Year : 2008 | Volume
: 19 | Issue : 3 | Page : 272--277
Fiber-reinforced technology in multidisciplinary chairside approaches
Neslihan Arhun1, Ayca Arman2,
1 Department of Conservative Dentistry, Baskent University, Faculty of Dentistry, Ankara, Turkey
2 Department of Orthodontics, Baskent University, Ankara, Turkey
Department of Conservative Dentistry, Baskent University, Faculty of Dentistry, Ankara
There is an increasing demand to improve dentofacial esthetics in the adult population. This demand usually requires a close collaboration within the various disciplines of dentistry and the patient at every stage of the therapy. The materials and techniques used by these interdisciplinary clinicians must be conservative and minimally invasive. Fiber-reinforced composite technology offers such solutions for chairside applications. This case report presents two cases where fiber-reinforced ribbon and composite complex was used in a multidisciplinary approach to improve esthetics.
|How to cite this article:|
Arhun N, Arman A. Fiber-reinforced technology in multidisciplinary chairside approaches.Indian J Dent Res 2008;19:272-277
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Arhun N, Arman A. Fiber-reinforced technology in multidisciplinary chairside approaches. Indian J Dent Res [serial online] 2008 [cited 2021 Dec 2 ];19:272-277
Available from: https://www.ijdr.in/text.asp?2008/19/3/272/42965
Increased patient demand for tissue maintenance, esthetics and reduced expense, together with the need to minimize the potential for intraoral diseases, causes clinicians to seek materials and techniques that can enable minimally invasive approaches for chair side applications. The use of adhesive techniques and composite materials reinforced with fiber systems allows clinicians to respond to these demands. 
The use of fiber-reinforced composite (FRC) resin provides a marked increase in flexural strength to the entire structure and allows the life of these FRC restorations to be extended. Different practical solutions are possible to create the composite and the fiber; the clinician may adapt the restorative technique to accommodate specific indications and obtain improved results with ease and reliability. 
Different fiber types have been added to composite materials to improve their physical and mechanical properties.  Glass fibers consisting of glass interlaced filaments, improve the impact strength of composite materials, but do not easily stick to a resinous matrix.  Carbon fibers prevent fatigue fracture and strengthen composite materials, but they have a dark color, which is esthetically undesirable.  Kevlar fibers made of an aromatic polyamide, are the evolution of nylon polyamide. They increase the impact strength of composite materials. However, they are also unaesthetic and hence, their use is limited.  Vectran fibers are synthetic fibers of a new generation, made of aromatic polyesters. They show a good resistance to abrasion and impact strength, but they are expensive and unwieldy.
Many investigators have confirmed the reinforcing effect of fibers on different polymer types. , The explanation for this increase was the transfer of stress from the weak polymer matrix to fibers that have a high tensile strength.  The stronger the adhesion between the fiber and the matrix, the greater the strengthening effect. 
Polyethylene fibers improve the impact strength, modulus elasticity, and flexural strength of composite materials. Unlike carbon and Kevlar fibers, polyethylene fibers are almost invisible in a resinous matrix and for these reasons, seem to be the most appropriate and esthetic strengtheners of composite materials.  However, Kolbeck et al ,  stated that the reinforcing effect of glass fibers was more effective than that of polyethylene fibers, and this was attributed to the difficulty of obtaining good adhesion between ultra-high modulus polyethylene fibers and the resin matrix.  Many surface treatments of polyethylene fibers have attempted to solve this problem, including plasma spraying, chemical, flame, and radiation treatments. 
According to literature, the mechanical strength provided by fiber reinforcement is generated by the material's ability to dissipate the tension lines and internal microfissures that would cause catastrophic fracture in a more rigid material.  It is widely accepted that directional orientation of the fiber long axis perpendicular to an applied force will result in strength reinforcement. Forces that are parallel to the long axis of the fiber, however, produce matrix-dominated failures and consequently yield little actual reinforcement.  Therefore, the fact that the fibers are not arranged longitudinally and are instead woven in alternating patterns would appear to increase the dispersion of the internal tension lines and thus, provide fracture resistance.  Use of neutral-colored fibers provides enhanced esthetics and enables natural light diffusion within the body of the resin.
