These tutorials give a general overview of Ribbond applications.
They are not to be used in place of the instructions that are included with the Ribbond kit.
Ribbond post-orthodontic fixed retainers are an excellent alternative to directly bonded wire. Esthetic, comfortable and fracture tough, Ribbond retainers are easy to make and will bond with any light cured composites. Ribbond retainers prevent rotation of the teeth because they are bonded at the interproximal contacts. Especially popular for adult patients Ribbond retainers have high patient acceptance.
Since 1992 Ribbond has been the #1 choice for fiber reinforcement by independent evaluators. Ribbond's ease of use, durability and esthetics make it an excellent option for post-orthodontic retention. .
Ribbond retainers are made directly and will bond to any light cured composites. For permanent retainers, some patients prefer it recessed within a shallow preparation.
Ribbond is offered in numerous sizes.
Use Orthodontic-THM for healthy teeth with 0.5 mobility or less.Use 2 mm or 3 mm Ribbond-THM for periodontal cases with more than 0.5 mobility.
Prepare the teeth for bonding using your standard bonding procedure. Apply a thin layer of a paste composite at the level of the interproximal contacts.
Wet the Ribbond with unfilled bonding resin (sealant). Adapt the Ribbond into the composite. Like a bonded bracket, the fixed Ribbond retainer must be closely laminated against the tooth.
Hold the adapted Ribbond against the tooth with your finger. Use an instrument to place the Ribbond into the interproximal contacts closely against the adjacent teeth. Continue one tooth at a time until the entire Ribbond retainer is placed.
The placement of a Ribbond retainer is different than a wire. The Ribbond is closely adapted against the teeth and deep into the interproximal contacts.
After placement, remove extra composite and cure.
Using applicator brushes, instruments or needle tipped syringes apply a thin coat of flowable composite over the Ribbond. Cure.
Esthetic and comfortable, the Ribbond retainer is complete.
Cut a shallow preparation in the teeth with a #4 round diamond, at the level of the interproximal contacts, and prepare teeth for bonding.
Place a thin layer of paste composite in the preparation. Wet the Ribbond with bonding resin and press the Ribbond through the composite and against the base of the preparation.Cure.
An additional layer of composite is applied so that the retainer is flush with the surrounding tooth structure.The finished retainer "disappears" within the composite and has no bulk
Unlike a metal wire Ribbond offers superior esthetics and is not visible.
Push Ribbond through
composite, against the teeth, and polymerize.
If using acrylic, wet polymerized Ribbond with
monomer.
Keep Ribbond towards gingival region in pontic.
Ribbond visible on occlusal 
Composite provisional bridge Finished
Ribbond
single-visit bridges provide strength, durability, and
immediate convenience. Ribbond bridges are cost effective
and reliable. Excellent for emergencies, implant
temporization, congenitally missing laterals and patients
who cannot afford conventional lab fabricated bridgework.
Use natural
tooth, denture tooth, or composite build-up for the pontic.
If clearance permits, a bridge can be made without preparation of the abutments. If there is not adequate space, shallow preparations might be necessary. The following shows the construction of a long-term bridge framework. For provisional bridges one layer of Ribbond can be used.
Cut off the root of the extracted tooth and fill pulp chamber
with composite.Build Ribbond framework.
Prepare an undercut lingual groove on the extracted tooth.
Bond natural tooth pontic to Ribbond framework with composite.
Choose and shape denture tooth to fit in the edentulous area.
Build Ribbond framework.
Prepare an undercut lingual groove in denture tooth to fit the Ribbond framework.
Use a small round burr to drill small holes in the pontic for extra mechanical retention. Sandblast groove for better mechanical retention.
Bond denture tooth to pontic with composite.
Build Ribbond framework.
Build composite pontic onto Ribbond framework using standard composite technique.
This case shows an elderly woman who lost a mandibular central incisor due to severe periodontal mobility. A Ribbond splint was made incorporating a framework to support a pontic for the edentulous space. The root of the extracted tooth was cut off and the crown was bonded to the framework. At last check this case was still in service after seven years.
Advantages of using Ribbond to constrain the flexing of cusps of
teeth demonstrating split tooth syndrome
A vital, functioning, comfortable tooth with no apical pathology.
Based on work by Jon C. Karna, DDS, "Conservative Treatment of Cracked Tooth Syndrome", Dental Products Report, September 2000.
The restoration of the endodontically treated tooth is a significant challenge to the restorative dentist. In the past cast metal post and cores and prefabricated metal posts were placed with cements that only created a frictional fit between post and tooth. These posts offered no structural reinforcement to the teeth they were helping restore. Also these materials would sometimes gray out the tooth and shine through all ceramic restorations. With today's materials, an esthetic bonded post and core can be placed that reinforces the endodontically treated tooth.
To keep the structure of the tooth as strong as possible, an engineering approach to rebuilding endodontically treated teeth should be taken. These principles were described by Dr. Jack Nicholls.
