| |

Received: 20 May 2020    Revised: 13 August 2020    Accepted: 14 August 2020

DOI: 10.1111/edt.12602

COMPREHENSIVE REVIEW

Fragment reattachment after complicated crown-root fractures

of anterior teeth: A systematic review

Priyal Khandelwal  | Siddharth Srinivasan | Buvaneshwari Arul |

Velmurugan Natanasabapathy

Department of Conservative Dentistry

and Endodontics, Faculty of Dentistry,
Meenakshi Academy of Higher Education
And Research (MAHER), Chennai, India
Correspondence
Velmurugan Natanasabapathy, Department
of Conservative Dentistry and Endodontics,
Faculty of Dentistry, Meenakshi Academy of
Higher Education And Research (MAHER),
Chennai, TN, India.
Email: vel9911@yahoo.com
Abstract
Background/Aim: Fragment reattachment is a procedure that can immediately re-
store form and function in crown-root fracture cases and is considered a minimally
invasive and cost-effective treatment option. The aim of this systematic review was
to analyze the methods used and the outcome of fragment reattachment for compli-
cated crown-root fractures of anterior teeth.
Materials and Methods: Five electronic databases (PubMed, Web of Science, Embase,
Scopus, and Google Scholar) were searched for English language articles regarding
fragment reattachment after complicated crown-root fractures of anterior teeth.
Results: Twelve case reports and two case series were selected for this review after
applying the inclusion and exclusion criteria. In eleven articles, the fracture line was
exposed prior to reattachment. Root canal treatment was performed in all cases
except one, where conservative pulp treatment was done prior to reattachment. A
post was used as part of the restoration in 85% of the cases. Additional fragment
preparation was done in 42% of the cases in the form of beveling and groove forma-
tion. Adhesive strategies used to reattach the coronal fragments were total-etch,
self-etch, or self-cure adhesive. Intermediate materials used for reattachment were
resin cement, glass-ionomer cement, composite and self-adhesive cement. Treatment
outcomes were favorable in all the included articles and the follow-up period ranged
from three months to seven years.
Conclusion: Fragment reattachment after complicated crown-root fractures of an-
terior teeth can be considered as a viable treatment option if the clinical conditions
are favorable.

KEYWORDS

crown-root fracture, dental bonding, dental trauma, fragment reattachment

1 |  I NTRO D U C TI O N Depending on pulp involvement, these injuries may be classified as

uncomplicated (without pulp exposure) or complicated (with pulp
Crown-root fractures (CRF) involve enamel, dentin, and cementum exposure).1 The majority of dental traumatic injuries affect the max-
1,2
and they account for 5% of all dental injuries in permanent teeth. illary anterior teeth causing aesthetic, functional, psychological, and

© 2020 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd

Dental Traumatology. 2020;00:1–16.  |

wileyonlinelibrary.com/journal/edt     1
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2       KHANDELWAL et al.
phonetic problems.3,4 It has been suggested that a horizontal force
on the tooth leads to the formation of compression zones, cervically
on the palatal aspect, and apically on the labial aspect. Shearing
stresses between these two compression zones result in a CRF.5
The clinical presentation of a complicated CRF is a fracture line
that originates labially in the crown portion, extending apically and
palatally in an oblique direction accompanied by pulp exposure. The
coronal fragment could be either partially attached or completely
detached. Manipulation of the attached fragment elicits pain for the
patient. Radiographic determination of the full extent of fracture is
often difficult, as the fracture line is perpendicular to the X-ray beam
or it is masked by overlapping of adjacent structures when the frag-
ments are close to each other.6
The current International Association of Dental Trauma (IADT)
2020 guidelines include coronal fragment reattachment as a treat-
ment option for uncomplicated crown fractures but not for com-
plicated CRF.7 The immediate management involves temporary
stabilization of the loose fragment to the adjacent tooth/teeth or to
the non-mobile fragment. In mature teeth with complete root for-
mation, removal of the pulp is usually indicated followed by covering
the exposed dentin with glass-ionomer cement or using a bonding
agent and composite resin. Future treatment options include comple-
tion of root canal treatment and restoration, orthodontic extrusion,
surgical extrusion, root submergence, intentional replantation with
or without rotation of the root, extraction or auto-transplantation.7
With rapid advances in adhesive dentistry, fragment reattachment
is another treatment option that is being increasingly considered for
management of these cases.8,9 It has various advantages as it re-es-
tablishes the aesthetic, morphological and functional aspect of the
tooth immediately, the achievement of lifelike translucency, incisal
edge wear rate similar to that of the adjacent teeth, preservation of
identical occlusal contacts, less chair-side time, and a positive psycho-
logical response.10 In addition, it is a minimally invasive, cost-effective
procedure, which restores the function, aesthetics, and phonetics
immediately. A recent systematic review reported that fragment re-
attachment could be a practical alternative treatment option to con-
ventional composite restoration in uncomplicated crown fractures11.
Numerous case reports and case series describe successful outcomes
after coronal reattachment in complicated CRF of anterior teeth.10,12–
16
Various techniques and different materials have been used for re-
attachment to date. Hence, the aim of this systematic review was to
analyze and evaluate the methods used and the outcome of fragment
reattachment for complicated CRF involving anterior teeth.
2 | M ATE R I A L S A N D M E TH O DS
This systematic review was conducted according to the Preferred
Reporting Items for Systematic Reviews and Meta-Analyses
17
(PRISMA) guidelines. It was registered with “Prospective
International Registration of Systematic Reviews (PROSPERO)” with
the ID CRD42020153091.
The search was defined based on the PICO strategy:
1. Population (P): Human permanent anterior teeth with compli-
cated crown-root fracture
2. Intervention (I): Fragment reattachment
3. Comparison or control (C): Not applicable
4. Outcome measures (O): Outcome of reattachment procedure
A literature search of four databases, PubMed, Embase (using
Ovid interface), Scopus, and Web of Science, was performed (Table 1).
For gray literature, Google Scholar was searched. All databases were
searched for published articles in the English language until February
2020. Keywords used during the searches were complicated crown-
root fracture, reattachment, permanent teeth, and dental injury.
Apart from the electronic databases, the following peer-reviewed
scientific journals were hand searched for relevant articles: Dental
Traumatology, International Journal of Periodontics and Restorative
Dentistry, Journal of Endodontics, International Endodontic Journal,
Operative Dentistry and the Australian Endodontic Journal.
Case reports, case series, case-control studies, cohort studies,
cross-sectional studies, clinical trials, and in vivo studies reporting
fragment reattachment of complicated CRF of human permanent
anterior teeth were included for this review.
Studies that did not perform fragment reattachment in compli-
cated crown-root fracture were excluded. Reviews, personal opin-
ions, book chapters, and conference abstracts were not considered
for this review. In vitro and animal studies were also excluded. Teeth
with multiple fractures, loss of tooth fragment, fractured posterior
teeth, deciduous teeth, or previously root-filled teeth were also
excluded.
Two independent investigators (PK and SS) performed the
searches. Screening of titles and abstracts was done, and duplicates
were removed. Full-text reading of the remaining articles was car-
ried out and those fulfilling the predefined inclusion criteria were
selected. In case of any disagreements, the senior investigators (BA
and NV) were consulted and the final decision was made through
discussion until consensus was reached.
The following variables were considered for the data extraction
from the chosen articles:
1. Demographic details of the patient: Age, gender, and country
2. Patient-related characteristics: Food habits, parafunctional hab-
its, and occlusion
3. Crown-root fracture characteristics: Time elapsed between
trauma and treatment, storage media used, tooth treated, level
and extent of the fracture, diagnostic tests, radiographs taken,
fragment detached, or attached
4. Reattachment techniques followed: Procedure to expose the
fracture, conservative pulp treatment, endodontic management,
fragment rehydration protocol, fragment preparation, adhesive
and luting material used, type and duration of splinting, follow-up
period and outcomes.
KHANDELWAL et al. |
      3

