Cosmetic Tribune U.S. No. 7, 2011
Biomimetic principles applied to cosmetic dentistry
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Cosmetic TRIBUNE
The World’s Cosmetic Dentistry Newspaper · U.S. Edition
July 2011
www.dental-tribune.com
Vol. 4, No. 7
Biomimetic principles
applied to cosmetic dentistry
By Susan M. McMahon, DMD and Emily
Evron
Biomimetic dentistry is based on
the philosophy that the intact tooth
in its ideal hues and shades and,
more importantly, its intracoronal
anatomy, mechanics and location
in the arch, is the guide to reconstruction and the determinant of
success. This approach is conservative and biologically sound and
in sharp contrast to the porcelainfused-to-metal technique in which
the metal casting with its high
elastic modulus makes the underlying dentin hypofunctional.
The goal of biomimetics in
restorative dentistry is to return
all of the prepared dental tissues
to full function by the creation of a
hard-tissue bond that allows functional stresses to pass through the
tooth, drawing the entire crown
into the final functional biologic
and esthetic result.1
According to Douglas A. Terry,
DDS, in dentistry there is no one
biomaterial that has the same
physical, mechanical and optical properties as tooth structure
(i.e., dentin, enamel, cementum)
and possesses the physiological
characteristics of intact teeth in
function. By utilizing biomimetic
therapeutic approaches, dentists
can improve and become closer to
natural biological structures and
their function.8
There are two major perspectives to which the term “biomimetic” is applied: a purist perspective that focuses on recreating
biological tissues and a descriptive
perspective that focuses on using
materials that result in a mimicked
biological effect.8 Although different, both share a common goal
of mimicking biology in restoration.8 This has been an increasingly common goal for dentists and
patients alike in achieving esthetic
and functional dentistry.
Biomimetic dentistry techniques
provide the patient with minimally invasive options that conserve
sound tooth structure as a clinical
imperative.2 Biomimetics is essentially described as a mimicking of
natural life, which can be accomplished using contemporary composite resins and adhesive dental
procedures.2 Conservation and bio-
Fig. 1: Preoperative smile.
Fig. 2: Note the significant spacing between the upper and
lower anterior teet
Fig. 3: Note staining and discolored spots.
logical mimicry make up the foundation of a biomimetic philosophy
and together produce the effect
that today’s patients expect.
From an esthetic/restorative
perspective, biomimetics or biomimicry is the application of methods and systems to artificially
replace biologic elements in order
to recreate optimal oral health.8
Practicing
interdisciplin-
ary esthetic restorative dentistry
enables dentists to achieve biomimetic results with cosmetic dentistry.8 These techniques and materials are crucial to modern dentistry
in that they combine a focus on
dental health and appearance. A
biomimetic material should match
the part of the tooth that it’s replacing in several important ways,
including the modulus of elastic-
ity and function of the respective
areas (e.g., pulp, dentin, enamel,
dentoenamel junction).8
The production of bone-, dentine- and enamel-like biomaterials
for the engineering of mineralized
(hard) tissues is a high priority in
regenerative medicine and dentistry.10 The ability to manufacture
such materials has allowed dental
restorations to attain significantly
more nature-like results that inevitably perform at a higher level than
less life-like materials of the past.
The physiological performance
of an intact tooth requires a balance between biological, mechanical, functional and esthetic parameters in order to achieve biomimetic qualities.
This necessitates the development of “anatomical morphological thinking” when developing a
restoration so that it replicates the
natural tooth in form, function and
esthetics.8 Such biological thinking
will enable dentistry to focus on
future health as well as the lasting
appearance of the patients’ smiles,
both of which are necessary for
patient satisfaction.
According to Wynn Okuda, DMD,
“modifications to existing cavity
design should be based on preservation of natural dentition. The
goals and objectives of biomimetic
replacement should be to mimic
the structure being replaced, thus
allowing minimal removal of nonaffected adjacent tooth structure.”8
Incorporating biomimetic principles stems from somewhat of a
philosophical approach to practicing dentistry, Okuda says.8 Dentists
must take time to research methods
of minimally invasive approaches
to solving dental problems.8
Over billions of years, nature
has created a formula for highly
functioning materials that have
withstood evolution. To create
structures that will continue to
function at such a level, dentistry
must copy and integrate nature’s
complex methods. Terry states
that “we need to develop treatment
modalities that allow us to reproduce the biomechanical behaviors
of the intact tooth. As research
scientists, clinicians and technicians work together in understanding the complex orientation of this
composite material called tooth
[2] =>
2C Clinical
Cosmetic Tribune | July 2011
Fig. 4: Postoperative smile. Note the natural appearance.
health of the patient.