Nicholls JI. An engineering approach to the rebuilding of endodontically treated teeth, J Clin Dent, 1:41-44, 1995
With this in mind, a number of pioneers in adhesive dentistry when restoring the endodontically treated tooth including Hornbrook, Karna, Bartel, and Antonson, started using fiber reinforcement ribbon, Ribbond®, to structurally reinforce teeth.
Formed in a conformable state
Retentive and antirotational (increase in each increases the retention)
This patient had an unesthetic porcelain-metal crown with a large metal post that demonstrates graying out at the cervical margin. Although the crown color is acceptable to the patient, the gingival darkness was unacceptable and exaggerated by the patient’s high smile lip line. She wanted to replace the crown with a better looking front tooth.
Clinical case: Dr. David Hornbrook
The crown was removed. The entire tooth was discolored. Any residual eugenol from the root canal sealer was removed by cleaning the canal with a 75% alcohol. Non-vital bleaching of the central incisor was done. Before doing the non-vital bleach the root canal was sealed with a glass ionomer cement to eliminate leakage of the bleaching material into the root canal. After bleaching, the tooth was now ready to be esthetically restored.
The decision to use a the color neutral, esthetic Ribbond post and core technique was based upon the amount of coronal tooth remaining, access and flare of canal, occlusion and final restoration being an all-ceramic crown.
The post length was created to be equal to the final height of the coronal preparation.
Technique for placement of Ribbond Reinforcement Ribbon into the canal. Select either 2 mm width or 3 mm for wide canals, use at least two fiber ribbons adapted into canal, wet the Ribbond with adhesive resin and the root canal is treated with an adhesive procedure.
The polyethylene fibers of Ribbond are plasma treated to allow the dental resin to bond to its surface.
Ribbond reinforcement ribbon being wetted with unfilled adhesive resin
The central incisor was prepared for an all-ceramic crown, impressed and sent to the laboratory. The Ribbond extending from the incisal edge can be covered with a flowable composite resin before making the impression.
Note: A Ribbond post and core is designed to be retentive. A ferrule or should preparation extending at least 1.5 mm on to the tooth is required to support the crown.
Clinical case: Dr. David Hornbrook
For this patient, his maxillary incisor had a traumatic fracture and was endodontically treated. Note large radicular space due to immature tooth, open apex.
Clinical
case: Bill Bartel, DDS
The tooth was endodontically treated with apexification using calcium hydroxide and then filled with gutta percha. Note the large canal space and thinned interior structure of the tooth.
The tooth was restored as previously described- the root canal was etched, an adhesive placed and a hybrid dual cure composite placed in canal. For this case two pieces of Ribbond 3 mm were placed into resin using a Ribbond Endodontic instrument.
2 pieces
of Ribbond 3 mm
placed into the canal
Because the patient was a young teenager the final restoration was a Class IV composite resin. The Ribbond shows up on the x-ray as being embedded into the composite resin.
Clinical case: Dr. David Hornbrook.
For this patient, his maxillary incisor had a traumatic fracture and was endodontically treated. Note large radicular space due to immature tooth, open apex.
The tooth was endodontically treated with apexification using calcium hydroxide and then filled with gutta percha. Note the large canal space and thinned interior structure of the tooth.
The tooth was restored as previously described- The root canal was etched, an adhesive placed and a hybrid dual cure composite placed in canal. For this case two pieces of Ribbond 3 mm were placed into resin using a Ribbond Endodontic instrument.
Because the patient was a young teenager the final restoration was a Class IV composite resin. The Ribbond shows up on the x-ray as being embedded into the composite resin.
Postoperative view- 3.5 years
Combination of microfill and
hybrid composite resin
Class IV restoration
The remainder of this series illustrates the durability of the Ribbond reinforced composite restoration and its mode of cracking.
The composite cracked in a process similar to the cracking of safety glass. Note that the brittle composite cracked, but was prevented from separating by the Ribbond that was reinforcing the distal-incisal angle. The blow resulted in no damage to the root.
Note core is intact
Case and Photos courtesy of William Bartel, D.D.S.
Measure the teeth and cut the Ribbond. Make a pattern by closely adapting a piece of tinfoil or dental floss to the teeth. Tuck the pattern into the interproximal contacts in the same manner as the Ribbond will be adapted
Use cotton pliers to remove the Ribbond from the package and cut to the measured length. Place the cut piece on a clean surface until ready to use.
Prepare lingual surfaces and labial interproximals for bonding. Clean the teeth with a sandblaster or prophy jet or use a diamond burr to roughen the enamel prior to cleaning. Finishing strips should be used to clean the interproximals. Prepare the teeth for bonding in your standard manner (pumice, acid-etch, and apply a thin layer of bonding adhesive).
Optional block-out and stabilization technique: After acid etching, apply a vinyl polysiloxane block-out gingival to the area to be splinted. This stabilizes the teeth during splint construction and makes clean up easier. Photos in these instructions show this block-out technique.
Note: Overhead operatory lights can cause premature setting of light-cured composites. Since the following steps involve light-cured composites, consider turning off the operatory light.
Apply composite in labial interproximals. To reduce the possibility of the teeth rotating and debonding, apply a small amount of tooth shade filled composite to the labial interproximals. Do not force the composite through to the lingual surface. Cure.