TA B L E 1   Search strategy

Pubmed (((((dental reattachment* OR dentin bond* OR fragment* reattach* OR segment* reattach* OR autologous reattach* OR reattach*
technique* OR reattach* technique*)))))) AND (((tooth fractures [MeSH Terms] OR tooth fracture* OR teeth fracture* OR
fractured tooth OR Fractured teeth OR crown fragment* OR crown segment* OR fractured crown OR broken tooth OR broken
teeth OR tooth segment* OR coronal fracture* OR traumatic dental injur* OR dental injur* OR tooth injur* OR tooth trauma OR
teeth trauma OR traumatized teeth OR traumatized tooth OR dental trauma OR dental traumas OR crown fracture* OR Tooth
fragment*)))
Embase (tooth fracture/exp OR tooth fracture OR teeth fracture OR fractured tooth OR Fractured teeth OR crown fragment OR
crown segment OR fractured crown OR broken tooth OR broken teeth OR tooth segment OR coronal fracture OR traumatic
dental injury OR dental injuries OR tooth injury OR crown injury OR tooth trauma OR teeth trauma OR traumatized teeth OR
traumatized tooth OR dental trauma OR dental traumas OR crown fracture OR Tooth fragment OR Incisor fracture OR Incisor
trauma OR Incisor injury) AND (dental reattachment OR dentin bonding OR fragment reattachment OR segment reattachment
OR autologous reattachment OR reattachment technique OR reattachment technique) AND (complicated OR crown-root OR
uncomplicated)
Scopus (tooth fracture OR tooth fracture OR teeth fracture OR fractured tooth OR Fractured teeth OR crown fragment OR crown
segment OR fractured crown OR broken tooth OR broken teeth OR tooth segment OR coronal fracture OR traumatic dental
injury OR dental injuries OR tooth injury OR crown injury OR tooth trauma OR teeth trauma OR traumatized teeth OR
traumatized tooth OR dental trauma OR dental traumas OR crown fracture OR Tooth fragment OR Incisor fracture OR Incisor
trauma OR Incisor injury) AND ( dental reattachment OR dentin bonding OR fragment reattachment OR segment reattachment
OR autologous)
Web of tooth fracture OR tooth fracture OR teeth fracture OR fractured tooth OR Fractured teeth OR crown fragment OR crown
Science segment OR fractured crown OR broken tooth OR broken teeth OR tooth segment OR coronal fracture OR traumatic dental
injury OR dental injuries OR tooth injury OR crown injury OR tooth trauma OR teeth trauma OR traumatized teeth OR
traumatized tooth OR dental trauma OR dental traumas OR crown fracture OR Tooth fragment OR Incisor fracture OR Incisor
trauma OR Incisor injury AND dental reattachment OR dentin bonding OR fragment reattachment OR segment reattachment
OR autologous reattachment OR reattachment technique OR reattachment technique AND complicated OR crown-root OR
uncomplicated
Google dental reattachment OR dentin bonding OR fragment reattachment OR segment reattachment OR autologous reattachment OR
scholar reattachment technique OR reattachment technique AND Crown-root fracture