Nowadays, there are many modern composite resins developed for
highly esthetic procedures that,
when properly used, can result in
restorations that are indistinguishable from natural dentition.24 This
article extrapolates the minimally
invasive biomimetic principles of
restoration and applies them to
procedures for introducing missing tissue and creating cosmetic
improvements, which ultimately
benefit the patient’s overall oral
health and appearance.
The process of mimicking tissue
that was not initially present uses
biomimetic methodology similar to
that used in restorative dentistry
that conserves tooth structure. Two
cases will be presented that demonstrate the diversity of options
biomimetic techniques provide for
the field of cosmetic dentistry.
Case No. 1
Fig. 5: Postoperative.
Fig. 6: Postoperative.
f CT page 1C
structure, improvements will continue.”12
The same philosophy of using
nature as a guide for restoration
and regeneration can be extended
to a functional solution creating
missing structures in cosmetically
focused patients.
Minimally invasive treatments
are procedures that restore form,
function and esthetics with minimal
removal of sound tooth structure.3
This is accomplished by removing only dental tissues that cannot
be adhesively bonded.9 This conservative approach leaves patients
with as much of their natural tooth
structure as possible while restoring or creating tissue that will
enhance utility and appearance.
While indirect porcelain veneers
can require a great amount of preparation and removal of tooth structure, direct composite bonding follows the conservative approach.
Direct resin composite restorations offer an alternative treatment
that provides excellent esthetics
and preservation of tooth structure given that the preparation is
limited to only areas of affected
unsupported enamel.23
Patients today want their dentistry more esthetic but less invasive and composite resin accomplishes both.11 Evidence suggests
that composites can provide optimal esthetics with minimal or no
tooth intervention, immediately
improving esthetics while leaving
options for future orthodontic and
restorative care.13 Furthermore, as
a person ages, so do their restorations.
Eventually, teeth that have been
restored will break down and
need to have those restorations
replaced.4 Fortunately, if an initial
restoration was created using minimally invasive procedures, there
should be more tooth structure to
work with at the time when a second restoration may be needed.2
In this way, the biomimetic
approach takes into account both
the present and future dental
A 34-year-old, healthy male presented for treatment of the spacing between his upper and lower
anterior teeth as well as whitening.
He desired a more esthetic appearance overall. After an examination,
the patient was presented with two
options. Both porcelain veneers
and biomimetic composite bonding would eliminate spacing and
create a whiter smile, though the
composite bonding technique demonstrated several advantages that
made it the right choice for the
patient.
The biomimetic effect of composite bonding ensures that the
patient will attain a natural and
highly functional result. Today’s
composites have much improved
physical and esthetic properties,
enabling minimally invasive treatment modalities to be performed
with immediate results that are
able to satisfy the most cosmetically discerning patients.14–19
Porcelain veneers, on the other
hand, require greater and irreversible tooth intervention. In addition, they would require at least
two appointments and somewhat
considerable tooth preparation.13
The composite bonding chosen for
this patient involves minimal intraenamel preparation from sandblasting or cleaning the enamel
surface with pumice and no local
anesthetic.13
With this type of treatment,
fewer teeth (or just parts of teeth)
can be treated and, becuase there
is no laboratory fee, there is less
cost for the patient.22 Composite
bonding can be considered as a
viable minimal or non-invasive
treatment alternative.20, 21
Treatment
An initial in-office whitening procedure was accomplished one
week before the composite fill restoration. Treatment for general
upper and lower diastemas was
then carried out and consisted of
the following: the maxillary anterior teeth and mandibular anterior
teeth were pumiced with Pumice
COSMETIC TRIBUNE
The World’s Dental Newspaper · US Edition
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Torsten Oemus
t.oemus@dental-tribune.com
Chief Operating Officer
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r.goodman@dental-tribune.com
Editor in Chief Cosmetic Tribune
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d.berland@dental-tribune.com
Managing Editor/Designer
Implant, Endo & Lab Tribunes
Sierra Rendon
s.rendon@dental-tribune.com
Managing Editor/Designer
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Online Editor
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Account Manager
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Dental Tribune America, LLC
116 West 23rd Street, Suite 500
New York, NY 10011
Tel.: (212) 244-7181
Fax: (212) 244-7185
Published by Dental Tribune America
© 2011 Dental Tribune America, LLC
All rights reserved.