Wet the Ribbond with resin. Wet the Ribbond with unfilled bonding adhesive, composite sealant or pit and fissure sealant
and blot off the excess with a lint free gauze or patient bib. The wetted Ribbond may now be touched with powder free gloves or clean fingers. Do not cure yet.
Note: We prefer not to use one-step or fifth-generation resins to wet the Ribbond because these materials contain acids or acetone that must be evaporated. If using these materials, blot off the excess resin with lint-free gauze and then holding the Ribbond with cotton pliers, evaporate the solvent with the air syringe.
Apply filled composite to the teeth. Apply a thin layer of paste-like, medium viscosity, translucent composite resin at the level of the contact area. A Centrix syringe makes application easier. Do not cure yet.
Adapt the Ribbond. Holding the wetted Ribbond with cotton pliers, position one end of the Ribbond against the composite on the tooth. Press the Ribbond through the composite with your finger or an instrument
Adapt the Ribbond in the interproximal contact. To avoid pulling out the Ribbond that has already been adapted, hold the adapted part in position with a finger or an instrument. Place the Ribbond deep into the adjacent interproximal contact with an instrument. Continue until the entire length is adapted. Do not cure yet.
Cover the Ribbond splint with a flowable composite. Using a syringe or an applicator brush, cover the splint with a flowable composite. Make the covering layer as smooth as possible prior to curing.
If a flowable composite is not available, apply a thin layer of filled composite resin over the splint and smooth it with a washed, gloved finger that has been wetted with unfilled bonding adhesive.
Note: If a channel preparation is used, cover the Ribbond with a filled composite resin. Light-cure the covering layer of composite.
Check occlusion, finish and polish. Remove excess composite and polish with a composite-resin polishing paste.
Ribbond does not polish well.
Do not cut into Ribbond fibers.
The finished splint is thin, comfortable and esthetic
Howard
Strassler, DMD
Professor and Director
of Operative Dentistry
Department of Restorative
Dentistry
Dental
School, University
of Maryland
Periodontal disease can be associated with bone loss and tooth mobility. The decision to splint teeth to control mobility should be based upon
Over the years dentists have been splinting teeth with a variety of techniques. One conservative technique involved the use of a gold partial coverage casting cemented and attached to the teeth with non-parallel pins screwed into the loose teeth. . An extension of that technique used resin-bonded metal retainers (Maryland bridge).
Other techniques used direct composite bonding with wire mesh embedded into the composite resin, and orthodontic wire tied around the teeth and covered with dental resin.
With the acceptance and clinical predictably of adhesive procedures, the use of conservative bonding techniques to splint teeth offers a useful alternative to more invasive restorative procedures. There have been early reports of clinical techniques embedding wires, pins, nylon and stainless steel mesh into restorative resins. The durability of these splints was limited due to the inability of the dental resin and reinforcement materials to be chemically integrated as one piece. Clinical failures occurred because these materials could not support the repeated loading stresses placed on the splint during normal and para-function.
In the early 1990’s a bondable, biocompatible, aesthetic, easily manipulated, colorless lock-stitch woven polyethylene ribbon, Ribbond Reinforcement Ribbon (Ribbond, Seattle, WA) that could be embedded into a resin structure was introduced. This woven ribbon reinforcement of composite resin has been well researched.
This patient presented with the chief complaint of discomfort while functioning on the mandibular anterior teeth. Note the loss of attached gingiva and recession.
The clinical evidence of severe periodontal disease was supported by radiographic evidence of over 70% bone loss to the mandiular incisors and the presence of a grade 2 mobility for all four incisors.
The teeth were scaled and root planed. After the completion of periodontal initial therapy, the decision was made to splint the mandibular incisors to treat the secondary occlusal traumatism. The technique to be used was a directly placed ribbon reinforced composite resin bonded splint to extend from canine to canine.
The teeth were isolated for the clinical procedure with a dental dam extending to the first premolars bilaterally. Because the teeth are mobile the dam is easy to apply. It is especially important that the holes punched for the rubber dam leave at least 2 mm of dam interseptally and the mandibular incisor holes be made with the smallest holes in the punch.
The teeth were cleaned on the facial and lingual surfaces using a prophylaxis cup with a non-fluoridated pumice paste. The teeth were thoroughly rinsed and dried. The interproximal surfaces of the teeth were cleaned and prepared with a CeriSander (Den-Mat, Santa Maria, CA) a medium grit diamond finishing strip in a handle.
To minimize bulk of the completed splint a definite tooth preparation into the lingual surfaces of #22-27 is done using a 330 bur to a depth of between 0.5-1.0 mm. The width of the channel is determined by the width of Ribbond selected. In most cases anesthesia will not be necessary because the preparation will only be into the enamel. The preparation channel extends only to the mesial half of the canines.
Another advantage of using a channel preparation is that the precut Ribbond Reinforcement Ribbon is easily placed into the groove during the restorative procedure.
