Use of Short-Fiber Reinforced Composites to Rescue Cracked Teeth

You're listening to The Dr. Phil Klein Dental Podcast Welcome to the show. I'm Dr. Phil Klein. Today we'll be discussing the benefits of adding a short fiber reinforced composite restorative into our specific restorative cases, the ones that need it the most, and we'll be talking about that. In conjunction with the universal composite, a fiber reinforced restorative has shown to offer significantly better fracture toughness in many applications versus a universal composite alone. Our guest is Dr. Ron Kaminer, an internationally known educator lecturing on dental lasers and other cutting-edge technologies in the dental market. And he's going to try to clarify all this because there certainly is a need for a fiber-reinforced material in dentistry. Dr. Kaminer maintains three practices, by the way. He's a pretty busy guy, so we're happy to have him on the show. One is in Hewlett, New York, one is in Oceanside, New York, and the other one is in Breezy Point, New York. Dr. Kaminer, it's a pleasure to have you on the show. Thanks, Phil. Always happy to do this. Let's talk about short fiber reinforced. As an endodontist, this interests me because, of course, I did a lot of post and cores for the referring dentists over the years, 14 years that I practiced. Having a fiber reinforced core makes a lot of sense, especially since the access prep has a tendency to undermine the crown part of the tooth. So why should a practicing dentist consider using a short fiber reinforced composite, number one? And how is it different from a universal composite, which is supposed to be pretty strong, or a bulk fill composite for that matter? It's very interesting because if we think of cracks and the technology, that's been created to try to avoid them. Cracks are a huge problem in our profession. I'm sure as an anodontist, you saw a ton of these things, and as a GP, I see a lot. Patient bites on something hard, and all of a sudden, a crack will propagate from the mesiobucle cost right down into the dentin, sometimes even into the pulp. Now, imagine that same situation with a composite already in there. Very often, what do we see? We'll see that the tooth is still cracked, even though that composite is bonded, it's still cracked into the dentin. Enter these short fiber composites. These fibers are meant to act as rebar, kind of rebar if you think of a cement structure. And when that composite is interlaced into those fibers, it forms this stronger union and bond to the tooth structure. So then in theory, If someone cracks that mesial buccal cusp, it's going to end at that composite and stop there. And the fibers, because of the bond, are not going to allow the propagation of those cracks. So I think it makes a whole lot of sense. And it's been a great additive to my arsenal since GC launched this. The fibers serve as a matrix, so to speak, strengthening the entire restorative process that's being placed on the tooth. So you're saying if there's a fractured cusp and that composite... adapted to that whole cusp and further down, it'll stop at the fracture point and won't be carried down through the rest of the restorative material because of the fibers. In theory, listen, that's why it was developed. The theory was that this composite, unlike anyone else on the market, would actually strengthen the tooth and strengthen the union of the buccal, lingual, mesial, distal aspects of that restoration. And having used this now for a good amount of time, yes, I don't have five years into this because it hasn't been around five years, but having used it for a good amount of time, it seems to do what it's supposed to do. Yeah, so I want to get into more of the clinical aspect of how you use this material and how you select the cases, how often you use it. What is the name of the product? So the product is called Everex Flow from GC America, and it comes in a dent and shade. and a bulk shade, so to speak. The bulk can be cured up to five and a half millimeters, the dent in two millimeters. So we can use it in a variety of ways. We could use it as a buildup material. So many dentists today are getting away from posts. So even if you have this molar that had an endo, if there are buccolingual walls, they may just do a buildup with a composite. And this would be an ideal material to do that buildup with. It can be used in a deep restoration in a sandwich technique using the Denton shade below and then maybe capping it with something else. It can be used actually as a, you know, as a base material like that Denton. But let's say, you know, very often today if I'm doing a class two, for instance, it's very, very deep. I'll go ahead and place a flowable underneath and then place my composite on top. This material is actually a flowable. The consistency is an interesting flowable. We'll talk about that. And I can get into all the nooks and crannies and place that as a small base layer and place my composite on top. So a lot of different ways to use the material. And it's something that we use day in and day out in the office. So years ago, I used to go to the dental shows and see a gentleman who was a dentist who invented this fiber material. that he wanted you to pack down into a composite. And that was a good idea, but it was not easy to do. The technique sensitivity to that thing was off the charts. I don't know who used it. I tried it a couple of times, and I didn't use it anymore as a practicing endodontist. So this material sounds like that it's all baked in the cake. Do you know which material I'm talking about? It was like a rib-on-like material. Yes, that's it, rib-on. It was rib-on, and it was very difficult to cut. It was very difficult to manipulate, and even if you manipulated properly, it wouldn't bond. There's nothing on it. You basically stuffed it in, and it was a fiber. In this material, you're correct. It actually has this fiber reinforcement in there, but don't misunderstand me. It handles, well, let's not say handles because we'll talk about handling in a second, but you treat it like a regular composite. You etch. place your G-Premio bond in the Denton, and then go ahead and either bulk fill or use the Denton shade as a regular composite. Am I right to say that you're primarily using this, predominantly using this as a core buildup material after an endodontic case or just a tooth that's been pretty much obliterated and you need to build this tooth up under a crown? Exactly correct. And