Fiber Placement in Restorative Dentistry

Fiber placement in restorative dentistry: Does it stop cracks, improve bonds or just add time to your restorative process? Dr. David Alleman, DDS, dives into the history of dental fibers, including Ribbond, Everstick Net and Ever-x Posterior, their uses in different clinical settings, and the research that shows how they support the restoration long-term. 

Articles referenced in this episode:

• Belli S., Et al. The effect of fiber placement or flowable resin lining on microleakage in class II adhesive restorations. J. Adhes. Dent. 2007; 9: 175-181
• Fennis  WMM,  Kuijs  RH,  Kreulen  CM,  Verdonschot  N,  Creugers  NHJ. Fatigue Resistance of Teeth Restored with Cuspal-Coverage Composite Restorations. Int J Prosthodont 2004 17(3)-313-317

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Transcript

0:27

Welcome to season four, episode five of the Six Lessons podcast. our topic is fiber, fiber, and restorative dentistry. When did this start? Well, it actually started with a periodontal application of a fiber called Ribbond that's woven. that polyethylene fiber was useful to stabilize anterior teeth that were periodontal compromised and they were loose. so that looseness was, mitigated or stabilized with this bonded fiber. And that's what it was invented for. Dave Rudo and his company made that, promoted then he gave it to a friend of his named Ray Bertolotti And Ray Bertolotti gave it to a friend of his named Sema Belli and Sema Belli was working with a graduate student in a PhD in Turkey and in Japan. And she said, what would happen if we put this fiber inside a restoration? She was thinking outside of the box, but it was going to help us in the box, which is restorative dentistry. And the high C factor stresses that are there. This all happened around the year 2000 2001. Sema Belli and Inokoshi published an important paper on resin coating. And then five years later, she was able to publish a paper on restorative dentistry with Ribbond inside as a liner. And what the liner did with Ribbond is that it changed the stress on the hybrid layer. this paper was published in 2006. She published a follow up paper in 2007 comparing Ribbond, which is the polyethylene fiber with ever stick net, which is a glass fiber. And she had some similar results of stress reduction to the hybrid layer, meaning maximization of the hybrid layer underneath the fiber that was placed the fiber was under underneath the restorative composite. What happened? Well, what happened is that the seal in these preparation that had the fiber was superior to the seal of a composite in a class two restoration or a class one restoration, because the fiber allowed a movement of the composite shrinkage in two directions. you put composite against here’s your cavity wall, you put composite, then you would like it to shrink towards the cavity wall. But the bulk of the composite means that it will shrink towards the enamel and lift off of the bottom of your box. So the composite moves like this, because the enamel attracts the polymerization of the composite more quickly. So that is a problem because you get leakage at the bottom of your box. when you put fiber on this wall, what happens? This area down here stays sealed. And that's because the movement of the composite is not putting stress here. it's actually able to move towards the surface of the tooth underneath the fiber. Now the Ribbond did it a little bit better than the Everstick net. But the principle was the same. The Ribbond was able to separate a little bit, the Everstick net was able to separate a little bit, but there was bond to the wall of the tooth and there was bond to the composite. But there's less bond as the fibers separated. And there were follow up articles by Ozel in 2007, El-Mowafy in 2007, and then the final one was Erkut in 2008, which was scanning electron microscopy actually showed that mechanism. And so people talk about fiber reinforced composite. I don't like that, although it does carry some valid scientific ideas. After Ribbond was used for periodontal splinting, there was a time when a group in Holland used the fiber to see if it could stop any fracture into the tooth. That's a very important thing fracture resistance. And so that group out of Holland at Nijmegen University with Kuijs and his associates, Fennis, Willem Finis, they were able to show that you can stop cracks with the fiber. so actually, in the six lessons approach, we used that concept that was published in 2005 to teach a fracture resistance or a fail safe. If you had a fracture of your orderly, you would like it to stop before it gets to two structures. So that's called a secure bond or a fail safe mechanism in the restoration. So we actually taught that in 2004, 2005, before the paper on the stress distribution or the stress relief was published by Sema Belli in 2006. So fibers can do two things. They can stop cracks, they can stress relief by allowing the shrinkage of composite to move in multiple directions instead of towards the center of the bulk of composite, which will always cause appealing at the edges of a restoration. You know, there's several concepts there, but basically the world's expert in understanding these. I'm one of them. But Mark Frater, a good associative of mine, we published several papers together at university. Mark Frater is the world's experts on both the ever X materials and Ribbond materials. And we've published a paper comparing using one only or both together. we've come to the conclusion that ever X is a little bit better on fracture resistance, but it's not as good on stress relief. And Ribbond is good on both. If I only had one fiber, I definitely would use Ribbond. But the fibers, if the of the glass fibers that are silanated they have a little bit more bond ability to the composites where Ribbond doesn't bond a composite because it has no methacrylate bonds that can be polymerized in a free radical polymerization reaction. But the fiber as a stress reliever is the most important concept in composite rather than a reinforcement. So I don't like to use the term fiber reinforced composites. So continuing our discussion of fibers. Simone Deliperi and I published a very important paper in 2017, it was titled The Wallpapering Technique that came from Wendell Robertson, one of our very creative partners in the biomimetic teaching at the Six Lessons. But the idea of a wallpaper is that if you place the fiber on a cavity wall, an axial wall, or a pulpal floor, if it was pulpal floor I guess it'd be carpeting rather than wallpapering. But if you place that fiber in these areas next to the pulp, the pulps here, your axial walls here, your pulp floors here. Those are the areas you want to protect from leakage and from infection. And so that wallpapering technique on vital teeth is for pulp health, a wallpapering technique on a non vital tooth. Obviously the pulp