For this patient the teeth were prepared using a 330 bur with a channel 1.0 mm in depth and width of 3.0 mm to accommodate the 3 mm wide Ribbond. Additional tooth preparation of the facial interproximals was also done using a thin, bullet-ended diamond to make additional room for facial composite resin.
The length of Ribbond needed was determined by placing a peice of dental floss into the lingual channel and cut to an equal length as the floss using the special scissors included in the Ribbond Kit. It is important to use the special scissors because the polyethylene fibers are very tough and resistant to cutting with even the sharpest dental scissors.
The Ribbond was impregnated with adhesive resin Tenure S (Den-Mat, Santa Maria, CA ) and blotted with a patient napkin to remove excess resin. The Ribbond is wetted with a few drops of adhesive dental bonding system. The ribbon is put aside and covered to keep light off it until it is placed on the teeth.
In some cases, direct bridges with composite resin or natural tooteh pontics combined with periodontal splinting a second piece of Ribbond would be used to reinforce the free-standing pontic.
The teeth are etched for 30 seconds with a gel phosphoric acid etchant (UniEtch, Bisco Dental, Schaumburg) being certain that etchant flows between all the teeth to be splinted and onto the facial surfaces. The etchant is kept away from all exposed root surfaces to avoid increasing root sensitivity. The teeth were then rinsed with an air- water spray for 10 seconds and gently dried.
The etched surfaces of the teeth have a frosty appearance. Note the most distal tooth surfaces of #22 and #27 had interproximal metal matrix strips placed to maintain separation. These matrices are conventional amalgam matrix bands that have been cut into small rectangles. The author prefers these for this use for their rigidity.
Wedges were placed interproximally. These are placed passively so as not to move the mobile teeth to a new position. The wedges help limit the flow of the composite resin into the gingival embrasure area.
For a different case, note that a recent innovation for managing the excess composite resin that flows into the interproximal, gingival spaces is the use of automixing polysiloxane impression material syringed into the interproximal spaces. Most times wedges do not adapt completely into the gingival embrasure and cleanup of excess composite resin is more time consuming. It is critical that the teeth first be etched and dried before using this block-out technique.
While any elastomeric impression material can be used and placed using an impression syringe, the author has found that a heavy-bodied or medium-bodied automix polysiloxane impression material is the easiest to use
A resin adhesive (Tenure S, Den-Mat, Santa Maria, CA) is applied to the etched enamel surfaces including the interproximal surfaces and facial interproximal areas using a disposable brush . Do not light cure until the composite resin is applied. If dentin or cementum is included in the restoration, these areas must be treated with an appropriate dentin primer from the adhesive being used. In most cases the preparation and restoration in enamel only.
Facial composite resin will be placed into the interproximal areas. . This facial extension of composite resin will function as a cross-splint for each tooth to prevent tooth movement and breakage of the final splint. Also, the facial composite resin will seal the interproximal areas against recurrent caries, provide for a 180O wrap of composite resin to each of the splinted teeth and stabilize the teeth to prevent movement when the composite resin and ribbon are placed into the lingual channel
A medium viscosity hybrid composite resin, Prisma TPH (Caulk/Dentsply, Milford, DE) in compule tubes was dispensed onto the facial surfaces of all the interproximal areas of the teeth to be splinted.
The facial surfaces are shaped and then light cured for 40 seconds. This step is important because once splinted, the interproximal surfaces of adjacent teeth can not be cleaned adequately. This step seals the interproximal surfaces from becoming carious.
The composite resin is then placed into the lingual channel. By placing the compule tube tip at right angles to the channel, the composite resin can be squeezed and flow into the channel easily.
The Ribbond is placed into the composite filled channel starting at the distal end of the channel of either canine and pushing the ribbon into the composite resin. When the ribbon is pushed into the composite resin in the preparation channel a slight excess of composite resin will extrude from the preparation. This can be smoothed and excess beyond the lingual surfaces is removed before light curing. The lingual surfaces are then light cured for 60 seconds for each tooth.
After removing any irregularities of cured composite resin, the surface of the restoration must be surfaced to be smooth. This is accomplished with a syringe-needle dispensed flowable composite resin (FloRestore, Den-Mat, Santa Maria, CA). The lingual surface is light cured for 40 seconds for each tooth.
The rubber dam is removed. The composite resin is shaped, finished and polished to remove excess bulk of restorative material and achieve an esthetic result. The lingual surfaces are finished and contoured with a football shaped finishing bur (OS1F, Brasseler, USA, Savannah, GA ) and polished with an aluminum oxide abrasive point (Enhance, Caulk/Dentsply, Milford, DE ) . Final polish is done with an SuperSmooth Soflex disk (3M, St Paul, MN ).
The facial surfaces are shaped with flat shaped abrasive Lamineer-S tips mounted in the Profin® Directional Handpiece (Dentatus USA, New York, NY ). The Profin has a reciprocating back and forth movement with the Lamineer tips.
