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The risk of bonded fragment loss in crown-fractured anterior teeth managed by fragment reattachment: a systematic review and meta-analysis



To identify the factors affecting the risk of bonded fragment loss in crown-fractured anterior teeth managed by fragment reattachment.


The study protocol followed the best practices of evidence-based medicine and was registered in PROSPERO. A comprehensive literature search was performed electronically in six databases (PubMed, Embase, SCOPUS, Web-of-Science, Lilacs, and Cochrane) on 18-09-2023. It was saved in EndNote-online and duplicates were removed. Selection of articles was performed in two stages, followed by data-extraction, risk of bias assessment, data-analysis, and meta-analysis. The quality of evidence for the outcomes was assessed by the GRADE-approach.


The study included six articles that had similar selection protocols with variations in duration from trauma to treatment and the observation period. Only one study employed pre-attachment fragment preparation and three performed post-attachment reinforcements. Overall loss of fragment was 20% (95%CI–13,30%). When the risk ratio for loss of restoration or fragment was compared, it was found to be 2.21 (95%CI–1.52,3.21) in uncomplicated crown fractures, 2.54 (95%CI–1.35,4.79) in complicated crown fractures. The risk of bias was found to be low in two and moderate in four studies. Grade of evidence for all the outcomes was very low.


Fragment loss was lowest in uncomplicated crown fractures where reinforcement had been performed, and highest when bonding was done in complicated crown fractures without reinforcement. The risk of fragment loss was higher than the loss of composite restorations.

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  1. Lam R. Epidemiology and outcomes of traumatic dental injuries: a review of the literature. Aust Dent J. 2016;61:4–20.

    Article  PubMed  Google Scholar 

  2. Bastone EB, Freer TJ, McNamara JR. Epidemiology of dental trauma: a review of the literature. Aust Dent J. 2000;45:2–9.

    Article  CAS  PubMed  Google Scholar 

  3. Goyal N, Singh S, Mathur A, Makkar DK, Aggarwal VP, Sharma A, et al. Traumatic dental injuries prevalence and their impact on self-esteem among adolescents in india: a comparative study. J Clin Diagn Res. 2017;11:ZC106–10.

    PubMed  PubMed Central  Google Scholar 

  4. Garcia FCP, Poubel DLN, Almeida JCF, Toledo IP, Poi WR, Guerra ENS, et al. Tooth fragment reattachment techniques-A systematic review. Dent Traumatol. 2018;34:135–43.

    Article  PubMed  Google Scholar 

  5. Bourguignon C, Cohenca N, Lauridsen E, Flores MT, O’Connell AC, Day PF, et al. International association of dental traumatology guidelines for the management of traumatic dental injuries: 1. fractures and luxations. Dent Traumatol. 2020;36:314–30.

    Article  PubMed  Google Scholar 

  6. Andreasen FM, Norén JG, Andreasen JO. Long-term survival of fragment bonding in the treatment of fractured crowns: a multicenter clinical study. Pediat Dentist Quintessence Intern. 1995;26:669–81.

    CAS  Google Scholar 

  7. Brambilla GP, Cavallè E. Fractured incisors: a judicious restorative approach–part 1. Int Dent J. 2007;57:13–8.

    Article  CAS  PubMed  Google Scholar 

  8. Bona AD, Boscato N. Clinical evaluation of allografts and homografts for restoration of missing tooth structure. J Prosthet Dent. 2000;84:163–8.

    Article  CAS  PubMed  Google Scholar 

  9. Cumpston M, Li T, Page MJ, Chandler J, Welch VA, Higgins JP, et al. Updated guidance for trusted systematic reviews: a new edition of the Cochrane Handbook for Systematic Reviews of Interventions. Cochrane Database Syst Rev. 2019;10:ED000142.

    PubMed  Google Scholar 

  10. Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ. 2021;372:n71.

    Article  PubMed  PubMed Central  Google Scholar 

  11. Moola S, Munn Z, Tufanaru C, Aromataris E, Sears K, Sfetcu R, et al. Chapter 7: Systematic reviews of etiology and risk. In: Aromataris E, Munn Z (Editors). JBI Manual for Evidence Synthesis. JBI, 2020. Available from

  12. Guyatt GH, Oxman AD, Schünemann HJ, Tugwell P, Knottnerus A. GRADE guidelines: a new series of articles in the Journal of clinical epidemiology. J Clin Epidemiol. 2011;64:380–2.

    Article  PubMed  Google Scholar 

  13. Yilmaz Y, Zehir C, Eyuboglu O, Belduz N. Evaluation of success in the reattachment of coronal fractures. Dent Traumatol. 2008;24:151–8.

    Article  PubMed  Google Scholar 

  14. Yilmaz Y, Guler C, Sahin H, Eyuboglu O. Evaluation of tooth-fragment reattachment: a clinical and laboratory study. Dent Traumatol. 2010;26:308–14.

    Article  PubMed  Google Scholar 

  15. Sarapultseva M, Sarapultsev A. Long-term results of crown fragment reattachment techniques for fractured anterior teeth: A retrospective case-control study. J Esthet Restor Dent. 2019;31:290–4.

    Article  PubMed  Google Scholar 

  16. Bissinger R, Müller DD, Hickel R, Kühnisch J. Survival analysis of adhesive reattachments in permanent teeth with crown fractures after dental trauma. Dent Traumatol. 2020;37:208–14.

