Use of fibres and composite in general dental practice
Ash Parmar presents a selection of cases that demonstrate the main uses and capabilities of fibres and composite, including replacing a missing anterior tooth and periodontal splinting.
Dental fibres in conjunction with composite can offer a fantastic range of clinical solutions to allow dentists to offer cost-effective, minimally invasive treatment solutions for patients in general dental practice. This article will cover the main uses of fibres in cases that I have treated. It is important to remember that the techniques described are easy to do, as most dentists are proficient at using composite.
The fibres and composite products that I use in private practice are by Sticktech and GC.
Dental fibres are made from glass and they are silanated. Sticktech fibres contain a patented product called interpenetrating polymer network (IPN), which is a mixture of polymethylmethacrylate found in denture resin material and bis-GMA – a cross linked polymer commonly found in composites.
The material allows for superior bonding and excellent handling. There is micromechanical and chemical bonding of the Everstick fibres to composites, adhesives or composite cements. The polymer matrix can also partially dissolve, allowing for ‘surface reactivation’ – in this way, indirect fibre laboratory-made restorations can also be made. Sticktech fibres offer:
- Minimally invasive and reversible treatments
- Cost-effective treatment options for patients
- Reduced costs (eg, lab costs)
- Superior mechanical properties
- Patented bonding
- Elasticity close to that of dentine
- Extensive research data with more than 300 scientific publications
- Long-term clinical studies show good success rates.
This article will present four cases I have performed:
- Extraction of a loose tooth and refitting the adjusted tooth with fibres/composite
- Fibre post/composite cores
- Replacing a missing anterior tooth with fibres and composite
- Periodontal splinting.
Extraction of a loose tooth and re-using it
This patient presented with a loose LL3 that required immediate extraction (Figures 1 and 2). After extraction (Figure 3), the majority of the root was carefully removed and the tooth replaced in the gap to check the height of the tooth was correct.
Clinical judgement has to be made as to how much anticipated gum shrinkage will occur, and this should be allowed for.
An endodontic file was used to clean the canal from the root end and a small undercut cavity was prepared at the root canal opening. This was etched, and some bonding resin then applied with light curing. Composite (flowable or enamel type composite) was carefully placed and light-cured. The root end was polished with Sof-Lex discs to make it smooth and easily cleansable. A groove was cut on the lingual aspect of the extracted tooth (in which the fibre would run) (Figure 4). The tooth was now ready to be refitted.
The adjacent teeth were etched with 37% phosphoric acid for 20-30 seconds (Figure 5), bonding resin was applied and light-cured. Thereafter, some flowable composite was added to the adjacent teeth and a premeasured length of Everstick Perio fibre attached.
Once the tooth was correctly positioned, a small light curing tip was used to ‘tack’ the composite and fibre ends for two seconds at each end. The tooth position was verified, and the flowable composite was fully light-cured.
Finally, some enamel composite was carefully placed over the fibre and light-cured. The occlusion was checked, and the composite was smoothed and polished with Sof-Lex discs.
Figures 6 and 7 show the final result.
One of the advantages of this technique is that the patient can have their own tooth securely replaced, avoiding an expensive implant or bridge treatment. The colour match will be perfect because it is the patient’s own tooth. The treatment can also be done fairly quickly, which helps keep costs down for the patient. Of course, further treatment can be provided in due course. However, the patient can get quite a number of years of service with this type of treatment.
Fibre post and core technique
Conventional fibres are circular in cross section, whereas root canals are almost never circular in cross section. This means that if conventional custom-made fibre posts are used, there will be some voids, which the composite material will take up.
This is perhaps not the strongest type of fibre post technique. I therefore recommend dentists try the following technique of post and core build-up following endodontic treatment for an incisor or canine, followed by a zirconia/E.max or E.max porcelain crown.
Firstly, it is important to choose the case carefully. There has to be at least 2mm of tooth substance above the gingival margin. Otherwise, I would recommend a cast post instead (if a decision has been made to save the tooth by a post and crown).