Of significant important is the use of the Lamineer tips for convienent access and control needed for delicate and precise interproximal shaping of any composite resin or hardened excess luting materials. Access to the gingival margins on the proximal surfaces is limited because the teeth are splinted. Finishing strips will not work well on rounded or concave root and interproximal surfaces. Likewise, rotary handpieces with rotating finishing diamonds and burs often used in these interproximal areas are contraindicated as they invariably create unnatural embrasures and notched irregular surfaces
The Lamineer tips have a variety of abrasive grit particles ranging from diamond grit sizes of 150 microns to 15 microns to leave a smooth texture for polishing these surfaces to a high gloss.
The final polishing and access to hard to reach areas for polishing is accomplished with composite resin polishing paste dispensed through a Lamineer hollow plastic tips or with the deformable V-shaped tips (Dentatus USA, New York, NY). The V-shape tips expand and conform to the shape of interproximal spaces.
With the embrasure spaces open, the patient is taught how to maintain and clean those spaces with a interproximal brush.
The final step for the splint is the verification of the occlusion without any occlusal changes and patient acceptance of the esthetics. adjustment of the occlusion and aesthetic appearance of the splint.
The completed splint provides tooth stabilization and increased function without bulk.
The radiographs of the completed splint verifies the joining of the periodontally involved incisors.
Expanded readings
Tarnow DP, Fletcher P: Splinting of periodontally involved teeth: indications and contraindications. New York State Dental Journal, 52(5):24, 1986
Strassler HE, Serio FG: Stabilization of the natural dentition in periodontal cases using adhesive restorative materials. Periodontal Insights 4(3):4-10, 1997
Christensen G: Reinforcement fibers for splinting teeth. In CRA Newsletter 21(10):1, 1997
There are three programs in the Ribbond splint series. For educational reasons so each program can be viewed independently, these programs have the same first five pages.
Periodontal disease can be associated with bone loss and tooth mobility. The decision to splint teeth to control mobility should be based upon
Other techniques used direct composite bonding with wire mesh embedded into the composite resin, and orthodontic wire tied around the teeth and covered with dental resin
With the acceptance and clinical predictably of adhesive procedures, the use of conservative bonding techniques to splint teeth offers a useful alternative to more invasive restorative procedures. There have been early reports of clinical techniques embedding wires, pins, nylon and stainless steel mesh into restorative resins. The durability of these splints was limited due to the inability of the dental resin and reinforcement materials to be chemically integrated as one piece. Clinical failures occurred because these materials could not support the repeated loading stresses placed on the splint during normal and para-function.
In the early 1990's a bondable, biocompatible, aesthetic, easily manipulated, colorless lock-stitch woven polyethylene ribbon, Ribbond Reinforcement Ribbon that could be embedded into a resin structure was introduced. This woven ribbon reinforcement of composite resin has been well researched.
This patient presented with a chief complaint of discomfort while functioning on the mandibular anterior teeth. Note the loss of gingival attachment and recession. All the incisors had grade 2 mobility.
Another complicating factor was that the patient had just completed two years of orthodontic treatment to close the space that existed in the anterior due to the loss of a central incisor because of periodontal disease. There is radiographic evidence of over 70% bone loss with the remaining central incisor.
The teeth were scaled and root planed. After completion of periodontal initial therapy, the decision was made to splint the mandibular incisors in order to treat the secondary occlusal traumatism. The technique to be used was a directly placed fiber ribbon reinforced composite resin bonded splint that would extend from canine to canine with no tooth preparation.
The teeth were isolated for the clinical procedure with a dental dam extending bilaterally to the second premolars. Because the teeth were mobile and there was spacing the dam was easy to apply.
The teeth were cleaned on the facial and lingual surfaces using a prophylaxis cup with a paste of water and pumice. The teeth were thoroughly rinsed and dried. The interproximal surfaces were cleaned using thin diamonds and a CeriSander (Den-Mat Santa Maria, CA), a medium grit diamond finishing strip with a handle.
For this case, the splint was placed on the lingual surfaces with no tooth preparation. Depending on the position of the teeth and experience of the clinician, the reinforcement ribbon can be placed directly on the lingual surface or in a channel prepared on the lingual surface. A splint when anterior teeth are rotated will have less bulk in the final restoration when a channel is used. Teeth that are well aligned can be splinted either with or without a channel preparation.
The length of Ribbond needed can be determined by placing a piece of dental floss from distal to distal point of the splint either on a cast of the teeth or directly on the teeth. The floss will adapt to the lingual surface. The floss is cut to length and will be a template to the length of Ribbond needed. It is important to use the special scissors provided in the Ribbond kit because the polyethylene fibers are very tough and resistant to cutting with even the sharpest dental scissors.
The Ribbond was impregnated with adhesive resin (resin bonding agent) and then blotted using a patient napkin to remove excess resin. The Ribbond should be only lightly wetted with resin. Put the ribbon aside and cover to prevent premature light polymerization until it is placed on the teeth.
The teeth were etched for 30 seconds with a phosphoric acid gel etchant being certain the etchant is placed on the lingual surfaces to be bonded and that it also flows interproximally between all the teeth to be splinted and onto the facial interproximal surfaces. The etchant is kept away from root surfaces to avoid increasing root sensitivity.