    Article  PubMed  Google Scholar 

  17. Bissinger R, Müller DD, Reymus M, Khazaei Y, Hickel R, Bücher K, et al. Treatment outcomes after uncomplicated and complicated crown fractures in permanent teeth. Clin Oral Investig. 2021;25:133–43.

    Article  PubMed  Google Scholar 

  18. Haupt F, Meyerdiercks C, Kanzow P, Wiegand A. Survival analysis of fragment reattachments and direct composite restorations in permanent teeth after dental traumatic injuries. Dent Traumatol. 2023;39:49–56.

    Article  PubMed  Google Scholar 

  19. de Sousa APBR, França K, de Lucas Rezende LVM, do Nascimento Poubel DL, Almeida JCF, de Toledo IP, et al. In vitro tooth reattachment techniques: A systematic review. Dent Traumatol. 2018;34:297–310.

    Article  PubMed  Google Scholar 

  20. Diangelis AJ, Andreasen JO, Ebeleseder KA, Kenny DJ, Trope M, Sigurdsson A, et al. International Association of Dental Traumatology. International Association of Dental Traumatology guidelines for the management of traumatic dental injuries: 1. Fractures and luxations of permanent teeth. Dent Traumatol. 2012;28:2–12.

    Article  PubMed  Google Scholar 

  21. Flores MT, Andersson L, Andreasen JO, Bakland LK, Malmgren B, Barnett F, et al. International Association of Dental Traumatology. Guidelines for the management of traumatic dental injuries. I. Fractures and luxations of permanent teeth. Dent Traumatol. 2007;23:66–71.

    Article  PubMed  Google Scholar 

  22. Flores MT, Andreasen JO, Bakland LK. Guidelines for the evaluation and management of traumatic dental injuries. Dental Traumatology. 2001;17:97–102.

    Article  CAS  PubMed  Google Scholar 

  23. Chazine M, Sedda M, Ounsi HF, Paragliola R, Ferrari M, Grandini S. Evaluation of the fracture resistance of reattached incisal fragments using different materials and techniques. Dent Traumatol. 2011;27:15–8.

    Article  PubMed  Google Scholar 

  24. Demarco FF, Fay R-M, Pinzon LM, Powers JM. Fracture resistance of re-attached coronal fragments–influence of different adhesive materials and bevel preparation. Dent Traumatol. 2004;20:157–63.

    Article  PubMed  Google Scholar 

  25. Karre D, Muppa R, Duddu MK, Nallachakrava S. Fracture resistance of reattached fragments using three different techniques with emphasis on vertical grooves and fiber-reinforced composite post: A novel technique. J Conserv Dent. 2017;20:474–8.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  26. Reis A, Francci C, Loguercio AD, Carrilho MR, Rodriques Filho LE. Re-attachment of anterior fractured teeth: fracture strength using different techniques. Oper Dent. 2001;26:287–94.

    CAS  PubMed  Google Scholar 

  27. Chan KHS, Mai Y, Kim H, Tong KCT, Ng D, Hsiao JCM. Review: resin composite filling. Materials (Basel). 2010;3:1228–43.

    Article  CAS  PubMed Central  Google Scholar 

  28. Kwon JH, Park HC, Zhu T, Yang H-C. Inhibition of odontogenic differentiation of human dental pulp cells by dental resin monomers. Biomaterials Research. 2015;19:2–7.

    Article  Google Scholar 

  29. Madhubala A, Tewari N, Mathur VP, Bansal K. Comparative evaluation of fracture resistance using two rehydration protocols for fragment reattachment in uncomplicated crown fractures. Dent Traumatol. 2019;35:199–203.

    Article  PubMed  Google Scholar 

  30. Rajput A, Ataide I, Lambor R, Monteiro J, Tar M, Wadhawan N. In vitro study comparing fracture strength recovery of teeth restored with three esthetic bonding materials using different techniques. Eur J Esthet Dent. 2010;5:398–411.

    PubMed  Google Scholar 

  31. Lauridsen E, Hermann NV, Gerds TA, Kreiborg S, Andreasen JO. Pattern of traumatic dental injuries in the permanent dentition among children, adolescents, and adults. Dent Traumatol. 2012;28:358–63.

    Article  PubMed  Google Scholar 

  32. Lauridsen E, Hermann NV, Gerds TA, Ahrensburg SS, Kreiborg S, Andreasen JO. Combination injuries 3. The risk of pulp necrosis in permanent teeth with extrusion or lateral luxation and concomitant crown fractures without pulp exposure. Dent Traumatol. 2012;28:379–85.

    Article  PubMed  Google Scholar 

  33. Robertson A, Andreasen FM, Andreasen JO, Norén JG. Long-term prognosis of crown-fractured permanent incisors. The effect of stage of root development and associated luxation injury. Int J Paediatr Dent. 2000;10:191–9.

    Article  CAS  PubMed  Google Scholar 

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Authors and Affiliations



The idea was conceptualized by NT and ZC. The team comprising all the co-authors designed the protocol and the methods of the study. The extraction of data was conducted by NT and MA. The steps of analysis were conducted by NT, MR, MA, AA, ZC, and PH. The initial draft of the manuscript was prepared by NT, ZC. It was revised by all the authors.

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Correspondence to Nitesh Tewari.

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Tewari, N., Cehreli, Z., Haldar, P. et al. The risk of bonded fragment loss in crown-fractured anterior teeth managed by fragment reattachment: a systematic review and meta-analysis. Evid Based Dent (2024).

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