TOWNIE CLINICAL: Immediate Bridge With Ribbond By Ara Nazarian, DDS

Steps
1. All risks, benefits and alternatives were reviewed with the patient who was suffering severe mobility with tooth #9 (Fig. 1).

2. After local anesthetic was administered, tooth #9 was atraumatically extracted (Fig. 2).

3. The extracted tooth (#9) as well as remaining dentition was inspected for any caries or debris.

4. The root of tooth #9 was shortened just apical (1.5mm) to the free gingival margin (Fig. 3). Once the proper length was achieved, the root was beveled to create a more conical root shape. This would allow the tissue to heal nicely around the tooth further enhancing the ability to clean the pontic.

5. The pulpal tissue was removed to prevent future discoloration or darkening of the tooth (Fig. 4). Four Seasons Bleach Shade was placed in the access opening.

6. A small channel was placed on the lingual surface of tooth #9 running mesial-distally where the Ribbond material would lie (Fig. 5).

7. A piece of floss was then used to measure the proposed area (#6-11) where Ribbond would be placed. This extension would also strengthen her other teeth that were already experiencing some mobility (Fig. 6).

8. After following the protocol for bonding Ribbond, Four Seasons super clear shade was used to blend in the final splint and restoration (Fig. 7).

Ara Nazarian, DDS is a graduate of the University of Detroit-Mercy School of Dentistry. Upon graduation, he completed an AEGD residency in San Diego California with the Untied States Navy. He is a recipient of the Excellence in Dentistry Scholarship and Award. His articles have been published in many of today’s popular dental publications. Dr. Nazarian also serves as a clinical consultant for the Dental Advisor, testing new products on the market. He is a member of the Academy of General Dentistry and the American Academy of Cosmetic Dentistry. If you would like him to lecture on Boosting Productivity in Your Practice he can be reached at (248) 457-0500 or at ara20002@comcast.net.