The teeth were rinsed with an air-water spray for 10 seconds and dried. The etched surfaces will have a frosty appearance. The resin adhesive is painted on all surfaces to be bonded including lingual, interproximal, and facial. On the lingual surface do not light cure until composite resin and fiber ribbon are in place.
Composite resin was placed in the facial interproximal areas to stabilize the mobile teeth before placement of the ribbon on the lingual. This facial extension will also function as a cross-splint for each tooth to prevent tooth movement and breakage of the splint. Wedges are placed passively so as not to move the teeth. The wedges limit the flow of composite resin into the gingival embrasure area.
Another technique to control the composite resin in the gingival embrasures is to use an automixing heavy- or medium-bodied polysiloxane (addition silicone) impression material and syringe it into the interproximal spaces. Most times wedges do not adapt well in the embrasure areas and cleanup of composite resin is more time consuming. It is critical that the teeth be etched and dried before using this blockout technique.
The composite resin on the facial surface was shaped to have minimum excess and then light cured for 30 seconds. The facial/interproximal composite also seals the interproximal contacts against recurrent caries.
If composite resin is not placed on the facial surfaces in the interproximal areas to create the 180 degree wrap to stabilize the teeth, the shear forces placed on the splint in function can cause a tooth to separate from the splint. This is an example of a splint where the tooth separated because of inadequate composite on the facial surface.
A medium viscosity hybrid composite resin in compule tubes was dispensed onto the lingual surface. By placing the compule tube tip at right angles to the tooth, the composite resin can be squeezed and flow onto the lingual surfaces easily. At the last tooth, push the tip into the tooth to "cut" the composite resin at this point.
The Ribbond was placed so that it is centered on the middle third of the lingual surface and pushed into the composite resin starting at the most distal end so that a slight excess of composite is both incisal and gingival to the ribbon. This conforms the ribbon to the tooth surfaces. Excess composite resin is removed before light curing.
After excess composite resin was removed, the composite resin splint is light-cured for 60 seconds on each lingual area to be certain the light penetrates the ribbon onto the composite resin against the tooth.
This is a view of the lingual of the splint after light curing. Note the ribbon is near the surface and the surface is slightly irregular.
After removing any surface irregularities of cured composite resin with a finishing bur, the lingual ribbon surface is smoothed with a flowable composite resin dispensed using a needle tip. Light cure the flowable composite for 20-40 seconds per tooth. The composite resin is finished and polished as is necessary.
The facial surfaces are shaped with flat shaped abrasive Lamineer-S tips mounted in the Profin® Directional Handpiece (Dentatus USA, New York, NY ). The Profin has a reciprocating back and forth movement with the Lamineer tips.
Of significant importance is the use of the Lamineer tips for convienent access and control needed for delicate and precise interproximal shaping of any composite resin or hardened excess luting materials. Access to the gingival margins on the proximal surfaces is limited because the teeth are splinted. Finishing strips will not work well on rounded or concave root and interproximal surfaces. Likewise, rotary handpieces with rotating finishing diamonds and burs often used in these interproximal areas are contraindicated as they invariably create unnatural embrasures and notched irregular surfaces.
The Lamineer tips have a variety of abrasive grit particles ranging from diamond grit sizes of 150 microns to 15 microns to leave a smooth texture for polishing these surfaces to a high gloss.
The final polishing and access to hard to reach areas for polishing is accomplished with composite resin polishing paste dispensed through a Lamineer hollow plastic tips or with the deformable V-shaped tips (Dentatus USA, New York, NY). The V-shape tips expand and conform to the shape of interproximal spaces.
With the embrasure spaces open, the patient is taught how to maintain and clean those spaces with a interproximal brush.
The completed lingual Ribbond reinforced composite resin splint. The final step is verification of occlusion without any occlusal changes and patient acceptance of esthetics. The completed splint provides function without bulk.
Facial view- note the mesial surface of the central incisor was reshaped to improve the esthetic shape and contour when compared to the adjacent lateral incisor. The patient reports that she can eat again on the front teeth without any pain. The teeth demonstrate no mobility.
From an incisal view the splint has minimal bulk. The radiograph verifies the joining of the periodontally involved teeth. Note the radiograph shows an x-ray visible ribbon embedded in the composite resin.
This is another example of a mandibular periodontal splint without tooth preparation. These teeth have been previously splinted with composite resin only. Every several months a tooth or teeth break free and the splint needs to be repaired.
No tooth preparation other than removal of the composite resin already on the teeth was done. The splint was fabricated as previously described.
The completed Ribbond splint provides support and stabilization for these periodontally compromised mandibular anterior teeth.
Expanded readings
Tarnow DP, Fletcher P: Splinting of periodontally involved teeth: indications and contraindications. New York State Dental Journal, 52(5):24, 1986
Strassler HE, Serio FG: Stabilization of the natural dentition in periodontal cases using adhesive restorative materials. Periodontal Insights 4(3):4-10, 1997
Christensen G: Reinforcement fibers for splinting teeth. In CRA Newsletter 21(10):1, 1997
With the acceptance and clinical predictably of adhesive procedures, the use of conservative bonding techniques to splint teeth offers a useful alternative to more invasive restorative procedures. There have been early reports of clinical techniques embedding wires, pins, nylon and stainless steel mesh into restorative resins. The durability of these splints was limited due to the inability of the dental resin and reinforcement materials to be chemically integrated as one piece. Clinical failures occurred because these materials could not support the repeated loading stresses placed on the splint during normal and para-function.