A subtle and under-reported attribute of FRC is a description of the fracture failure. In addition to the mechanical properties of the adherent/adhesives, the nature of the bond failures may also shed light on possible variables in this process. A specimen may catastrophically fail in an instant while another may simply bend under increasing load. 
Ribbond (Ribbond Inc., Seattle, Wash) is a reinforced ribbon made of ultrahigh molecular weight polyethylene fiber that has an ultrahigh modulus. It is treated with cold gas plasma to enhance its adhesion to synthetic restorative materials, including chemically cured or light-cured composite resins. The special fiber network of this material allows efficient transfer of forces. It is virtually pliable and thus, adapts easily to tooth morphology and dental arch contours. Its translucency makes it an esthetic material and it can be cured with light-cured composites. Ribbond fibers can also be cut by using special nippers without fraying or losing their original dimensions. ,
Ribbond is a spectrum of 215 fibers with a very high molecular weight. These fibers have a very high coefficient of elasticity (117 GPa); this means there will be resistance to stretch and distortion. They also have a very high resistance to traction (3 GPa) as a result of their "closed stitch" configuration and good adaptability. Ribbond fibers are also characterized by impact strength five times higher than that of iron. They are translucent and assume the color of the resin to which they are added. Ribbond fibers easily absorb water because of the "gas plasma" treatment to which they are exposed. This treatment reduces the fibers' superficial tension, thus ensuring a good chemical bond to composite materials.
Ribbond, Ribbond THM and Ribbond triaxial consist of cold plasma-treated polyethylene fibers differing in their shape and thickness. Ribbond THM is made from a higher concentration of thinner (smaller diameter) fibers than Ribbond, whereas Ribbond triaxial is braided in three axes. The construct consists of preimpregnated, silanized, plasma-treated polyethylene fibers. 
This paper presents two cases demonstrating multidisciplinary chairside applications of fiber-reinforced ribbon and composites for minimally invasive restoration techniques.
The first case was a 41 year-old female patient. Her chief complaint was esthetic in nature as she presented a huge diastema between her central incisors. She exhibited a Class I dental relationship with increased overbite and overjet [Figure 1].
The treatment plan was to reduce the midline diastema, overjet and overbite using fixed edgewise appliances and to close the remaining space and correct the Bolton discrepancy using composite resin restorations. The upper anterior teeth and first premolars were bonded and the treatment was initiated with a 0.016" Ni-Ti archwire. The diastema was closed by using 0.016 x 0.016" closed elastic chains and 0.016 x 0.016 stainless steel archwires. Enamel stripping was performed to re-contour the incisors to achieve better contact surfaces. After 6.5 months of orthodontic treatment, the overjet and overbite was reduced and a residual space of 1.5 mm was present between the central incisors [Figure 2]. Gingivectomy, frenotomy and fiberectomy procedures were performed in order to increase the clinical crown length and to minimize the risk of relapse in sequence.
After esthetically closing the diastemas between teeth no. 12, 11, 21 and 22 with a self etching adhesive system and resin composite, it was decided to include a fixed lingual retainer in the retention protocol. The overbite space was not enough for a continuous retainer, thus, a partial fiber-reinforced ribbon/composite lingual retainer and composite restorations were accomplished to avoid relapse. The required length of ribbon between teeth no 11 and 21 was determined by using dental floss on the diagnostic cast [Figure 3]. The ribbon was wetted with unfilled resin (Filtek Flow, 3M, St. Paul, MN, USA). Care was taken to keep the wet ribbon away from light to prevent initial polymerization, which would interfere with the manipulation of the ribbon. Mid-palatinal surfaces of teeth no. 13 and 23 were cleaned with pumice and acid-etched with 37% phosphoric acid (Scotchbond Etchant, 3M ESPE, St. Paul, MN, USA). Bonding agent (Single Bond, 3M, St. Paul, MN, USA) was applied and light-polymerized with a halogen light of 500 mW/mm 2 for ten seconds (Hilux, Benlioglu, Turkey). A thin layer of universal hybrid composite resin (Filtek Z250, 3M, St. Paul, MN, USA) was placed on the palatinal surfaces of teeth no. 11 and 21 and extended slightly to the proximal surfaces of each tooth. The wetted ribbon was pressed into the composite resin and light-polymerized for 40 seconds from the lingual and proximal directions and covered by another layer of composite resin. The distal contact of teeth no. 11 and 13-12 and the distal contact of 21 and 22-23 were splinted by composite resin alone.
