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Stress-Reduced Direct Composites For The Restoration of Structurally Compromised Teeth - Fiber Design According To The Wallpapering'' Technique
Stress-Reduced Direct Composites For The Restoration of Structurally Compromised Teeth - Fiber Design According To The Wallpapering'' Technique
Clinical Relevance
When most of the dentinoenamel complex (DEC) is lost, the ‘‘wallpapering’’ of the residual
cavity walls with Leno weaved ultra-high-molecular-weight polyethylene fibers may help
to both emulate the crack shielding mechanism of the DEC and absorb the stress from
either polymerization shrinkage or occlusal load.
and voids, from which crack propagation may dentin adjacent to the interface. The mantle dentin
start, is also reduced. The fibers’ tight adapta- is a thin material layer close to the DEC that is
tion to tooth structure allows a dramatic somewhat softer than the bulk dentin, showing
decrease of the composite volume between decreased peritubular dentin and tubule density.
the tooth structure and the fiber, thus protect- They explained crack arrest by the gradually
ing the residual weakened walls from both the increasing toughness from enamel to mantle dentin.6
stress from polymerization shrinkage and the Although there is little consensus on the mechanism
occlusal load. of crack arrest at the DEC, research definitely agrees
Conclusion: By using a similar approach, fiber- that the DEC is a very strong, durable, damage
reinforced stress-reduced direct composite tolerant, and well-bonded interface that is unlikely
Friedy, Chicago, IL, USA) was used to measure the surfaces, with each piece stopping at an imaginary
mesio-distal distance and the pulp chamber-coronal DEJ line on the top and folding down onto the axial-
length of the cavity. Two 4-mm-wide by 11-mm-long pulpal floor line angle on the bottom at both the
Ribbond fiber pieces (Ribbond THM, Ribbond Inc, facial, lingual and proximal walls (Figure 11). Being
Seattle, WA, USA) were wetted with an unfilled bondable reinforcement fibers, they could be closely
resin first (Ribbond Wetting resin, Ribbond Inc).12,27 adapted to the residual tooth structure. The fibers’
After removing the excess resin, fibers were covered tight adaptation to tooth structure was the key to
with a very thin layer of tacky flowable composite, decreasing the composite volume between the tooth
Ribbond Securing Composite (Ribbond Inc); fibers structure and the fiber; thus, stress from polymer-
were C-shaped prior to insertion into the cavity. The ization shrinkage could be prevented on the residual
first Ribbond fiber was bonded immediately against weakened walls. In cases of visible cracks, structural
the lingual wall and cured for 20 seconds (Figure 10). weakness of the pulp chamber floor, or patients with
The same procedure was also completed for the parafunction, another piece of Ribbond may be
second polyethylene fiber which was placed on the prepared in the same manner and bonded closely
facial wall and cured for 20 seconds. The Ribbond against the pulpal floor. In a similar clinical
pieces overlapped one another at the proximal scenario, one more piece of Ribbond may be placed
Figure 8. Multiple 1- to 1.5-mm triangular-shaped (wedge-shaped) increments were used to reconstruct the cervical third of both the lingual and
distal surfaces.
Figure 9. The circular matrix was replaced with a sectional matrix and the peripheral enamel skeleton was built up first using wedge-shaped
increments.
238 Operative Dentistry
Figure 10. The first C-shaped polyethylene fiber is bonded immediately against the lingual wall and cured for 20 seconds.
cavities.34 In a study published in 2006, Belli and The literature suggests that cracking along the
DEC occurs very rarely.5-9 The DEC seems to be a
others described that Ribbond increased the micro-
very well- and strongly bonded interface that
tensile bond strength and lowered the C-factor
provides crack tip shielding. Preserving the DEC
effect.35
during cavity preparation as much as possible is the
The former laboratory studies were performed first rule each restorative dentist should follow.