In this case, the patient was an 18-year-old who had a root-filled UL1 (Figure 8). I used Gates Glidden burs (sizes 3 and 4) to remove the gutta percha (GP) from the canal until about halfway down the canal (Figure 9). This avoided any perforation, as the Gates Glidden are non-end cutting.
The objective was to completely remove the GP, and have clean axial canal walls for proper bonding of the fibres/composite to the dentine. This is very important.
Everstick Post fibres
There are three sizes of the Everstick Post fibres (0.9mm, 1.2mm, 1.5mm) (Figure 10), which should all be kept in the fridge. I mainly use the 0.9mm and 1.2mm fibres.
The canal was dried slightly before placing the fibre. A periodontal probe was used to laterally condense the fibre and the excess was cut. This was then reinserted back in the space within the canal.
As it was a wide canal, the periodontal probe was reused to make the two fibre pieces join together and create more space. A second fibre was opened and used.
Once the canal space was mainly occupied by the fibres (Figure 11), I light-cured from the top for about 20-30 seconds, which made the fibres a bit more rigid.
I then took a marker pen and made a very small dot on the labial side of the fibre bundle – this helps to orientate the custom-made fibre post correctly in to the canal. The fibre post was now ready to use (Figure 12).
The canal was etched with 37% phosphoric acid for 15 seconds. The etchant was washed out and the canal partially dried. Paper points were used to remove the excess moisture from the canal, care being taken not to over dry the canal (remember, we are bonding to dentine).
I then used the prebond liquid from Luxabond (DMG) using the fine application brush. This was gently agitated in the canal for a while, after which the excess was removed with paper points.
The two bonding resin liquids (A and B) were mixed, and applied in the canal with a new application brush. This was carefully applied to the whole axial surface area of the prepared canal. Paper points were used to remove the excess bonding resin before the canal was light-cured.
Next, Luxacore (DMG) was introduced into the canal using the microfine tip until there was a slight excess that oozed out from the canal opening.
The prepared post was placed in the canal and fully light cured. Further Luxacore material was then added to complete the composite core (Figure 13).
After a further light cure, I waited four minutes before completing the crown preparation.
Figure 14 shows the final result with an E.max porcelain veneer fitted on UR1 and an E.max porcelain crown fitted on UL1.
Replacing a missing anterior tooth
A missing single tooth, especially an upper incisor, can be a really big issue for a patient. There are traditional options to replace the missing tooth, such as an implant (with or without bone grafting), a denture, a Maryland bridge or even a fixed bridge. However, these all have advantages and disadvantages.
The next case will demonstrate an alternative treatment option, which is very conservative (regarding tooth preparation), highly aesthetic and, importantly, a fixed option – using composite. The treatment is clinically proven with excellent long-term survival rates.
This patient had a missing UL1 (Figures 15-17). Due to bone loss, it was decided not to do a bone graft and implant, and the patient did not want to continually wear a denture. We decided to do a fibre/composite bridge in a single visit. The patient also didn’t want to have a very long-looking tooth (the patient had a high smile line and this area would show). This required the use of pink composite material to simulate the gum tissues cervically.
Shade selection was carried out prior to rubber dam application (Figure 18). The proximal surfaces of UR1 and UL2 were slightly roughened with a diamond bur. No local anaesthetic was required for the treatment.
Everstick C&B fibre
The length of the Everstick C&B fibre that was required was determined by placing a thin piece of the packaging (floss can also be used) between the two teeth to measure accurately (Figure 19). A piece of fibre was then carefully cut and put aside (Figure 20).
The entire proximal surfaces of the retainer teeth were etched with 37% phosphoric acid for 30 seconds, washed and dried (Figure 21). There was a frosted effect visible to indicate a good etch pattern (Figure 22). Optibond primer was applied for about 30 seconds, and gently air-dried. Optibond bonding resin was then applied for 30 seconds, and light-cured (Figure 23).
The fibre was correctly placed and attached to UR1 and UL2 using G-aenial Universal Flo A2. This material is slightly thicker than other flowable composites and also has excellent handling properties. The fibre was correctly curved in the anteroposterior and mesiodistal directions to take into account the curve of the arch (Figures 24 and 25). An additional piece of fibre was placed horizontally using the flowable composite (Figure 26).