In the early 1990's a bondable, biocompatible, aesthetic, easily manipulated, colorless lock-stitch woven polyethylene ribbon, Ribbond Reinforcement Ribbon that could be embedded into a resin structure was introduced. This woven ribbon reinforcement of composite resin has been well researched.
Typically periodontal splints are fabricated for mandibular anterior teeth. Their root length and shape makes these teeth more susceptible to mobility in the presence of periodontal destruction.
With occlusion usually on the facial surfaces of these teeth, the placement of the splint is usually on the lingual surface making it virtually invisible in this esthetic zone A lingual splint will usually not interfere with occlusion and has minimal impact on the final esthetics of the restoration. This is not true of maxillary periodontal splints.
For maxillary anterior teeth with periodontal destruction and significant mobility a tight occlusion will interfere with lingual placement of a direct fiber-reinforced composite resin splint.
Even with a lingual channel preparation, the minimal thickness of composite resin overlaying the fiber ribbon is going to wear in function eventually exposing the fibers. The exposed fibers feel "fuzzy" to the tongue and pick up stain.
For this five year-old case, the wear in function exposed the reinforcement fibers. This is typically described by clinicians as a material failure. It is not. This problem is associated with poor treatment planning. This program presents a rational approach to maxillary direct placement resin splints to avoid past problems.
When occlusal stops are on the lingual surfaces of maxillary teeth, a channel preparation can be placed on the facial surfaces. The channel preparation is made using a 330 bur to a depth of 0.5-1.0 mm extending from and to at least the mesial half of the canines. The width is determined by the width of reinforcement ribbon selected.
For this case, the patient has severe periodontal destruction of the left maxillary anterior segment that includes the incisors and canine. The lateral incisor and canine have grade 2 mobility and over 60% bone loss. The patient has a chief complaint of pain on chewing and the teeth are uncomfortable most of the time.
The decision was made to place a direct fiber-reinforced composite resin splint using Ribbond Reinforcement Ribbon. Because of the tight occlusion and the need to maintain the occlusal stops on the teeth, a facial splint was treatment planned. Also, a facial splint is desirable because the forces of occlusion are exerted into the adhesive bond.
The teeth were scaled and root planed. After completion of periodontal initial therapy, the treatment to splint the incisors and canine due to secondary occlusal traumatism was accomplished.
The
teeth were isolated for the clinical procedure with a dental
dam. Because the teeth were mobile and there was spacing between
the teeth the dam was easy to apply.
The teeth were cleaned on the facial and lingual surfaces using
a prophylaxis cup with paste of water and pumice. The interproximal
surfaces were cleaned using thin diamonds and finishing strips.
Because of the tight occlusion, the splint was placed on the facial surfaces with a channel preparation. A channel preparation using a 330 bur to a depth of 0.5-1.0 mm extending from the mesial half of the first premolar to the central incisor. The 2.0 mm width of the channel was determined by the 2.0 mm width of the Ribbond. The teeth were etched for 30 seconds, rinsed and dried. Adhesive resin was painted on the etched surfaces. Do not light cure until composite is placed.
The length of Ribbond needed was determined by placing a piece of dental floss from distal to distal point of the splint. The floss will adapt to the facial surface. The floss was cut to length and was a template.
The Ribbond was impregnated with adhesive resin (resin bonding agent) and then blotted using a patient napkin to remove excess resin. The Ribbond should be lightly wetted with resin. Put the ribbon aside and cover it to keep light off it until it is placed on the teeth.
When the embrasure areas are tight it may be necessary to block out the gingival embrasures to make the clean-up of the composite resin less time consuming. A convenient technique is to use an automixing heavy or medium bodied polysiloxane (addition silicone) impression material and syringe it into the interproximal gingival spaces. It is critical that the teeth be etched and dried before using this blockout technique.
A medium viscosity hybrid composite resin in compule tubes was dispensed onto the facial surface. The Ribbond was placed so that it was centered in the channel and pushed into the composite resin.. Excess composite resin was removed before light curing.
An incisal view shows the adaptation of the Ribbond into the channel leaving minimal excess on the facial surface.
The completed splint has stabilized and splinted the teeth with minimal thickness. The patient reports being able to eat comfortably on the splinted teeth.
For this case, the patient presented with the desire to keep her upper teeth and "get them fixed." A diagnosis of severe periodontitis was made with most of the maxillary teeth having a grade 2 or 3 mobility and 70% bone loss. Prognosis for these teeth was poor.
During treatment planning the patient was presented with several restorative treatment options in conjunction with periodontal therapy including an immediate maxillary denture. The patient chose a direct fiber-reinforced composite resin splint and periodontal surgery because she did not want to lose her teeth.