Cosmetic Tribune strives to maintain
utmost accuracy in its news and clinical reports. If you find a factual error or
content that requires clarification, please
contact Group Editor Robin Goodman at
r.goodman@dental-tribune.com.
Cosmetic Tribune cannot assume responsibility for the validity of product claims
or for typographical errors. The publisher also does not assume responsibility
for product names or statements made
by advertisers. Opinions expressed by
authors are their own and may not reflect
those of Dental Tribune America.
Tell us what
you think!
Do you have general comments or criticism you would like to share? Is there
a particular topic you would like to see
articles about in Cosmetic Tribune?
Let us know by e-mailing feedback@
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hearing from you!
[3] =>
Clinical
Cosmetic Tribune | July 2011
underlying tooth structure can be
preserved for the present and
future dental health of the patient.
CT
References
1.
Fig. 7: Pre-operative peg-lateral incisor.
Fig. 8: Postoperative.
Preppies (Whip Mix Corp.), rinsed
and dried.
The teeth were then treated with
Ultra Etch 35 percent phosphoric acid (Ultradent Products) for
15 seconds, rinsed and left moist.
Bonding agent Prime & Bond NT
(Dentsply Corp.) was applied to the
teeth, air thinned and then light
cured for 20 seconds.
The diastemas were restored
with Esthet-X HD Micro Matrix
Restorative (Dentsply Corp.). A
layer of A2 was applied to block
light transmission through the
diastema, simulating the dentin
layer. Characterization was accomplished by adding Pink Tint Venus
applied with a No. 10 endodontic
file into the surface of the A2.
This layer was cured for 20 seconds. A second layer of Esthet-X
HD enamel shade WE was applied
and contoured simulating the
enamel layer. This layer was light
cured for 20 seconds. The composite resin was then contoured,
finished and polished with Sof-lex
discs (3M ESPE).
Case No. 2
A 23 year-old healthy male presented with one peg-lateral incisor
that he wished to improve esthetically. A peg-shaped lateral incisor
can be defined as a tooth with
reduced meso-distal diameter and
with proximal surfaces converging
markedly in the incisal direction.25
This tooth’s shape and size alteration is inherited genetically and
occurs in the range of 1–2 percent
of the population.25,26 Options for
treatment again included a porcelain veneer or restoration with
composite bonding. The patient
again opted for the biomimetic
procedure of restoring with composite bonding.
Treatment
Treatment consisted of direct composite bonding to the upper right
lateral incisor. No prepping of
the tooth was required. The tooth
was cleaned with pumice (Pumice
Preppy, Whip Mix Corp.). A 35 percent phosphoric acid (Ultra Etch,
Ultradent Products) was applied
to the entire enamel surface for
15 seconds. The etchant was then
rinsed off, leaving the enamel surface moist. The bonding agent,
Prime & Bond NT (Dentsply Corp.),
was applied, air thinned and light
cured for 20 seconds.
Esthet-X HD Micro Matrix
Restorative (Dentsply Corp.) shade
C1 was applied, contoured and
cured. This was followed by a
layer of Esthet-X HD Micro Matrix
Restorative (Dentsply Corp.).
The ideal characteristics of very
high polishability, varied opacity
options and contourability make
the Esthetix-X HD an excellent
choice for this application. The
restoration was then finished and
polished with Sof-lex Discs (3M
ESPE).
Summary
Biomimetic principles can be
applied to cosmetic dental cases to
minimize the reduction of existing
healthy tooth structure in the pursuit of improved esthetics. The
results can accomplish the esthetic
enhancement, the cost to the
patient can be reduced and the
Magne M, Magne P. The Center for Esthetic and Biomimetic Restorative Dentistry. USC
Oral Health Center. 2004–2006.
2. Malterud MI. Minimally Invasive Restorative Dentistry: A
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Proced Aesthet Dent. 2006;
18(7): 409–414.
3. Christensen GJ. The Advantages of Minimally Invasive Dentistry. J Am Dent Assoc. 2005;
136(11):1563–1565.
4. White JM, Eakle WS. Rationale
and Treatment Approach in
Minimally Invasive Dentistry.
J Am Dent Assoc. 2000; 131(9):
1250, 1252.
5.
Rainey JT. Understanding the
Applications of Microdentistry.
Compend Contin Educ Dent.
2001; 22 (11A):1018–1025.