not only that, when you cut on it, so I do, you know, one of the tricky things with most core material is you cut from tooth to core material, and you'll ditch the core material because it's softer than the tooth. But this material actually cuts like dentin. When you cut on it, you have the feel of dentin, so you're not going to ditch it. So you're correct. The core built-up material is an ideal place, and that's where I use it predominantly because I feel like I'm going tooth to tooth, and I have this strong... restoration in the middle and on the sides that's reinforcing the entire existing tooth stump if you will. Right so intuitively if you think about a composite that's flowable you really want to get the adaptation which is the key thing when you're doing this in the first place and then you add the fibers in how do the short fibers affect the adaptation compared to a universal composite because that's that handling characteristic and adaptation is a key thing for a clinical dentist. So I think there's a tiny learning curve here, and the learning curve is that this material doesn't flow like a regular flowable composite. It almost flows like Vaseline in a syringe. It flows everywhere, and it's great, and it'll get into every nook and cranny. But when you press on the plunger of a flowable, and depending on the consistency, it's either going to run, or if it's a thicker flowable, it's going to place. This kind of doesn't run. And it places, imagine you squirted Vaseline out. Now I can take a plastic and kind of mold it around or smear it around where I want, and it just sits where you place it. So I love the handling on it. I actually shot a video at one point for GC on the handling of this. And the learning curve is such that it's just different than what we've used, but the learning curve is one case or half a case or the first time you put your instrument on it, and it's going to place the way you want. On your endodontic cases, do you use EverX Flow as a build-up material routinely? 100% of the time. Okay. Let's say, I can't say 100, 97% of the time I'm using EverX Flow. Right. This material is published in the literature already. It shows that it's actually even stronger than traditional composites. And that's why I think it was put out there into the market, because it was better than what the other composites, than the other composites on the market. Now, what happens if you have an aesthetic requirement in your restorative procedure that you're doing where you're using Evorex Flow? What do you use to cap it, if anything? Again, if it's in any kind of an aesthetic situation, lower bicuspid, upper bicuspid, something like that, and I'm doing a class two, for instance, I'll go through my adhesive process, so selective etch, G-premio bond on the dentin and the enamel, light cure, and then I'll place Evorex Flow. the dentin let's say as a base on the floor and then i'm going to cover it with um genial injectables which are flowables that are super super aesthetic but they're also easy to handle and the market's going to go this way with a lot of these thicker flowables because the dentist likes quicker and easier and the genial injectables not only are really aesthetic They're also very radiopaque, and they're also extremely strong in themselves for a composite. So now you have fiber reinforced at the base. Imagine you have fibers grabbing all these walls, keeping it together, and you're placing this strong aesthetic composite right over the top, and you're getting really an ideal, very strong composite restoration in your class twos, and probably even more important in an MOD than it is even in a DO. You mentioned the track record on this is about five years since the product's been out, something like that or less? Yeah, a little bit less than that. It was launched in Europe, I think, first, a little bit less. But there are studies already out there on fiber-reinforced composites strengthening the teeth and minimizing cracks. So the research is coming. But it's already out there that shows some very promising futures in that as more and more dentists use this, teeth will be stronger. And I want to add one last thing, Phil, is that with zirconia crowns being the prevalent crown today, being so hard and so strong, you know, what we don't know is when someone bites something really hard, what force or pressure is transmitted on this art structure to the underside. And I think this is where it becomes even more important. for using these fiber reinforced composites. Yeah, that's a really good point. That's an excellent point because there's really no give on that zirconia and that every force that's being placed on that tooth is carried through and that underlying material has to be strong to sustain that. And that's a very good point. My last question before we wrap it up, and this has been a very good podcast, Dr. Kaminer, as usual, is this fiber reinforced material possibly a solution to get patients through? a period where they have some financial compromises, they have financial limitations of paying for a full crown, and you don't want the tooth to fracture during that period of time where they may be unemployed or they just have other financial issues that are a priority. Is this something you would use where it can get them through this period until they get their final crown? A hundred percent. I mean, we've done that on a number of patients that have had financial issues or someone gets sick or someone is, I had someone two weeks ago that's in the middle of chemotherapy. They broke a tooth. I etched, bonded, built it up with EverX Flow. And I said, hey, when you're done with your chemo, when you're feeling better, we'll go ahead and put the crown on it. Listen, I'll always tell them not to go eat nuts on it. We don't have to, we're not looking to test the material in the mouth, but if they ate a nut on it, likely nothing's going to happen because of the strength. It's a great point, and we definitely do it to get people through certain times. Dr. Kaminer, it's always been a pleasure to have you on the show. I'd love to get an update on this material down the road, and you continue to contribute so much to Viva Learning and the dental profession through all your CE stuff. It's amazing. It was great seeing you in Chicago at the KOL meetings, and I wish the best for you and look forward to having you on the show soon again. Thank you very much. Thanks very much, Phil. Always enjoy doing this. Have a great day.