The final step was the adjustment of occlusion and esthetic contouring of the splint. Care was taken to avoid centric and eccentric occlusal contacts on the splint. The retainer was finished and polished (Sof-Lex, 3M, St. Paul, MN, USA). [Figure 4] and [Figure 5] present the frontal view and the splint at the one-year follow-up recall.
The second case was a female aged 41 years and five months having noncontributory medical history. The patient first visited the periodontology clinic of our facility because of the mobility of her maxillary anterior teeth. She was taught periodontal oral hygiene measures and placed on periodontal maintenance care with professional cleaning, scaling root planning, curettage and flap operation prior to orthodontic treatment.
She exhibited a dental Class I relationship with increased overbite/overjet and multidiastemas in the upper arch due to periodontal disease and crowding in the lower arch. Teeth no. 35, 45 and 23 were missing and teeth no. 75, 85 and 63 were still present in the dentition. Clinical and radiological examination revealed mobility, gingival recession, severe vertical and horizontal alveolar bone loss and black triangular spaces of the maxillary anterior teeth. The right central and left lateral incisors were extruded and protruding due to periodontal bone loss [Figure 6].
On discussing the treatment options, the patent decided to restore and preserve her teeth and agreed to undergo orthodontic treatment. The treatment plan was to close the spaces in the maxillary arch by retrusion of the incisors, intrude the periodontally involved maxillary anterior teeth, reshape the incisors to achieve ideal contact surfaces to eliminate black triangles, resolve the mandibular crowding by protrusion and enamel stripping of the lower incisors to achieve an acceptable occlusion and restore esthetics.
Teeth no. 12, 11, 21 and 22 received endodontic treatment at the initiation of the orthodontic treatment. Both the upper and lower arches were bonded and teeth were leveled by continuous arches starting with 0.014" Ni-Ti arch wires and working up to 0.016 x 0.022 stainless steal arch wires. As the patient presented severe periodontal problems, light orthodontic forces were preferred. The maxillary right central and left lateral incisors were intruded and overcorrected by step-up bends. An opening coil spring was used to create space mesial to the primary canine for resin restoration. Active orthodontic treatment was completed in eight months and an acceptable occlusion with normal interincisal relationship was achieved prior to the final restorative phase [Figure 7] and [Figure 8].
There were two options for the final restorative treatment plan. One alternative was constructing a bridge on the anterior teeth and the other option was to restore the black triangles and the diastema of the primary canine conservatively by using resin composite. Finally, it was decided that the readily available, periodontally compromised teeth were not ideal to carry out such a definitive restoration; thus, resin composite was the treatment choice of the orthodontist, periodontist and prosthodontist.
Tooth no. 63 was conservatively restored similar to a canine and the black triangles were closed by resin composite [Figure 9] and [Figure 10]. The retention protocol included a fixed retainer and it was decided to use fiber-reinforced ribbon and resin composite as in the first case. Both of the retainers were accomplished as previously described. [Figure 11],[Figure 12] present the frontal and occlusal views in the 14-month recall appointment.
Both of the patients were asked to score parameters such as the restorations' color, size, durability and their overall satisfaction on a scale of 1 to 5, with 1 being "very unsatisfied" and 5 being "very satisfied".  Both patients' answers were 5.
The desire to improve dental appearance is a key motivating factor in the adult population. These appereance-concious patients demand esthetic restorations that usually require a comprehensive interdisciplinary approach. Coordinated orthodontic, periodontal and restorative treatments with careful consideration of patients' expectations and requests, are critical for a successful outcome and patient satisfaction.  These restorations are important not only because of esthetic and functional concerns, but also there may be a positive psychological impact for the patient. 
A close collaboration between the disciplines is mandatory to evaluate, diagnose and resolve at the following stages: (1) before and in early orthodontic treatment where the patient is reasonably motivated for the initial periodontal therapy and orthodontic treatment, (2) the immediate postorthodontic period when the restorations are planned and accomplished and (3) in the long-term, when the requirements of orthodontic retention are done to avoid relapse.