6. Brantley
CF,
Bader
JD,
Shugars DA, Nesbit SP. Does
the Cycle of Restoration Lead
to Larger Restorations? 1995;
126(10):1407–1413.
7. Lutz F, Krejci I, Besek M.
Operative Dentistry: The Missing Clinical Standards. Pract
Periodont Aesth Dent. 1997;
9(5):541–548.
8. DiMatteo AM. Duplicating
Nature: Biomimetics and Dentistry. Inside Dentistry. 2009;
5 (10).
9. Alleman D, Deliperi, S. StressReducing Protocol for Direct
Composite Restorations in Minimally Invasive Cavity Preparations. Pract Proced Aesth Dent.
2009; 21(2):E1–E6.
10. Firth A, Aggeli A, Burke JL, et
al. Biomimetic Self-Assembling
Peptides as Injectable scaffolds
for Hard Tissue Engineering.
Nanomed. 2006; 1(2):189–199.
11. Chistensen GJ. Veneer Mania.
J Am Dent Assoc. 2008;
137:1161–1163.
12. Magne P, Belser U. Bonded
Porcelain Restorations in the
Anterior Dentition: A Biomimetic Approach. 1st ed. Carol
Stream, IL: Quintessence Publishing; 2002.
13. Nalbandian S, Millar BJ. The
Effect of Veneers on Cosmetic
Improvement. British Dental
Journal. 2009; 207:E3
14. Morley J. The Role of Cosmetic Dentistry in Restoring
a Youthful Appearance. J Am
Dent Assoc. 1999; 8:1166–1172.
15. Dietschi D. Free-hand Composite Resin Restorations: A
Key to Anterior Aesthetics. The
International Aesthetic Chronicle. 1995; 7:15–25.
16. Goldstein RE, Lancaster JS.
Survey of Patient Attitudes
Toward Current Esthetic Procedures. J Prosthet Dent 1984;
52:775–780.
17. Peumans M, Van Meerbeek
B, Lambrechts P, Vanherle G.
The Five-year Clinical Perfor-
3C
mance Direct Composite Additions to Correct Tooth Form
and Position. Part I: Aesthetic
Qualities. Clin Oral Investig.
1997, 1:12–18.
18. Peumans M, Van Meerbeek
B, Lambrechts P, Vanherle G.
The Five-year Clinical Performance Direct Composite Additions to Correct Tooth Form
and Position. Part II: Marginal
Qualities. Clin Oral Investig.
1997, 1:19–26.
19. Meijering AC, Roeters FJM,
Mulder J, Creugers NHJ.
Patients’ satisfaction with different types of veneer restorations. J Dent. 1997; 25:493–497.
20. Douglass T. Application of
Direct and Indirect Composite
Parts I Et. II. Int Dent (Australasian ed) 2008; 3(1):50–54.
21. Tyas M. Lack of Reliable Clinical Evidence for or Against
Direct and Indirect Veneers.
Evid Bosed Dent. 2004; 5:43.
22. Jackson, RD. Today’s Composite Resins Part I: Versatile, Aesthetic and Conservative. Dent
Today. 2009 Jul; 28(7):116,
118–119.
23. Higashi C, Loguercio A, Rels
A. Anterior Crossbite Correction with a Series of Clear
Removable Appliances: A Case
Report. J Esthet Restor Dent.
2009; 21(5):304–316.
24. Higashi C, Loguercio A, Reis A.
Re-anatomization of Anterior
Eroded Teeth by Stratification
with Direct Composite Resin.
J Esthet Restor Dent. 21:304–
317, 2009.
25. Alvesalo L., Portin P. The
inheritance pattern of missing, peg–shaped, and strongly
mesio-distally reduced upper
lateral incisors. Dental Aktieselskabet. 1969; 18(6):563–575.
26. Meskin L.H., Gorlin R.J. Agenesis and peg-shaped permanent maxillary lateral incisors.
J Dent Res 1969; 27:563–573.
About the author
Susan McMahon, DMD, has
served as a clinical professor
in prosthodontics and operative dentistry at the University
of Pittsburgh School of Dental
Medicine. She is a guest lecturer in cosmetic dentistry at
West Virginia University School
of Dentistry and lectures to dentists in the United States and
Europe on tooth whitening and
cosmetic dentistry.
McMahon is a six-time award
winner in the prestigious American Academy of Cosmetic Dentistry Smile Gallery competition.
You may contact McMahon
at:
SouthSide Works Office
2643 East Carson St.
Pittsburgh, Pa. 15203
(412) 381-3969
www.wowinsmile.com
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