Data extraction was done into an Excel spreadsheet. Data ex- met the inclusion criteria, and hence, it was considered as a single
traction was verified for accuracy by the senior investigators (BA case report. Thus, the included articles consisted of 12 case reports
and NV). and two case series in the end accounting for a total of 19 teeth. In
Methodological quality assessment of the articles was done using the scientific merit assessment using the JBI tool for case reports,
the “Joanna Briggs Institute (JBI) clinical appraisal checklist for case se- two case reports were found to be of high risk of bias, five articles
ries and case reports.” A separate JBI tool exists for case reports and were of moderate risk of bias and the other five were of low risk of
18,19
case series and, the articles were assessed using the respective tool. bias, respectively.18 Both the case series were assessed by the JBI
Two investigators (PK and SS) independently scored the articles. In case tool for case series and were found to have moderate risk of bias19
of disagreement, the senior investigators (BA and NV) were consulted,
and the final decision was reached through discussions. The percentage TA B L E 2   Reason for excluding the articles after reading full text
of positive answers (yes) was used to calculate the final score. The risk
of bias (RoB) was categorized as “high” (score equal or lower than 49%), Number
20 Reason for exclusion of articles
moderate (50% to 69%), or low (higher than 70%).
Multiple fragments 11
Open apex 4
3 | R E S U LT S No follow-up 5
Complicated crown fracture 23
The entire search strategy is shown in Table 1. A total of 1,720 arti- Multiple fracture line 4
cles were identified from the initial search. After the title and abstract Uncomplicated crown fracture 14
screening and removal of duplicates using Zotero version 5.0.8, 1618 No attachment 3
articles were excluded. After full-text reading of the remaining 102
Previously treated teeth 10
articles, 88 were excluded, as they did not meet the inclusion crite-
Secondary trauma 3
ria. The reasons for exclusion are given in Table 2. Finally, 14 articles
Interim procedure for orthodontic extrusion 3
were assessed for quality assessment as they fulfilled the inclusion
Incomplete fragment retrieved 3
criteria (Figure 1). Included articles consisted of 11 case reports and
Composite/ crown as final restoration 5
three case series. In one case series, only one of the cases mentioned
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4       KHANDELWAL et al.

(Figures 2 and 3). The agreement between the two examiners was of the extent of fracture.10,12–15,22–25,27 In addition to an IOPA, an
calculated by Cohen's kappa coefficient and was found to be 0.749 orthopantomograph (OPG)29 and a soft tissue radiograph26 were
21
(Table 3). taken in one article each. An OPG was the only radiograph taken in
The patient's age in all included studies ranged from 11 to one article28, while in another article, a diagnostic radiograph was
40 years. The male to female ratio was 12:1. Three articles did not not taken.16 Eight articles10,15,16,24–26,28,29 reported that the frac-
13,16,22
mention the gender of the patient. Seven articles were from ture line was violating the biological width whereas, in four articles
India,12,13,22–26 two each from Turkey15,27 and Brazil14,16 and one it was mentioned that there was no violation.13,14,22,27 In two arti-
28 10 29
each from Portugal, Bangladesh, and Malta (Table 4). cles, detail regarding the extent of the fracture line was not men-
Occlusal contacts were checked in patients after reattachment tioned.12,23 The fractured coronal fragment was reported to be
10,15,26–29
in only six of the included articles (Table 5). Details regard- detached (avulsed) in two articles (1 case report and a tooth of a
ing patient-related characteristics such as chewing habits, food hab- case series).14,27 In all the remaining 13 articles (11 case reports, 1
its, or presence of any parafunctional habits were not reported in case series and a tooth of a case series),10,12,13,15,16,22–29 the coronal
any of the articles. fragment was partially attached to the main tooth structure. The at-
The time elapsed between trauma and management ranged from tached coronal fragment was removed in all cases and rehydrated
3 to 30 days. Out of a total of 19 teeth assessed, 15 were maxillary using a storage medium. Saline was used as a storage medium in six
central incisors and the remaining four were maxillary lateral inci- of the articles,12,15,23,26,28,29 while distilled water was used in five of
sors. Tooth mobility and percussion tests were used as diagnostic the articles.10,13,22,25,27 In one article, the fragment was stored in fro-
13,15,22,25,28,29 13,29
tests in six and two articles, respectively. In ten of zen distilled water for 6 hours and then thawed at room temperature
the included articles, only a single straight angled pre-operative in- in water for 30  minutes prior to reattachment.16 Details regarding
tra-oral periapical (IOPA) radiograph was taken for the assessment the storage medium was not mentioned in two articles14,24 (Table 5).