Special attention must be given to the periodontal status of adults before orthodontic treatment because they are more likely to be susceptible to or have already suffered from periodontal disease.  Particularly in the maxillary anterior region, functional discomfort is usually accompanied by compromised esthetics. Orthodontic treatment for realignment of migrated, periodontally involved teeth is initiated only after control of the periodontal inflammation has been achieved.  Previous reports have demonstrated that, with adequate plaque control, teeth with reduced periodontal support can undergo successful tooth movement without compromising their periodontal situation. ,
Splinting teeth for periodontal, orthodontic or posttraumatic reasons is a common procedure. In the past, direct stabilization and splinting of teeth using an adhesive technique required the use of wires, pins or mesh grids. These materials could only mechanically lock around the resin restorative. Due to this, there was the potential of creating shear planes and stress concentrations that would lead to fracture of the composite and hence, premature failure. When the splint failed, the clinical problems that occurred included traumatic occlusion, progression of periodontal disease, and recurrent caries.  With the introduction of bondable, polyethylene woven ribbons, many of the problems with older types of reinforcement were solved  and splinting teeth with reinforcement fibers that can be embedded in composites, has gained popularity. Procedures can often be completed in a single appointment. It also has acceptable strength because of good integration of fibers with the composite resin; this leads to clinical longevity. Due to the use of a thinner composite resin, the volume of the retention appliance can be minimized. In addition, the appliance can easily be repaired in case of fracture due to wear-and-tear. There is no need for removal of any significant tooth structure, making the technique reversible and conservative. Moreover, it meets patients' esthetic expectations. 
Strassler et al .  reported the use of polyethylene fiber for postorthodontic stabilization and retention, tooth replacement, and periodontal splinting. They splinted 64 teeth in 30 patients using Ribbond. Clinical results were based on 12-48 months of evaluation. All periodontal splints and fixed orthodontic retention with Ribbond were successful and none exhibited debonding or recurrent caries. In two patients in whom maxillary retention was applied, ribbon fibers were exposed because of the occlusal function; hence these regions were covered with flowable composite. Only one out of nine natural tooth or composite resin pontics was fractured during the study and although the fracture of the composite resin was apparent, the pontic did not separate from the abutment tooth because the ribbon held it in its place. The crack was repaired by using an adhesive enamel/composite resin technique. In all cases, the color of the teeth or the composite resin was not affected by the Ribbond. However, Bearn stated that reinforcement fibers have the disadvantage of a rigid splint, which limits physiological movement and contributes to a higher clinical failure rate. 
The strength of FRCs is often reported with values at the ultimate flexural strength of the final fracture, which is somewhat questionable for clinical use. , A more important parameter could be the initial failure point showing the onset of failure, as sometimes only a crack in the splint may be evident but the splint is still effective.
In the follow-up period, the patient should be recalled frequently to check the splint, periodontal status and oral hygiene of the patient. Exposure of the fiber to the oral environment could increase the degradation of the fiber-reinforced structure and result in a surface difficult to polish. When the fiber is exposed, Ribbond's manufacturer recommends the removal of the exposed portion and repairing it with composite.
The overhang of composite resin material provides support to the interdental papilla. However, it may also lead to plaque retention, food impaction and periodontal pathology. Strict adherence to oral hygiene instructions is critical to maintain the health and the appearance of treatment results. Both of the patients were clearly informed about the importance of oral hygiene by giving more attention to plaque control and traditional homecare procedures using proximal brushes and dental floss and there were no gingival reactions caused by the fiber retainers.
The chairside approach using the combined technique of polyethylene fibers and resin composite retainers described in this clinical report, offered a fast, minimally invasive approach that combined the benefits of fiber-reinforced technology for a functional and durable result.
We thank Sule Bulut, DDS, PhD and Emine Alaaddinoglu DDS, PhD of the Department of Periodontology; Mete Ungor DDS, PhD of the Department of Endodontics, Faculty of Dentistry, Baskent University for their contributions to the patients' treatment illustrated in this paper.
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