After initial periodontal therapy and before surgery, the teeth were splinted. Due to a tight occlusion, the splint was placed on the facial surface. A broad saucer shaped channel was prepared using an egg-shaped diamond. Interproximal areas were reduced to allow for a more lingual Ribbond placement.
As part of the treatment plan, the missing canine will be replaced with a fiber reinforced composite resin pontic supported by a double piece of the Ribbond Reinforcement Ribbon. The splint will include most of maxillary teeth.
As previously described, a full length piece of Ribbond was cut using a template of dental floss. The Ribbond will extend to include the remaining maxillary teeth. The teeth were etched, adhesive resin placed and composite resin placed on all the teeth in the channel.
In the area of the missing canine, a double-piece of Ribbond was placed for structural strength of the pontic area. The second piece of ribbon was placed to extend into the pulp chamber of the endodontically treated premolar.
A palatal view shows the double thickness of Ribbond in the pontic area and how the pulp chamber of the endodontically treated first premolar was filled with composite resin supported by the ribbon. The Ribbond was pushed lingual in the interproximal areas.
The completed Ribbond composite resin splint. The patient is scheduled for periodontal surgery.
Surgical treatment includes osseous recontouring and a repositioned gingival flap on the facial and lingual surfaces.
The surgical flap was replaced and sutured. Note the more apical position of the composite resin to the attached gingiva on the facial surface. As part of the treatment plan the facial surfaces of the teeth will be restored with porcelain veneers.
Eight weeks post-surgery, the tissues are healing well. The periodontist granted clearance to proceed with additional restorative treatment.
Porcelain veneer preparations were done for the maxillary canines and incisors. In some cases, the preparation exposed the reinforcement ribbon on the facial but not the stabilizing proximal surfaces. An impression was made and porcelain veneers were fabricated.
Copyright 1999 Howard
E. Strassler, D.M.D., F.A.D.M.
Dental School, University of Maryland
Ribbond ® is a Registered Trademark of Ribbond, Inc.
The porcelain veneers were returned from the laboratory. Note the veneers extended onto the lingual surface and individual veneers were fabricated.
Copyright 1999 Howard
E. Strassler, D.M.D., F.A.D.M.
Dental School, University of Maryland
Ribbond ® is a Registered Trademark of Ribbond, Inc.
The completed porcelain veneers have been bonded to place and the teeth are splinted together with the Ribbond Reinforcement Ribbon. Note the radiographs show x-ray visible composite resin and Ribbond Reinforcement Ribbon.
Copyright 1999 Howard
E. Strassler, D.M.D., F.A.D.M.
Dental School, University of Maryland
Ribbond ® is a Registered Trademark of Ribbond, Inc.
Expanded readings
Tarnow DP, Fletcher P: Splinting of periodontally involved teeth: indications and contraindications. New York State Dental Journal, 52(5):24, 1986
Strassler HE, Serio FG: Stabilization of the natural dentition in periodontal cases using adhesive restorative materials. Periodontal Insights 4(3):4-10, 1997
Miller TE: A new material for periodontal splinting and orthodontic retention. Compend Contin Educ Dent 14(6):800, 1993Christensen G: Reinforcement fibers for splinting teeth. In CRA Newsletter 21(10):1, 1997
Strassler HE, Scherer W, LoPresti J, Rudo D: Long term clinical evaluation of a woven polyethylene ribbon used for tooth stabilization and splinting. Journal of the Israel Orthodontic Society. 5(3):11, 1997 Strassler HE, Haeri A, Gultz JP: New-generation bonded reinforcing materials for anterior periodontal tooth stabilization and splinting, Dental Clinics of North America 43(1):105-126, 1999. Serio FG: Clinical rationale for tooth stabilization and splinting. Dental Clinics of North America 43(1):1-6, 1999. Pollack RP: Non-crown and bridge stabilization of severely mobile, periodontally involved teeth: a 25-year perspective. Dental Clinics of North America 43(1):77-104, 1999. For other references on Peridodontal Splinting and Stabilization go to Grateful Med and Search Copyright 1999 Howard E. Strassler, D.M.D., F.A.D.M.
Check occlusion, finish and polish. Remove excess composite and polish with a composite-resin polishing paste.
Ribbond does not polish well.
Do not cut into Ribbond fibers.
The finished splint is thin, comfortable and esthetic.
The
degree of rigidity is completely under the control of the
dentist. The degree of mobility is determined by how
closely the dentist adapts and bonds the Ribbond on the teeth into the
interproximal contacts, and the width of Ribbond the
dentist selects for treatment.
The
closer the Ribbond is adapted and bonded on the teeth into
the interproximal contacts, the more rigid the splint.
Conversely, the greater the length of Ribbond not bonded onto the teeth at the
interproximal region, the less rigid the splint.
The greater the width of Ribbond used for the splint, the more multi directionally stable it can be
constructed yet remain semi-rigid.
A: No composite on teeth in interproximals
B: Contaminate interproximal contacts with waxed floss to prevent bonding contacts together
C: Ribbond bonded to teeth with composite
Prof. Dr. F. Vinckier U.Z. KULeuven