F I G U R E 1   Literature search flow

diagram
KHANDELWAL et al. |
      5

F I G U R E 2   Graphical representation
of scientific merit assessment of included
articles using the Joanna Briggs Institute
(JBI) tool: (A) Case reports (B) Case
series

F I G U R E 3   Scientific merit assessment

scoring of individual articles using the
Joanna Briggs Institute (JBI) tool: (A) Case
reports (B) Case series
 |
6       KHANDELWAL et al.
JBI Questions
1 Were patient's demographic characteristics clearly
described?
2 Was the patient's history clearly described and
presented as a timeline?
3 Was the current clinical condition of the patient on
presentation clearly described?
4 Were diagnostic tests or assessment methods and
the results clearly described?
5 Was the intervention(s) or treatment procedure(s)
clearly described?
6 Was the post-intervention clinical condition clearly
described?
7 Were adverse events (harms) or unanticipated
events identified and described?
8 Does the case report provide takeaway lessons?
Note: The inter-examiner agreement was calculated using Cohen-Kappa inter-rater reliability and
was found to be above 0.749.
With regard to the exposure of the fracture, the following
procedures were done: mucoperiosteal flap surgery in eight arti-
cles,10,14–16,24,26,28,29 mucoperiosteal flap surgery with osteoplasty
and osteotomy in five articles,10,15,16,28,29 and only gingivectomy
12,15,23,25
in four articles. However in three articles, exposure of the
fracture was not done.13,22,27
Pulp preservation as a treatment option was carried out (direct
pulp capping with calcium hydroxide) in only one article14 whereas,
in the remaining 13 articles, endodontic treatment was carried
out.10,12,13,15,16,22–29 A post was described as a treatment option in 11
articles.10,12,13,15,22–27,29 Details regarding the type of post, adhesive
strategy for bonding of the post and reattachment of the fragment,
and the intermediate materials used for reattachment in the articles
are described in Figures 4 and 5.
Out of the 11 articles where a post was used as a treatment
option, in nine articles tooth preparation was done inside the
coronal fragment to accommodate the post. Retention boxes
and grooves13,22 were mentioned as preparation in two articles
26 15 25
each and a post-hole, small hole, dentine removal , small
recess 23 , and internal notch10 in one article each. After reat-
tachment, additional preparation was done on the margins of
the approximating surfaces in the form of a groove in four arti-
cles13,14,22,24 and a double chamfer in one article. 25 Another ar-
ticle did not mention the type of beveling done. 23 Splinting was
done in only one article with inter-proximal flowable composite
26
for two weeks (Table 5).
The follow-up period ranged from 3 months to 7 years. In nine
articles, periodic follow-up was done with intervals ranging from
10,12,13,22–24,26,27,29
1 week to 1 year. The outcomes measured were
categorized into clinical, radiographic and esthetic success (Table 6).
The outcomes were considered successful in all the articles, with
none of them reporting any untoward results.
TA B L E 3   Modified Joanna Briggs
Cohen kappa inter-rater
Institute (JBI) Critical Appraisal Checklist
reliability between evaluators
for case series and case reports
1.000
0.781
0.749
0.787
1.000
0.822
0.760
0.755
4 | D I S CU S S I O N
The aim of this systematic review was to analyze the reattachment
treatment option for complicated CRF of anterior teeth. To the best
of the authors’ knowledge, there has been no review done on this
topic. The included studies were mainly case reports and case series;
hence, the available evidence is considered low (level 4b according
to the Joanna Briggs Institute levels of evidence).30 Currently, there
are no randomized clinical trials available on this topic and hence the
evidence can be obtained only from existing clinical studies or case
reports.
In this systematic review, a total of 14 articles comprising 12
case reports and two case series published between 2008 and 2017
were included for analysis. The articles included were analyzed for
the quality assessment using the JBI tool for case series and case
reports. In the overall scientific merit assessment, two articles were
12,27
found to be of high risk of bias, seven articles of moderate risk and
five of low risk.18,19 A meta-analysis was not possible in this system-
atic review due to vast heterogeneity in the methods and materials
used for reattachment in the included articles.
The current IADT guidelines include coronal fragment reattach-
ment as a treatment option for uncomplicated crown fracture but
not for complicated CRF.7 However, numerous case reports have
suggested this adhesive reattachment to be a successful proce-
dure.10,12,15,22,27 Interestingly, the vast majority (93%) of the articles
included in this review were from developing nations (India, Brazil,
Bangladesh, Turkey, and Malta). This could be attributed to reat-
tachment being an immediate, simple, and cost-effective procedure
when compared to other treatment options.
The IADT guidelines for CRF suggest one parallel periapical ra-
diograph, two additional angulated periapical radiographs and one
occlusal radiograph, or CBCT for the assessment of the extent of
KHANDELWAL et al. |
      7

TA B L E 4   Details of the articles and demographic data

Number of tooth
Sr No. Author, year Type of study involved Gender Age Country
28
1 Machado et al 2017 Case report 1 Male 17 Portugal
16
2 Taguchi et al 2015 Case report 1 Not mentioned 21 Brazil
3 Sivagami et al 201426 Case report 1 Female 11 India
24
4 Akhtar et al 2014 Case report 1 Male 34 India
5 Nair et al 201323 Case report 2 Male 40 India
25
6 Kulkarni et al 2013 Case report 1 Male 11 India
7 Islam et al 201310 Case report 1 Male 20 Bangladesh
27
8 Akyuz et al 2012 Case series Case 1-2 Male Case 1-21 Turkey
Case 2-1 Case 2-19
9 Tosun et al 201215 Case series Case 1-1 Male Case 1 - 12 Turkey
Case 1 - 1 Case 1 - 11
10 dos Santos et al 201114 Case report 1 Male 14 Brazil
12
11 Badami et al 2011 Case report 2 Male 22 India
12 Rajput et al 201122 Case report 1 Not mentioned 23 India
29
13 DePasquele et al2008 Case report 1 Male 32 Malta
14 Rajput et al 200913 Case report 1 Not mentioned 25 India
Total Case report – 12 19
Case series - 2