is gone but we want conserve the coronal tooth structure for as long as possible. The weak link in an endodontically treated tooth is the root that cannot be strengthened or even biomimetic restored because the root of it be treated. Tooth now changes from a more tough material to a more brittle material without the hydration of the pulp, but the coronal portion of the tooth can be reconstructed in a way that has not failed. If we've ever had a failure in an endodontically treated tooth where we're using ribbond as part of the reconstruction, it's always been in the root. The root has fractured. Doesn't happen that often, but it can happen. So our first goal in a biomimetic approach is to prevent endo. But what had the endo, is it worth the effort to save the and not have it extracted? Thinking that an implant might be the best option? Over the last 25 years, we've been able to conclude that implants are not the best next option because implants have a failure rate that can be up to 1,517%, depending on who you talk to. And implants are quite expensive. So if you have even a 10% failure, you would feel like the patient's at risk of having to do some more expensive dentistry. If this is one of the 10% of the implants are going to fail in the next ten years. And so now that we've been doing reconstructions biomimetic with the six lessons for over 25 years and with fiber since 2006. So that's 20 years. for 20 years we've been able to say, what's our failure rate? And it's nowhere near 10% in ten years. And so I've had two failures. Davey’s had one failure, Simone’s had one failure, Davey’s had two. Simone’s had one that I know of. So that's five in three full time dental practices in a biomimetic approach. And so a patient if they're given the option in our office. And I try to be, you know, I say, you know implants are good if you've lost a if you have a tooth that's going to be extracted because a doctor can't figure out how to fix Well, we've figured out how to fix it, and we've taught hundreds of dentists to fix them around the world. And the feedback we get is that this is preferred over implants. Our best example of is Doctor Andras Forster in Budapest, Hungary. He worked for five years in the most exclusive implant clinic in the world, the Urban Clinic, and Doctor urban is an internationally expert in implants, he also restores teeth in his office. And Doctor Forster was the dentist in charge of the treatment plans to this tooth is restored or this tooth is not restored after he learned the six lessons. This is six years ago. Every year they did more and more restorative on teeth and less and less extraction of teeth. Now that's important clinical data that you won't learn anywhere else. But we have that because we have masters are associated with experts in implants, we have masters who, because they can use fiber in this wallpapering technique that Simone and I have written about on an endodontically treated molar that is now over 15 years successful, we can show that the fiber reconstruction. I almost said fiber reinforcement, but I'm trying to get away from term that has been used kind of loosely, but the fiber placement in this restored molar that Simone and I had two purposes. The first purpose was make sure that the hybrid layer next to the dentin is as strong as possible. then on the enamel we have the idea of placing the ribbond close the enamel, but we keep it still out of the peripheral seal and all of a sudden we have the best of both worlds. We have a tooth that if you had fracture in the coronal portion, you would have a crack in the enamel. Well, this is very biomimetic. It's like a A tooth can have a crack in enamel and not allow bacteria to go into the pulp. The cracks. Thoughts that the DEJ ribbond does the same thing. Ever X posterior does the same thing. in this wallpapering technique, now the ribbond becomes the DEJ mimicking aspect of the restoration. The DEJ has two materials, Enamel and dentin, coming together strongly. Now we have Ribbond allowing enamel replacing materials and dentin replacing materials to come together very strongly. if we have a wallpapering of all the walls of an treated molar, for example, it's kind of like a basket. So we call this a Ribbond basket. wallpapering and Ribbond basket, we use those phrases interchangeably in the six lessons approach. But these baskets of Ribbond that are next to the walls now can be filled with layers of ever x posterior ever x flow. Because the fracture resistance inside is good, it's just not so good because it shrinks too much. if it shrinks inside a Ribbond basket, the Ribbond takes care of that shrinkage stress by deforming a little so that idea of having Ribbond on the outside of core build your core build up done with ever x posterior. We've never had a reported failure in those coronal portions of a tooth that's reconstructed with the fibers, both with Ribbond and ever X posterior. So fracture resistance on over X materials a little better. The stress relief, which is the most critical part a biomimetic restoration is superior with Ribbond. So to summarize a vital tooth is our goal. the vital tooth is always restored. The best with Ribbond. If the tooth has died the pulp has died. The reconstruction with the Ribbond is still the best. If you don't have an option to have a combination of Ribbond and the ever X material, ever X material inside a Ribbond is something that we use on a regular In a vital you may have a very deep cavity that you might want to use technique, a very wide cavity where you wallpaper the walls and then fill that with Ribbond. But again, this is where your sophistication and your training in biomimetic dentistry will very valuable, because you'll have a framework to understand what are you trying to accomplish? And we usually say the six lessons approach is a bottom to top approach. We have a hierarchy of bond ability, the hierarchy means the bottom of the restoration is the most important. Caries removal. Crack removal, mimicking the DEJ with the immediate sealing resin coating mimicking the dentin with deep margin elevation then enamel replacement only design and then occlusion. so we teach the most important aspects first caries removal, crack removal, gap diagnosis, immediate dentin sealing, hybrid layer formation. And then your dentin replacement has to be stress reduced so that you don't compromise your hybrid layer. And so if you have a bottom to top approach, that's the best way to think about restoring a Till next time stay bonded. And we'll probably have another lecture about more of that. Reconstructing ended up being treated teeth in our next episode. Perfect, perfect. All right. Make sure I have enough. Why don't you just just talk a little bit? Summary about how Ribbond teeth. Not nonviolent teeth. Any time you're looking at you have to understand stress, stress reduction, things like that. Yeah. Okay. So let's summarize.