The Direct Bridge – Ribbond

Direct bridges are a much cheaper, and at times easier, option for you and your patients instead of the traditional indirect bridge. My first encounter with them as a treatment option was in my first 2 months of work. My patient had one made by another dentist a few years ago, and it had come loose. The patient had been very happy with it, and asked me for a new one. I knew what ribbond was, but I had never used it before and didnt have a clue about how to start! Luckily I had one of the most experienced nurses at my clinic, so she discreetly walked me through it while we did it.

Ribbond, what is it?

Directly from www.ribbond.com – “A bondable reinforcement ribbon that prevents fracture failures in dental composites and acrylics. Its unique combination of patented weave and bondable, high-strength fibers gives results unsurpassed by any other reinforcement. It is perfect for a wide variety of dental uses.”

Basically, its a piece of ribbon which you can bond to and integrate into your restorations.

Some Indications for a Ribbond Bridge

• Semi-permanent bridge replacing mandibular central or lateral incisor
• Temporary bridge replacing maxillary central or lateral incisor
• Trauma splinting
• Periodontal splinting

How to use it?

Taken directly from the Ribbond instructions included with the product

1. Measure and cut 2 pieces of ribbond. Cut one piece to span the entire bridge, and another to span only the pontic area    
2. Wet the ribbond with unfilled bonding resin and blot off the excess. Blot off the excess with a piece of pt bib or similar.
3. Apply composite to the abutment teeth (fig.2). If you have prepped the adjacent teeth, place into the preparation, allowing room for the ribbond to be placed into the preparation with room for further ribbond over the top
4. Adapt ribbond to the abutments, remove excess, and cure one at a time (fig.6). I’ve found it easier to tac cure the first attachment for a few seconds, before properly adapting the other end. Ensure youre happy with the placement of the ribbond spanning the pontic space. It should be mid crown, under the incisal edge of the tooth to be replaced. After that, completely cure each abutment.
5. Apply composite over the span of ribbond and place the second piece across the span (fig.7).Place only a thin layer of composite, just enough to allow thetwo pieces of ribbond to mesh together
6. Cover abutment ribbond with composite and cure whole structure. Ensure all parts of ribbond on the abutment teeth are covered with composite as ribbond will not polish. If exposed in the mouth it will fray and become a food trap – it must be covered.
7. Prepare and place the pontic. There are three options for what to use:
   1. Extracted tooth – Clean, and cut to size by removing the root. Cut a slot on the lingual/palatal of the tooth so that it will fit over the ribbond support in the correct position. Bond it in place with composite , adjust occlusion if necessary, and polish, ensure no part of the ribbond is exposed, it must be covered with composite
   2. Denture tooth – Used in the same way as an extracted tooth, as above
   3. Build from composite – Build up incrementally over the ribbond support

Example Case – Direct bridge following perio extraction

Pt presented with loose lower tooth (42), reports problem has progressively worsened over the past 6 months. Plan for new denture next year, but cannot fast-track due to insufficient funds at present. After a semi-permanent tx which will avoid leaving a gap and at minimal cost. Discussed options of exo, bonegraft/implant, indirect bridge, direct bridge, essix retainer, denture – along with plan for deteriorating periodontal condition. Pt opts for direct bridge followed by periodontal tx with hygiene department.

Tooth extracted and socket allowed to heal for 2 weeks. Lingual surface of abutment teeth roughened (No slots prepared) and ribbond framework bonded into place. Extracted tooth cleaned, cut to shape and slot prepared. Bonded into place with composite and minor occlusal adjustment completed.

Tips:

• In this case I left the extracted tooth dry, and soaked it in saline a few hours before the procedure. As a result, the tooth was a different colour. This should return to normal, but an easy problem to avoid for next time
• I trimmed the tooth and checked fit prior to using the ribbond. Once in a good place, I covered the labial surface in a large amount of composite without etch/prime/bond. Then I checked the occlusion like this to check the tooth was in a good position

This case didn’t turn out perfectly due to the colour mismatch (which should resolve on its own), wear and mal-alignment of the dentition. Its important to note that not every case can look like a model case, but in this case, the treatment gave the patient a functional and affordable result with aesthetics that she was happy with.

Keep the option of a direct bridge in the back of your mind when treatment planning for missing teeth. It wont always be the best option, but sometimes it will satisfy all of your patients needs.