the fracture.7 An intra-oral periapical radiograph was the only radio-
graphic examination performed in most articles (78%). Multiple an-
gulated radiographs, occlusal radiograph, or CBCT were not used in
any of the included articles. The use of three-dimensional imaging in
these cases would prove highly beneficial, as it would allow for better
evaluation of the fracture without overlapping of anatomical struc-
tures.31 Future studies should consider using CBCT in CRF involving
adult patients, while its use in pediatric patients must be done with
caution.
None of the studies mentioned patient-related characteristics
such as food habits, chewing habits, or the presence of parafunc-
tional habits, which could result in undue forces on the reattached
tooth and eventually lead to early loss.32 Only six articles (43%) had
10,15,26–29
checked the occlusion of teeth after reattachment.
In the majority of the articles (86%), the fractured fragment
was not completely detached from the remaining tooth and ex-
hibited moderate mobility. The partially attached fragment was
intentionally detached prior to reattachment and was preserved in
a storage medium. The most commonly used storage medium was
saline (43%) followed by distilled water (36%). Previous in vitro
studies have reported improvement in bond strength following
33–38
rehydration of a fragment. Most of the studies recommend
rehydration for 15 to 30  minutes in a storage medium such as
33,34,36–38
saline, distilled water or milk prior to bonding. A longer
rehydration time of 24  hours prior to bonding was suggested by
Farik et.al. 33 The current IADT guidelines suggest rehydration of
a tooth fragment in water or saline for 20 minutes for uncompli-
cated crown fractures.7 The fragment is rehydrated not only to
increase fracture resistance but also for the preservation of the
original tooth color. 33 Keeping the fragment hydrated ensures
better bond strength as there is no or minimal collapse of dentin
collagen fibers. 39
Biological width violation was seen in 57% of the cases. In 78%
of the articles, exposure of the fracture was done either by gingi-
vectomy or mucoperiosteal flap elevation with osteotomy. Exposure
of the fracture not only helps in maintaining isolation but also helps
in better evaluation of the course and nature of the fracture. Teeth
with fractures extending apically or those with multiple fractures
need to be extracted because of poor prognosis. The patient has to
be prior informed about the possibility of change in treatment that
can occur after flap elevation.
A previous systematic review of fragment reattachment
in laboratory studies suggested ten different tooth prepara-
tion techniques for the coronal fragment. 8 Tooth preparation
(43%) was done in the form of bevel and groove in only six of
the included articles of this systematic review. Post-preparation
was done in the majority (64%) of the articles in the coronal
fractured fragment. Earlier studies reported higher fracture
resistance of the coronal fragment when prepared prior to reat-
tachment as compared to those without any preparation of the
fragment. 40–44
The longevity of the coronal fragment reattachment depends
on the adhesive system used and the intermediate materials used
to bond the fractured fragment to the remaining tooth structure.45
The majority of the articles included in this review used adhesives
along with an intermediate material. The adhesive strategy and the
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8       KHANDELWAL et al.

TA B L E 5   Summary of reattachment procedure in CRF in case reports/case series

Fragment
S Time Diagnostic detached/ Fracture line
No. Author, year Tooth lapsed test Radiograph Extent of fracture attached Storage media exposure

1 Machado 21 30 d Pulp Orthopantomograph Fracture line located Attached Saline Mucoperiosteal flap
et al 201728 Sensibility intra-osseously, surgery along with
test invading the biologic osteotomy and
Mobility width osteoplasty done in
test palatal region

2 Taguchi 11 N/A N/A N/A Subgingival and Attached Frozen distilled Mucoperiosteal flap
et al 201516 intraosseous invading water for surgery along with
biological width period of osteotomy and
6 h and then osteoplasty done
thawed in in palatal region
water for removing 1 mm of
30 min bone tissue

3 Sivagami 11 N/A N/A IOPA, soft tissue Mesiogingival edge Attached Saline Mucoperiosteal flap
et al 201426 radiograph following the oblique surgery
course to distocervical
end of the tooth both
buccally and palatally

4 Akhtar 11 N/A N/A IOPA Fracture line extended Attached N/A Mucoperiosteal flap
et al 201424 from middle third surgery
on buccal aspect
to cervical third on
palatal side

5 Nair 11,21 1 d N/A IOPA Horizontal fracture Attached Saline Gingivectomy
et al 201323 line on the middle
of the labial surface
extending obliquely to
the subgingival area on
the palatal side

6 Kulkarni 21 7 d Mobility IOPA Fracture line extended Attached Distilled water Gingivectomy
et al 201325 test in a oblique direction
bucco-lingually
and the margin
was subgingival on
the palatal aspect
involving the biologic
width.