arturo5203	11/22/2003 1:54:00 PM
Nice result. These cases are relatively easy and very dramatic. Did you round off the root stump b4 bonding it in place?
healthytooth	11/22/2003 4:44:12 PM
Very Nice Job. I have a couple questions. Have you ever done these before? Any failures if you have? What kind of life expectancy do you think it will have? Is Ribbond difficult to work with? Are you associated in any way with Ribbond? Sorry for all the questions. I’ve seen Ribbond advertised, but was never quite trusting of it. I think you provided a tremendous service to your patient.
Drnaz	11/22/2003 9:36:40 PM
Thanks guys! After grinding the root down to the desired length, and removing any pulpal tissue, I filled the hole with composite and then tapered and rounded the tip a bit. This would aid in keeping it clean with a floss threader and facilitate an ovate pontic site when healed. I have done a few of these instant bridges before, and so far [they] have worked great! You definitely want to check occlusion, though. I really use Ribbond a lot in perio splinting, and ortho as well. The material handles very well, but you must follow the instructions. I feel the bridge in this case would probably outlive the teeth. Finally, I have no financial interest in Ribbond. I too had seen their advertisements and thought I might try it. The good thing is that Ribbond is not very expensive at all, offers your patients alternatives, and pays for itself ten times over if not more. Check out their website. It really helped me.
Itrtgums	11/23/2003 9:54:42 AM
Nice Case. I also have had good experience with Ribbond. What do you charge for this procedure and what code do you use?
cerecsurg	11/24/2003 12:26:20 AM
Does it work with crowns on the adjacent teeth?
Drnaz	11/24/2003 7:14:38 PM
Thank you for the compliments! I charged $600 for the splinting and $150 for the tooth to be added. In other words for the price of a crown, we stabilized her teeth and did a bridge. She was very pleased and this was very easy to do. I would recommend it for all.
xcell	11/24/2003 9:38:45 PM
Did you get her to sign anything in terms of what you thought of the overall prognosis? I have a similar case to deal with this Thursday, where the patient has severe bone loss on #24 and loss of interdental papillae. She wants a bridge but I told her that the recession (dark triangles) and bone loss really makes a bridge a poor prognosis. So I thought about your case...Maybe I’ll post some pics so that I can get some ideas….
Drnaz	11/25/2003 6:29 AM
As far as using Ribbond on adjacent teeth that are crowns, I’m not sure. I guess if you etch and silanate the porcelain it might hold, but not for very long. As far as doing a bridge on teeth that are questionable, I think this stuff is great! Not expensive for patient, you can always add on to, easy to insert...but please if you like show us the case so we may all learn...or others may have better input than me.
Drnaz	11/27/2003 6:11 PM
BTW, I forgot to mention that I didn’t have her sign anything, I just informed her that this would help her situation for a while until she decided what she wanted to do long term.
jerseydentist	11/28/2003 11:15 AM
I have had the opportunity to do a few cases like this with Ribbond and worked well. I always place some kind of a bone graft to maintain edentulous ridge architecture as much as possible. Nice result!
husaskin	2/4/2004 2:35 PM
Nice job. Would Ribbond hold in the posterior as well?
hack2	2/4/2004 11:54 PM
When I do an ext for say an implant, I sometimes bond the tooth in place after extraction. What does the Ribbond add to this that I don’t get with composite alone? I had a case I bonded––patient disappeared for 4 months. Tooth came out, GP used Ribbond and put it back...two weeks later, it was out again. What does this add, and what data is there to say it’s superior? Is it simply ease of use, or something more? By the way, I need to increase my fees for this. I don’t think I’ve charged for the ones I’ve done in conjunction with implant placement. I also don’t think it ate up more than 10 minutes of chair time and a few bucks in material.
ssherv	2/5/2004 11:00 AM
I’ve done these using a paperclip instead of Ribbond. I still create the channel in the extracted tooth, and extend the clip to the adjacent teeth where there is no occlusal interference, then etch and bond it with flowable composite. They look great, but I think they look too good. Every time I have done it, the patient inevitably forgets that it’s temporary and bites into something that breaks it right off. And once it’s off, there is no way doing it again will make it hold for more than one week at most. My longest one lasted about 4 months. I tend to shy away from these, and rely more on stayplates these days. It makes the patient remember that it is a temporary measure, and I think it motivates them further to pursue a permanent solution than the bonded bridge does.
jeremy_rudo	2/25/2004 2:17 PM
In regard to Husaskin’s question, Ribbond can be used for some but not all posterior bridges. It depends on many factors. Such considerations are the condition and size of the abutments. What kind of preparations are involved? What is designed longevity of the bridge? How long is the span? What kind of occlusal forces are expected, etc? I would suggest that you call us at 1-800-624-4554 to determine if Ribbond can be used for your particular case. Moving on to Hack2, composite resins resist compressive forces well but fracture when subjected to tensile forces. Fibers behave in the opposite manner. They resist tensile forces but not compressive forces. The use of Ribbond is a derivative of the same fiber-composite-laminate technology used to make airplane tails, skis and boat hulls. When combining fibers with dental resins we can make a structure that resists both compressive and tensile forces. You mentioned a case in which a Ribbond prosthesis debonded. There’s not enough information here to comment. Please call us for further discussion and I will be happy to help you regarding this case. Also, if you call us I can send independently authored 48 to 84 month recall studies to you that clearly demonstrate how Ribbond prevents fracture failures. Finally, Ssherv. A paper clip behaves very differently than Ribbond and the failures that you experienced using a paper clip for reinforcement do not reflect the results expected using Ribbond. The high-tech industries that make airplane tails and boat hulls out of epoxy resins use fibers for reinforcement and not metal wire for a reason. Again, please call me if you want to discuss this in further detail.
Drnaz	2/5/2004 5:25 PM
Thanks Jeremy for all the great info. Hack2, I have also tried just doing splinting and reinforcements using composite. It just doesn’t work very well or it’s bulky and ugly looking. Not only is this stuff strong it’s aesthetic. It just blends in very well whether it’s for splinting perio or ortho cases or temps. The other advantage is that you can wrap around the lingual interdentally portions of teeth (following the manufacturers guidelines). The stresses are distributed nice and even, unlike just using composite alone. I’ve used these for splinting trauma cases as well and I must say very easy to work with. The intro pack I purchased has paid for itself at least 20 times over if not more. I would always see the ads but thought what would I use this for, then a new patient came into the office that was referred by an orthodontist who uses Ribbond exclusively for splinting. It looked so great and conservative that I thought I better give it a try. View their website and I’m sure you’ll stop just using composite alone. It was very informational to me. Ssherv, the great thing about this stuff during temps is that you can eliminate making a channel for temps. I just place them over the temp’s incisal before slapping the stint for the temps it comes out great! In conclusion, it is critical to address the patient’s chief concerns in a timely manner. Having the materials to be able to provide alternative or intermediate treatment not only boosts patient acceptance, but also boosts patient confidence in the provider. In the long run, it enhances the patient-provider relationship and opens the door for more comprehensive and rehabilitative care.