The alternative is to place a smaller piece of fibre vertically to form a ‘cross’. The fibres form the ‘skeleton’ or base for the false tooth, onto which the composite layers are added.
G-aenial composite kit
Using the G-aenial composite kit, shade A2 dentine was used to build up the majority of the tooth internally. A thin layer of opaque AO2 layer was applied. Bleach dentine was added in certain areas, which were whiter.
A scalpel blade was used to carefully create a very thin ‘crack’ or groove vertically (ie, a ‘smoker’s line’). IC4 stain was then carefully applied to the crack using a thin tinting brush tip. A second, clean brush can be used to remove any excess stain. Cervically, IC5 stain was used, and a very diffuse area was created in the incisal zone middle region using a larger brush. Some TE enamel was placed on the distal side vertically.
The gum effect cervically was created with shade from the pink composite range (Figure 27). Finally, JE enamel was overlaid to achieve the optimal fluorescence, opalescence, value and polish ability. JE was used in this case to increase the value or create a slightly ‘whiter’ look.
An excellent tip to ensure the surface is created correctly is to use a larger (flatter) brush tip rather than a dental instrument. This technique achieves excellent manipulation of the material.
After the complete build-up of the pontic in the composite material, the rubber dam was removed.
Occlusion was checked and adjusted as appropriate in centric occlusion, protrusive and lateral guidances. Finally, the restoration was polished using Sof-Lex discs and diamond polishing paste used to create a shiny surface (Figure 28).
This case illustrates the use of Everstick Perio fibre and composite being used to splint loose teeth to make them more secure.
The patient had extensive periodontal treatment and oral hygiene instruction with the hygienist (Figure 29).
To do the splinting procedure, it is best to use rubber dam and also use the two ‘Stepper’ instruments (Figure 30) that come with the kit.
After the rubber dam was applied (Figure 31), the teeth were cleaned using pumice and water. Floss was used to measure the distance from canine to canine (Figure 32). This was then used to cut the accurate length of fibre required for the procedure (Figure 33).
A groove can be cut into the lingual surfaces of the six lower anterior teeth to enable a more positive location of the fibre.
The teeth were etched with 37% phosphoric acid for 30 seconds (Figure 34), bonding resin applied and light-cured. A small amount of flowable composite was then placed on the lingual surfaces of each of the lower six teeth and the fibre positioned over this. The two Stepper instruments were used to stabilise the fibre at the LR3.
Using a small tip, the fibre/composite was light-cured for two seconds to tack it in to place (Figure 35). This was repeated per tooth until LL3 was reached. A full light cure was carried out. Enamel composite was then placed above this, shaped and polished with Sof-Lex discs (Figure 36).
This treatment significantly stabilises the teeth and gives the patient more confidence when eating. Of course, it is imperative for the patient to maintain excellent oral hygiene. As well as see the hygienist for regular professional gum maintenance therapy.
There is a lot of scientific research supporting the excellent results that can be achieved with fibres and composites. After watching the recommended Youtube videos, and purchasing the relevant fibres and the two Stepper instruments, dentists will be in a position to offer a range of treatment solutions that are truly minimally invasive, cost-effective and with great benefit for patients.
We are all used to using composite in daily practice. Learning to do fibre/composite dentistry should be a natural and also easy journey for dentists.
Everx Flow is a flowable dentine replacement composite material that has short fibre pieces impregnated within it. It is a great base composite for a large restoration in a posterior tooth, and requires enamel type composite layered on top. It is also an ideal core material before a crown is done.
Youtube Video guides
Everstick Post for root canal: bit.ly/33i4iKF
Everstick C&B for anterior region: bit.ly/33mt9gu
Everstick C&B for posterior region: bit.ly/2HE4Bb7
Everstick Perio for periodontal splinting: bit.ly/39lTH59
To request a list of scientific research and literature, email [email protected].
- Luxabond DMG
- Luxacore DMG
- Everstick C&B GC & Everstick Perio GC/Post GC
- Everx Flow GC
- G-aenial composite anterior GC
- Gradia pink composite GC
- Optibond Prime & Bond Optident