7 Islam 21 15 d N/A IOPA Fracture line was Attached Distilled water Mucoperiosteal flap
et al 201310 oblique extending surgery along with
in apical direction osteoplasty done
from palatal to labial in labial aspect as
surface. Biologic width well as gingival
violated on the labial recontour
aspect

8 Akyuz C1: N/A N/A IOPA C1- Apical direction C1: Distilled water N/A
et al 201227 11,12 from labial to palatal Attached
surface in the level of
the alveolar crest at
the lingual aspect

C2: 21 C2- Oblique fracture C2:

of palatal portion Attached
extending subgingival
KHANDELWAL et al. |
      9

Endodontic
management Type of post Post adhesive strategy Fragment Adhesive strategy Additional preparation Occlusion Splinting

Root canal Not Done Not Applicable Etchant: 37% Phosphoric N/A Checked Not done
treatment acid Adhesive: Total-etch
(OptiBond FL)
Intermediate material:
MicroHybrid composite
(Heated z100 3M,USA)

Root canal Not Done Not Applicable Etchant: 37% Phosphoric N/A Not Not done
treatment acid Adhesive: Total-etch checked
(Adper Single Bond)
Intermediate material: Light
cure resin cement (Variolink
Veneer Ivoclar Vivadent)

Root canal Glass fiber- Etchant: N/A Adhesive:N/A Etchant: 37% Phosphoric Post -hole within coronal Checked Inter-proximal
treatment reinforced post Luting cement: Flowable acid Adhesive: applied but fragment was prepared splinting with
followed by (Mirafit white) composite (manufacturer's details N\A flowable
post-placement details N/A) Intermediate material: composite
Composite resin (3M ESPE) for 2 wk

Root canal Fiber post N/A Etchant: Not Applicable Before and after Not Not done
treatment (Parapost, Adhesive: Not Applicable reatachment V-shaped checked
followed by Coltene Intermediate material: GIC ( groove was made
post-placement Whaledent GC Fuji II)

Root canal Fiber-reinforced Etchant: N/A Adhesive: Self- Etchant: N/A Adhesive: Self- Small recess was Not Not done
treatment composite post etch (ParaBond-Coltene etch (ParaBond-Coltene prepared in the pulp checked
followed by (TenaxFiberTrans- Whaledent) Whaledent) chamber of fractured
post-placement Coltene Luting cement:Dual cure Intermediate material: Dual segment and after
Whaledent) luting cement (ParaBond- cure resin (ParaCore- reattchment, bevel was
Coltene Whaledent) Coltene Whaledent) prepared

Root canal Glass Fiber post Etchant:N/A Adhesive: Total
treatment (Fibra Post Plus) etch (Adper TM Single
followed by bond 2, adhesive; 3M
post-placement ESPE AG)
Luting cement:Dual cure
core built up composite
(Sealacore DC, Products
Dentaires SA)
Etchant: 37% phosphoric
acid Adhesive: Total etch
(Adper TM Single bond 2,
adhesive; 3M ESPE AG)
Intermediate material:
Microhybrid composite(
Filtek Z250, 3M ESPE AG)
Dentine from inner Not Not done
aspect of fragement checked
to provide space
for the post. After
reattachment double
chamfer margin was
created 1 mm coronally
and apically to the
fracture line

Root canal Glass Fiber Etchant: 37% Etchant: 37% Fractured fragment was Checked Not done
treatment composite post orthophosphoric orthophosphoric acid prepared by making
followed by acid Adhesive: Not Adhesive: Not Applicable internal notch where
post-placement ApplicableLuting cement: Intermediate material: the fiber post will
Dual cure self-adhesive Dual cure self-adhesive occupy
resin cement (Embasee resin cement (Embasee
WetBond) WetBond)

Root canal Light transmitting Etchant:N/A Adhesive:N/ Etchant: K Etchant Adhesive: Retention box on Checked Not done
treatment fiber post (DT ALuting cement: Dual cure Self-etch (ED primer) the fragement was
followed by Light post) universal resin cement Intermediate material: Dual prepared
post-placement (Panvia F 2.0) cure universal resin cement
(Panvia F 2.0)

Root canal transmitting fiber Etchant:N/A Adhesive:N/ Etchant: K Etchant Adhesive: Retention box on Checked Not done
treatment post (DT Light ALuting cement: Dual cure Self-etch (ED primer) the fragement was
followed by post universal resin cement Intermediate material: Dual prepared
post-placement (Panvia F 2.0) cure universal resin cement
(Panvia F 2.0)

(Continues)
 |
10       KHANDELWAL et al.

TA B L E 5   (Continued)

Fragment
S Time Diagnostic detached/ Fracture line
No. Author, year Tooth lapsed test Radiograph Extent of fracture attached Storage media exposure

9 Tosun C1: 22 C1: Mobility IOPA C1: Horizontal on the Attached Saline C1: gingivectomy
et al 201215 7 d test buccal, 3 mm above
the gingival margin and
oblique in the buccal-
palatal direction,
extending 3 mm below
the gingival margin on
the palatal

C2: 21 C2: C2: Oblique fracture C2: Mucoperiosteal

3 d 4 mm below the flap surgery along
gingival margin on with osteotomy was
the distal, extending performed
subgingivally

10 Tosun 11 7 d Pulp IOPA Fracture line started Detached N/A Mucoperiosteal flap
et al 201215 sensibility on the incisal portion surgery
test of the palatal surface,
extended obliquely
to the buccal side
and was slightly
subgingival

11 Badami 11,12 10 d N/A IOPA Fracture lines of Attached Saline Gingivectomy
et al 201112 both teeth were
supragingival on the
labial aspect and
below the gingival
margin on the palatal
aspect

12 Rajput 12 5 d Mobility IOPA Fracture line was Attached Distilled water Not needed
et al 201122 test oblique extending
in apical direction
from labial to palatal
surface. The margin
on palatal surface was
located about 1.5 mm
from the free gingival
margin

