Bonding of Fractured Fragments using Various Bonding Materials as a Treatment Modality in Cases of Vertical Root Fracture- A Systematic Review
Correspondence Address :
Sharad Pawar Dental College, Wardha, Maharashtra, India.
Introduction: Vertical Root Fracture (VRF) is third most common factor leading to extraction of root canal treated tooth. It has a longitudinal orientation. This occurs due to reduction in structural integrity and dehydration of dentine. Most common treatment includes extraction of the teeth. Other modality is amputation of involved root in molars. Various materials can also be used for bonding of the fragments.
Aim: To compare and evaluate the effectiveness of dentine bonding systems in re-attatchment of fractured root.
Materials and Methods: The present systematic review included a comprehensive search of last 10 years was performed in the systematic electronic database PubMed. In-vitro laboratory studies that evaluated the microtensile bond strength and fracture resistance of multiple dentine adhesive systems and compared them in human and/or animal teeth in which VRF had occurred were included. A total of 16 non duplicated studies were retrieved in the systematic search.
Results: Out of 16 studies four studies were included in the systematic review. One study assessed the bond strength of the adhesive using table top testing machine. Two studies assessed the microtensile bond strength using stereo microscope and one study assessed recurrence of the fracture using Instron Machine. The studies demonstrated large variability among methodology used for evaluation. In one study, acid phosphate monomer showed highest microtensile bond strength (p<0.05), and in another study Refracture (RF) occurred easily in samples bonded with Glass Ionomer Cement (GIC) as compared to those bound with Perma Bond and Gluma (p<0.0003).
Conclusion: From the present study's analysis, dual cure adhesive resin cement either reinforced with polyethylene fibers or glass fibers, and glass ionomer cement may increase the fracture resistance of bonded tooth.
Adhesive systems, Longitudinal fractures, Re-attachment
Vertical Root Fracture has longitudinal orientation and originates from apex of the root and propagate to the coronal part of the tooth (1). It is third most common factor leading to extraction of root canal treated tooth (1). Changes occurring in Root Canal (RC) treated tooth are decreased stiffness and also leads to decreased fracture resistance. This occurs due to reduction in structural integrity and dehydration of dentine. In such cases endodontic crowns are better to be used instead of full crowns (2). Post and core is also the better restorative modality in cases of RC treated tooth (3).
The VRF leads to poor outcome of the tooth. Complete root or a part may be involved in the fracture (4). It may extend to only one or both sides of the root (4). Diagnosis of VRF is quite difficult. It is likely similar to the periodontal disease or the failed endodontic treatment (1). In multi-rooted teeth, fracture is commonly oriented in buccolingual direction. In anterior teeth also it is directed buccolingually (4). VRF can be classified as: initiating from the coronal tooth structure and one initiating from the apex. It can also be classified as complete and incomplete VRFs (4). VRF presents with multiple clinical features, thus making it difficult to diagnose. It presents delayed signs and symptoms. Clinical and radiographical features include deep periodontal pocket, pain, j-type radiolucency and sinus tract. Most common treatment includes extraction of the teeth (5). Other modality is amputation of involved root in molars. Bonding of the fragments can also be done (5). Sugaya T et al., developed the method which includes atraumatic intentional extraction followed by rotational replantation of the tooth (6). Adhesive resin are used to restore the tooth. Extraction of fragment helps to clear granules. Rotational replantation creates contact in the crack and healthy periodontal tissue (7). Various materials can be used for bonding of the fragments. It includes Methyl Methacrylate (MMA) based resin material, dual cure composites and GIC (7),(8),(9).
The purpose of this systematic review was to assess the success of dual cure composite with three adhesive systems [Clearfil SE Bond (SE), Tokuyama Bond Force (BF) and Clearfil DC Bond (DC)], MMA based adhesive resins, dual cure resin cement with polyethylene fibers and glass fibers, GIC, resin and Cyanoacrylate cement to bond fractured fragments. The hypothesis is none of the above bonding materials have successful results in treatment of VRF.
This systematic review was conducted according to the guidelines of the PRISMA statement. The studies were selected according to the inclusion and exclusion criteria. All abstracts and full texts were reviewed. None of the manuscript author was contacted during this process. Disagreements between authors were evaluated and the studies were eliminated through discussion among researchers until a consensus was reached.
Inclusion criteria: The eligibility criteria considered in-vitro laboratory studies that evaluated the microtensile bond strength and fracture resistance of multiple dentine adhesive systems and compared them in human and/or animal teeth in which VRF has occurred. The studies in the review were included from year 1993 to 2013 and duration of systematic review was 2 months.