placing the composite into the cavity without
Interestingly, Bechtle and others9 reported that
following a stress-reducing protocol; both the matu-
crack arrest occurs only if cracks approach the DEC
ration of the bond36,37 and the strategic layering/
from the enamel side. If cracks are induced from the
curing protocol may further reduce stress concen- dentin side, samples fractured after elastic and some
tration on the residual cavity walls.4,24 In the first amount of plastic deformation. This in vitro finding
three to five minutes following the polymerization of does have clinical significance.
the adhesive system, early bond strength to enamel
was reported to be twice as strong as the early bond During occlusal loading, vertical loading creates
strength to dentin38; this trend changes dramatically lateral forces against the cavity walls (the Poisson
after a five-minute period as the late bond strength effect); the lateral forces create a tensile force across
the pulpal floor that may be responsible for the
to dentin may be even higher than the one to
initiation of a crack on the residual cavity walls. Due
enamel.39
to the composite resin’s intrinsic lack of toughness, a
Combining composite stratification with wedge- catastrophic failure may occur if structurally com-
shaped increments and polymerization with a low- promised teeth are restored with a resin bonded
intensity approach is also mandatory to reduce composite only.34,43,44 The wallpapering of the
stress in the restoration. Multiple wedge-shaped residual cavity walls with the Ribbond polyethylene
increments are placed trying to contact no more than fibers is intended to diminish the possibility of a
two bonded cavity walls; the technique allows the failure while preserving the residual sound tooth
decrease of stress from polymerization shrinkage by structure. When a failure occurs, it happens in a safe
reducing the composite mass (per increment) and mode due to the energy absorbing mechanism and
transforming the high C-factor configuration into stress distribution effect of the fibers; the damage on
Deliperi, Alleman & Rudo: Stress-reduced Direct Composites and Fiber Laydown Technique 241
the tooth-restoration complex is minimal and can be nism of the DEC. The use of ultrasonic tips definitely
easily repaired because it occurs above the CEJ.23 helps to smooth the sharp line angles; however,
The intrinsic characteristic of the fiber network and covering these areas with Ribbond fibers is recom-
the correct fiber insertion into the cavity walls may mended to avoid stress concentration on these areas
help clinicians to push the envelope with direct and avoid the formation of cracks either on the
restorations; if a stress-reduced approach is adopted, pulpal floor and axial walls.
direct restorations may be extended to structurally Cavity preparation, material design, and occlusal
compromised vital and devitalized teeth without equilibration represent different stages of the re-
requiring cusp coverage of residual weak walls.
storative procedure to achieve stress reduction and
However, the thinner the remaining cavity walls,
assure the longevity of the tooth-restoration com-
the higher the risk for a catastrophic failure of the
2. Bazos P, & Magne P (2011) Bio-emulation: biomimetically 17. Rudo DN, & Karbhari VM (1999) Physical behaviors of
emulating nature utilizing a histo-anatomic approach; fiber reinforcement as applied to tooth stabilization
structural analysis European Journal of Esthetic Dentist- Dental Clinics of North America 43(1) 7-35.
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18. Karbhari VM, & Wang Q (2007) Influence of triaxial braid
3. Lee JJW, Kwon JY, Chai H, Lucas PW, Thompson VP, & denier on ribbon-based fiber reinforced dental composites
Lawn BR (2009) Fracture modes in human teeth Journal Dental Materials 23(8) 969-976
of Dental Research 88(3) 224-228.
19. Belli S, & Eskitascioglu G (2008) Biomechanical proper-
4. Deliperi S, & Bardwell DN (2002) An alternative method ties and clinical use of a polyethylene fiber post-core
to reduce polymerization shrinkage in direct posterior material in fiber posts and endodontically treated teeth.
composite restorations Journal of American Dental In: Ferrari M, Breschi L, Grandini S (eds) A Compendium
Association 133(10) 1387-1398. of Scientific and Clinical Perspectives, 1st Ed Modern
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evaluation of stress-reducing direct composite restora- & Lambrechts P (2003) Microtensile bond strengths of an
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Operative Dentistry 37(2) 109-116. as a function of surface treatment Operative Dentistry
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resin: A pilot clinical study Journal of Adhesive Dentistry properties and energy density of light cure Journal of
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