13 DePasquele 22 N/A Percussion IOPA and dental The fracture line was Attached Saline Mucoperiosteal flap
et.al test panoramic at the level of the surgery along with
200829 Mobility tomogram gingivae buccally, osteotomy done
test however, distopalatally distopalatally
it extended
subgingivally and
apical to the bone
crest, invading the
biologic width

14 Rajput 21 3 d Percussion IOPA The fracture line was Attached Distilled water Not needed
et al 200913 test oblique, extending
Mobility in apical direction
test from labial to palatal
surface. The margin
on palatal surface was
located about 2 mm
from the free gingival
margin

Abbreviations: C, Case; IOPA, Intraoral periapical radiograph; N/A, Non available information.
KHANDELWAL et al. |
      11

Endodontic
management Type of post Post adhesive strategy Fragment Adhesive strategy Additional preparation Occlusion Splinting

Root canal Fiber-reinforced Etchant: N/A Adhesive:Self- Etchant: N/A Adhesive: self- A small hole was created Checked Not done
treatment polymer post etch (Liner Bond 2V, cure dental adhesive (Super in the middle of the
followed by (Ribbond, Kuraray Inc, Tokyo, Japan Bond C&B, Sun Medical Co. crown fragment
post-placement Ribbond Inc) Luting cement:Dual cure Ltd. Japan) in which to lay the
resin cement (Panavia F Intermediate material: Not polyethylene fiber
2.0, Kuraray Medical Inc, Applicable
Japan)

Root canal Fiber-reinforced Etchant: N/A Adhesive:Self- Etchant: N/A Adhesive: self- A small hole was created Checked Not done
treatment polymer post etch (Liner Bond 2V, cure dental adhesive (Super in the middle of the
followed by (Ribbond, Kuraray Inc, Tokyo, Japan Bond C&B, Sun Medical Co. crown fragment
post-placement Ribbond Inc) Luting cement:Dual cure Ltd. Japan) in which to lay the
resin cement (Panavia F Intermediate material: Not polyethylene fiber
2.0, Kuraray Medical Inc, Applicable
Japan)

Direct pulp Not Done Not Applicable Etchant: 37% phosphoric After 15 d a groove Not Not done
capping acid Adhesive: Etch-and- extending from the checked
with calcium rinse (Prime & Bond 2-1®, buccal to the palatal
hydroxide DENTSPLY) side of the tooth was
Intermediate material: prepared along the
Light-cured microhybrid fracture line
composite resin (TPH®,
DENTSPLY

Root canal Glass fiber post Etchant: Post-surface
treatment (Radix fiber post) treatment done using 37%
followed by phosphoric acid Adhesive:
post-placement Total etch (Prime & Bond
NT)
Luting cement:Dual cure
resin (Calibra esthetic resin
cement Dentsply)
Etchant: 37% phosphoric
acid Adhesive: Total etch
(Prime & Bond NT)
Luting cement:Dual cure
resin (Calibra esthetic resin
cement Dentsply)
Retention boxes in both Not Not done
coronal fragments checked
to accommodate the
heads of the posts

Root canal Light transmitting Etchant: 37% phosphoric Etchant: 37% phosphoric A groove was made on Not Not done
treatment fiber post (DT acid (Total etch, Ivoclar acid (Total etch, Ivoclar the fractured fragment checked
followed by Light post Viva Vivadent) Adhesive: N/ for the comfortable
post-placement dent) Adhesive: Total etch AIntermediate material: fit of the post. After
(Prime and Bond NT dual Dual cure resin (Calibra reatchment another
cure) esthetic resin cement groove was made
Luting cement: Dual cure Dentsply) app. 0.3 mm deep,
resin (Calibra esthetic resin extending app. 1.5 mm
cement Dentsply) incisally and gingivally
from the fracture line

Root canal Fiber-glass post Etchant: N/A Adhesive: N/A Etchant: Phosphoric acid N/A Checked Not done
treatment (Parapost Luting cement:Dual cure Adhesive: N/A
followed by Whaledent resin cement (Panvia F) Intermediate material:Dual
post-placement cure resin cement (Panvia F)