Exclusion criteria: Studies that considered extraction as a treatment option for VRF were excluded.
A systematic search without restrictions was performed by two independent reviewers in the electronic database PubMed without restriction on year of publication. No filters or limits were applied in the searches. The selection of the descriptors was based on the most cited terms in previous publications related to this theme. The Boolean operators ‘AND’ and ‘OR’ were used to create the keywords search (Table/Fig 1). The keywords used were “VRF,” “re-attatchment of fragment”, “material for bonding”. The search details were VRF (all fields) AND re-attatchment OR bonding (all field) AND bonding material (all field).”
Selection of the Studies
Two independent authors selected the studies, examining the retrieved titles and abstracts according to the search strategy. When it was not possible to judge the studies by title and abstract, full text was obtained for the final decision. This review included in-vitro studies. For this reason, the Patient Intervention Comparison Outcome (PICO) system was adapted: population (studies conducted in human/animal extracted teeth), intervention (evaluation of success of material used for the treatment), comparison (between the materials used), and outcomes (success rate of the material). Disagreements on inclusion criteria were solved by consensus with a third author following the predefined inclusion criteria. Studies that appeared to be duplicated in the database search were considered only once.
Quality Assessment of Studies
In second step full text of the chosen articles were read out for data extraction and quality assessment was done as per Oral Health Assessment Tool (OHAT) by two independent reviewers (PC, KR) (10),(11). In cases of difference between reviewers, the third senior reviewer (MC) clarified the discrepancy. Flow chart for this systematic review is shown in (Table/Fig 2).
In the beginning, 21 articles were selected which included bonding of fractured root fragment with the dentine adhesive. Five articles were excluded due to duplication. Out of remaining 16 articles, six studies were excluded due to wrong study design, no relevant result, no proper comparison of the adhesive system, different intervention and six more articles were excluded due to unavailability of full text. Hence, only four articles were selected (Table/Fig 2). Title, abstract, a scientific context based on bonding of fractured root fragment with dentine adhesive was included. Also, rationale, objectives hypothesis, methodology showing study type was incorporated. Intrusion, statistical analysis, evaluation period were also used and main results were extracted from each experimental study.
In this study, after quality assessment for risk of bias was done by three independent reviews and by OHAT tool, it was found that all studies included low risk of bias (Table/Fig 3) (7),(8),(9),(12).
Research question: Is bonding of the fractured fragment using various bonding material is the effective treatment modality in cases of VRF?
Search findings and study characteristics: A total of 21 articles were found. After screening the titles and the abstracts of the identified studies, four studies were included in the full-text analysis. No additional relevant studies were found from hand searching. The four studies included were in-vitro studies. As the articles were heterogeneous in design/methodology and contained disparate data types, quantitative analysis was not possible and a qualitative systematic review was performed.
The initial screening of the retrieved studies was conducted using titles and abstracts. The corresponding full text was read when the results were unclear. The authors independently evaluated the studies and discussed the results until a decision was reached by consensus. The outcome of the included studies is mentioned in (Table/Fig 4). The performance of the included articles on the JBI The Joanna Briggs Institute Critical Appraisal tool (JBI) is presented in (Table/Fig 5) (13).
The studies included in this systematic review did not have common materials to compare. Hence, it is difficult to give an appropriate conclusion. Studies with common parameter for comparison are required to come to proper conclusion. As these studies conducted were in-vitro, more in vivo studies are required on the use of these materials in re-attatchment of VRF.
By reviewing the above studies, it is demonstrated that dual cure composite resin with resin adhesive system, MMA based resin (SB C and B) showed significant results for bonding in cases of VRF. Dual cure adhesive resin cement either reinforced with polyethylene fibers or glass fibre, and GIC can be used to increase the fracture resistance of bonded tooth.
Date of Submission: Apr 29, 2021
Date of Peer Review: Jul 03, 2021
Date of Acceptance: Jan 03, 2022
Date of Publishing: May 01, 2022
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? NA
• Was informed consent obtained from the subjects involved in the study? NA
• For any images presented appropriate consent has been obtained from the subjects. NA
PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: May 03, 2021
• Manual Googling: Dec 02, 2021
• iThenticate Software: Jan 22, 2022 (20%)
ETYMOLOGY: Author Origin
- Emerging Sources Citation Index (Web of Science, thomsonreuters)
- Index Copernicus ICV 2017: 134.54
- Academic Search Complete Database
- Directory of Open Access Journals (DOAJ)
- Google Scholar
- HINARI Access to Research in Health Programme
- Indian Science Abstracts (ISA)
- Journal seek Database
- Popline (reproductive health literature)