calculated for the study groups. One-way ANOVA and then Tukey tests were used

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to compare shear bond strength among groups. The statistical analysis was performed with
SPSS 17 (SPSS Inc., Chicago, IL, USA). The significance level was set at P < 0.05.

3. Results

In all specimens, fractures occurred at the connection of the fractured segment with the
remaining tooth tissue. Comparison of the means of the shear bond strength was performed
by one-way ANOVA (Table 1). The highest mean shear bond strength was obtained using the
labial and palatal bevel (Figure 2).

The Kolmogorov and Smirnov test was applied to evaluate normality of distributions. This
test showed that the variable distribution of shear bond strength was normal, so parametric
tests could be used to test the hypothesis. The Levene's test results show that the hypothesis
of equality of variances was not ruled out for the shear bond strength. Hence, the post-hoc
multiple comparisons test (Tukey’s test) was used for pairwise comparisons between the
groups. The results of Tukey’s test are shown in Table 2 and they show that there was a
significant difference between the mean of shear bond strength in the control group and the
other three groups. Also, there was a significant difference between the mean shear bond
strength in the palatal bevel group and the labial and palatal bevel group.

There was a statistically significant difference between the mean shear bond strength in the
composite veneer group and labial and palatal bevel group.

There was no statistically significant difference between the mean shear bond strength of the
composite veneer group and the palatal bevel group.

4. Discussion

The reattachment of a fragment to a fractured tooth can provide long-term esthetics because
the tooth’s original anatomic form, color, and surface texture are maintained.17 Maxillary
central incisors were included in this study since they are the most susceptible to trauma.18
The results showed that reattachment of the fractured fragment using all three methods
increased shear bond strength compared to the control group. The highest shear bond strength
was obtained with the labial and palatal bevels, while there was no significant difference
between the shear bond strength of the palatal bevel and the composite veneer.

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Andreasen et al.19 investigated 334 permanent incisors with fractures of the crown or crown
and root by reattaching the fragment with a composite resin. They showed that retention of
fragment reduced to 50% over 30 months. Two methods of fractured crown reconstruction,
including fracture reattachment and direct restoration with the acid‐etch composite resin
technique, were compared in another study and this revealed that the fracture reattachment
technique had a better long term (over a 5‐years‐period) prognosis than composite
restorations.20 Reis et al. 21 reported that a simple reattachment with no additional preparation
of the fragment or tooth was able to restore only 37.1% of the intact tooth’s fracture
resistance.

Several factors play a significant role in determining how long the reattached tooth fragment
remains functional, such as the media used to store the tooth fragment after fracture, type of
material used for adhesion, and the technique used for the reattachment procedure.22 The
veneer acts as a thin layer of a material covering the labial surface of a tooth and can be
applied directly to the tooth, or by indirect methods.23 The superiority of the fifth generation
of dentin bonding agents compared with earlier generations has been shown in the most
studies.24 Generally, according to the results of the present study and previous studies, the use
of different preparation methods increases the bond strength in the reconstruction of
traumatized teeth compared to cases of simple fracture reattachment. In many studies, bevel
preparation increased the bond strength of the fragment.25 Since the thickness of the
restorative material used had a significant effect on the shear bond strengths, the bond
strength was higher in the group with labial and palatal bevels than in the group with only a
palatal bevel. Also, dehydration of the tooth surface, especially dentin, negatively affected
adhesion between components, so the specimens were kept in 0.9% normal saline solution
throughout the study.

The cross-sectional area of the tooth when the incisal edge is cut using a diamond bur differs
from that in which the incisal edge breaks naturally. Reis et al.26 used the fracture method
instead of cutting with a diamond bur. This technique used a universal testing machine to
break the tooth. This is similar to what happens in a clinical situation when a tooth is broken
and, the matching between the fragments will be greater. In the present study, fractures were
created with a diamond disc. Short-term and long-term positive results have been reported in
fractured tooth restoration by using the fracture reattachment technique.27

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5. Conclusion

All three methods (palatal bevel, labial and palatal bevels and veneer composite) increased
the shear bond strength of central incisors restored with the fragment reattachment technique,
compared to simple attachment without any bevel. The highest shear bond strength was
obtained with the labial and palatal bevels combination.

Funding

None.

Conflict of interest

The authors report no conflicts of interest. The authors alone are responsible for the content
and writing of this article.

Ethical approval

The study was approved by the Research Ethics Committee of Tabriz University of Medical

Sciences (IR.TBZMED.REC.1398.302.).

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Figure legends

Figure.1. A) Sample tooth after the simulated fracture had been created by cutting the crown
with a thin diamond disc. B) Mounted sample from the palatal bevel group. The arrow
indicates the positions of the bevel. C) Mounted sample from the labial and palatal bevel
group. Arrows indicate the positions of the bevel.

Figure.2. The highest mean shear bond strength was obtained using the labial and palatal
bevel preparation.

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Table. 1 Means and standard deviation for the different groups
Standard deviation P-value*
Bevel preparation Mean (MPa)
(MPa)
Control group <.001
81.48 8.18
Palatal bevel
preparation 97.74 11.42
group
Labial and
palatal bevel
131.56 9.26
preparation
group
Composite veneer
104.36 5.51
group
Table.2 Tukey’s test results for pairwise comparisons between the groups.

Bevel Bevel
preparation preparation Mean difference P-value
(I) (J) (I-J)
Palatal bevel
preparation -16.25985* <.001
Labial and
Control group palatal bevel
preparation -50.08182* <.001
group
Composite veneer -22.88182* <.001
Labial and
palatal bevel
Palatal bevel preparation -33.82197* <.001
preparation group
Composite veneer -6.62197 .298
Labial and
palatal bevel
preparation
Composite veneer 27.20000* <.001
group