Root canal Light transmitting Etchant: 37% phosphoric Etchant: 37% phosphoric A groove was made on Not Not done
treatment fiber post (DT acid (Total etch, Ivoclar acid (Total etch, Ivoclar the fractured fragment checked
followed by Light post Vivadent) Adhesive: Total Vivadent) Adhesive: N/A for the comfortable
post-placement etch (Prime and Bond NT Intermediate material: Dual fit of the post. After
dual cure) cure resin (Calibra esthetic reattchment another
Luting cement: Dual cure resin cement Dentsply) groove was made
resin (Calibra esthetic resin Etchant: 37% phosphoric approximately 0.3 mm
cement Dentsply) acid (Total etch, Ivoclar deep, extending
Vivadent) Adhesive: N/A 1.5 mm incisally and
Intermediate material: Dual gingivally from the
cure resin (Calibra esthetic fracture line
resin cement Dentsply)
 |
12       KHANDELWAL et al.
intermediate material used varied across the included articles. Total
etch (36%) was the most commonly used adhesive strategy. Dual
cure resin cements (43%) were used predominantly as intermediate
materials followed by microhybrid composites (21%). Previous stud-
ies and a systematic review have found that use of an adhesive with
an intermediate materials (composite or resin cement) significantly
8,32,44–48
increased fracture resistance.
F I G U R E 4   Post-adhesive strategy: (A)
Post used (B) Adhesive strategy for post-
bonding, (C) Post-luting material
Two previous retrospective cohort studies have evaluated clin-
ical outcomes of reattachment after complicated CRF.9,49 However,
both of these studies were not included in this current review, as
details regarding the reattachment procedures were missing. One of
the studies reported reattachment to be successful in 90% of teeth
after 2 years,49 while the other study reported 66.7% success after
9.5  ±  3.7  years.11 The follow-up period in this systematic review
KHANDELWAL et al.
F I G U R E 5   Fragment adhesive
strategy: (A) Adhesive system for
fragment reattachment, (B) Intermediate
materials
ranged from 3  months to 7  years. The longest follow-up was with
the teeth in which conservative pulp treatment was performed. In
cases where endodontic treatment was done, reattachment was
successful in 78% of the cases after 1 year. This success rate is sim-
ilar to treatment options such as orthodontic and surgical extru-
sion.50,51 Hence, reattachment can be considered as a cost-effective
treatment option for the management of complicated crown-root
fractures.
Various possible adverse events could accompany fragment re-
attachment in CRF namely, discoloration or detachment of the coro-
nal fragment, periodontal pocket formation, bone loss, or resorption.
However, none were mentioned in any of the included articles which
52
could be regarded as reporting bias.
Previous studies have concluded that fragment reattachment
in CRF teeth was generally associated with mild gingival inflam-
mation. A frequent periodic periodontal examination needs to be
carried out in cases with subgingival CRF as any bone loss that
occurs due to periodontal derangement will compromise future
implant placement.
|
      13
Future case reports should provide a complete history of
the patient and the treatment performed by adhering to the
CARE guidelines for reporting of case reports 53 and the IADT
guidelines for treatment. 7 Further long-term cohort studies
need to be done to determine long-term survival and success
of reattachment for complicated CRF. Future studies should
consider providing complete details of the procedure done,
frequent periodic follow-up, and reporting of adverse events
if any.
5 | CO N C LU S I O N
The level of evidence for reattachment in complicated crown-
root fracture is low due to the observational nature of studies
included. However, the short-term success of the reattachment
procedure is good and hence it can be considered as a viable in-
terim treatment option for complicated crown-root fractures of
anterior teeth.
 |
14      

TA B L E 6   Follow-up period and outcomes

Sr No. Author, year Tooth Clinical features Radiographic features Esthetic features Follow-up period
28
1 Machado et al 2017 21 No mobility Absence of radiographic signs of No color change 12 mo
Good periodontal health and root resorption,
asymptomatic
2 Taguchi et al 201516 11 Satisfactory periodontal health N/A Fracture line was not visibly 4 mo
observable
3 Sivagami et al 201426 11 Clinically acceptable N/A Restorative treatment 1 wk, 4 mo and
clinically acceptable 9 mo
4 Akhtar et al 201424 11 Asymptomatic N/A Satisfactory aesthetics 1 wk, 1 mo, 6 mo I
y, 1.5 y and 2 y
5 Nair et al 201323 11,21 Asymptomatic, no periodontal pocket, Intact tooth structure Satisfactory aesthetics 6 and 12 mo
normal gingival tissues
6 Kulkarni et al 201325 21 No mobility, good periodontal health, No periradicular pathology Good aesthetics 3 mo
asymptomatic, functional
7 Islam et al 201310 21 No associated endodontic or No periradicular pathology Satisfactory aesthetic 1, 3, 6 and 12 mo
periodontal problem.
8 Akyuz et al 201227 Case 1:11,21 Functional, no mobility, satisfactory Satisfactory healing Excellent esthetics and no 6, 12, 24 mo and
Case 2:21 periodontal health discoloration 3 y
9 Tosun et al 201215 Case 1:22 Asymptomatic, good periodontal No periradicular pathology No color change 3 y
health
Case 2:21 Functionally acceptable, periodontal No periradicular pathology Aesthetically pleasing 1.5 y
tissues were healthy
10 dos Santos CL et al 201114 11 Signs of pulpal vitality, good No resorption Good esthetic 7 y
periodontal health, asymptomatic
11 Badami et al 201114 11,12 Good periodontal health, normal No resorption N/A 1 and 12 mo
mobility
12 Rajput et al 201122 12 Satisfying function, no mobility, Satisfactory healing Excellent esthetics and no 2.5 y
periodontal status was satisfactory discoloration
13 DePasquele et al 200829 22 Fully functional and stable No resorption Good coronal aesthetic 6 mo and 1 y
reattachment,periodontal health, and
no discomfort
14 Rajput et al 200913 21 Satisfactory function No periradicular pathosis Excellent esthetics 1, 2 mo and 2 y

Abbreviation: N/A, non available information.

KHANDELWAL et al.
KHANDELWAL et al.
C O N FL I C T O F I N T E R E S T
The authors confirm that they have no conflict of interest.
ORCID
Priyal Khandelwal  https://orcid.org/0000-0002-8396-2170
Velmurugan Natanasabapathy  https://orcid.
org/0000-0003-2878-6837
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How to cite this article: Khandelwal P, Srinivasan S, Arul B,
Natanasabapathy V. Fragment reattachment after
complicated crown-root fractures of anterior teeth: A
systematic review. Dent Traumatol. 2020;00:1–16. https://
doi.org/10.1111/edt.12602