By Hilarie Galloway, DMD
Biomimetic dentistry refers to minimally invasive dentistry which aims to replicate or “mimic” natural dentition through dental restoration. The overall mindset in biomimetic dentistry is less-is-more and utilizes restorations that approximate natural teeth in aesthetics, strength, and function. Using dental materials and techniques that imitate the innate biology of teeth allows the dentist to remove a minimal amount of tooth structure and create long-lasting restorations.
Another benefit of biomimetic dentistry is the cost-effectiveness of the restorative materials and techniques, an economic efficiency that can be directly passed along to patients. Patients generally appreciate the less-is-more mentality as well as the lower price point, creating a dynamic in which patients recommend the dentist to their friends and family, providing the dentist with valuable internal marketing simply by rendering ideal dental care.
Understanding Biomimetic Dentistry
The term “biomimetic” originated in 1957 with Otto Schmitt, an American inventor. Stemming from the literal translation “life imitating,” the concept was first introduced in dentistry in 1955 with Dr. Michael Buonocore’s paper on adhesive dentistry. In his book entitled, Bonded Porcelain Restorations in the Anterior Dentition, Pascal Magne defined the term “biomimetic restorative dentistry” in 2002 and brought the practice solidly into the public eye.
Traditional dentistry techniques remove both healthy and diseased tooth structures when repairing a tooth with a cavity or fracture. The removal of healthy teeth in these techniques was required to improve retention of the restoration due to limitations in previously existing dental materials.
In some cases, this meant that there was limited remaining tooth structure to fix once the diseased tooth was removed and the healthy tooth ideally “prepared” for restoration, sometimes leading to extraction or root canal of the tooth in question.
Conversely, biomimetic dentistry relies on improved bond strength between tooth and restoration, which is achievable given modern dental materials and specific, proven techniques. This improved bond strength enables minimal “preparation” of a tooth for a restoration which, in turn, allows for maximized natural tooth structure remaining in a restored tooth.
The keys to biomimetic dentistry that allow for this improved bond strength are isolation, immediate dentin sealing, resin coating, and dentin replacement with composite resin in thin increments.
Once a prepared tooth has been ideally sealed, resin coated, and dentin replacement completed, an indirect restoration can be cemented. Indirect restorations are ideal from a biomimetic standpoint, as reduced polymerization shrinkage occurs with indirect restorations, subsequently resulting in less stress on the tooth.
As modern innovations in bonding and resin composite materials have improved biomimetic dentistry, so has the advancement of chairside milling technology. It is now possible to create a chair-side indirect restoration on the same day as caries removal/tooth preparation.
Current chair-side milling materials are ideal for biomimetic dentistry in their comparable aesthetics, function, and strength to natural teeth. This technology improves patient experience and outcomes and saves valuable time and money for the dental provider and patient alike.
Reduced Chair Time
One benefit of biomimetic dentistry is that it allows for reduced chair time. A main principle of biomimetic dentistry is being minimally invasive. Removing less healthy tooth structure through preparation allows for less time spent in the dental chair.
Similarly, the use of indirect restorations means that the time typically used to create a restoration in the chair can be used elsewhere. Whether this means the dentist working with another patient while the same-day chair-side restoration mills, or the patient returning for a lab-fabricated restoration another day, overall chair time can be reduced with the use of indirect restorations. This simple benefit may be considered a significant advantage as a driver of practice throughput and overall efficiency.
Durable Features
Restorations are fabricated with increased durability and longevity through the use of biomimetic dentistry. Immediate dentin sealing combined with excellent isolation allows for the elimination/reduction of bacterial contamination, as well as significantly increased bond strength. Together, this makes for long-lasting restorations.
Similarly, the incremental composite layering technique creates less stress on the tooth/restoration by minimizing polymerization shrinkage. This in turn allows for more durable restorations. Another aspect of biomimetic dentistry that improves durability is minimal tooth reduction/preparation which facilitates the maintenance of a more natural tooth structure.
Recent advancements in dental materials allow for strong, durable restorations with reduced minimal thickness requirements. For example, the CAD/CAM GC Initial LiSi Block accommodates a fully crystalized restoration to be milled chair-side with no need for glazing prior to seating in a patient’s mouth.
This reduces shrinkage and drives improved marginal integrity, which in turn contributes to overall durability. Biomimetic dentistry also strives to reduce the need for root canals and extractions with minimally invasive dentistry. Vital teeth have been found to be up to three times more fracture resistant than previously root canal treated teeth. This also contributes to the overall durability and longevity of teeth/restorations.
Excellent Bond Strength
Another core feature of biomimetic dentistry is increased bond strength over that of traditional dentistry. Immediate dentin sealing by applying dentin bonding agent following preparation (prior to impressions being taken) has been found to improve bond strength by up to 400% in comparison to traditional dentin bonding which takes place just prior to cementation.
Excellent bond strength allows for a strong seal around restoration margins that can stand up to occlusal forces and reduce the chance of bacterial infiltration and secondary caries. This in turn reduces the need for more drastic procedures, such as root canals and extraction, and extends the life of the tooth.
Self-Curing Ability
Especially ideal in the case of non-vital teeth, pulp chambers can be restored using dual-cure composites. The ability of the material to self-cure (or chemical cure) slowly over the first 5 minutes after placement allows for the formation of a strong hybrid layer. This allows for a strong bond even when the composite is placed in larger increments, thanks to delayed polymerization.
Best Same-Day Techniques
In biomimetic dentistry, using the best same-day techniques is critical. These techniques allow for minimally invasive tooth preparation and maximum bond strength/longevity of restorations. The key to all of these techniques is choosing the right materials—gold standard bonding systems (3-step total-etch and 2-step self-etch dentin bonding systems are ideal), and strong and aesthetic lithium disilicate ceramics (eg fully crystalized GC Initial LiSi block) to effectively mimic strength, function and aesthetics of natural teeth.
Techniques utilized in biomimetic dentistry allow for increased bond strength and reduction of stresses which in turn increase longevity of dental restorations and teeth. As a part of same-day technique, any cracks in dentin should be removed to within 2mm of the DEJ (dentinoenamel junction).
Without pulpal exposure, the dentist should remove as much of a dentin crack as possible to prevent further crack propagation caused by forces related to dental function. Following the removal of caries and dentin cracks, onlay cusps should be 2mm in thickness at a maximum to reduce stress to the bond of the hybrid layer.
In order to improve bond strength, the preparation should be air abraded and MMPs (matrix metalloproteinases) deactivated. This can be accomplished with a 30-second treatment with chlorhexidine 2%, benzalkonium chloride, or an MDPB monomer-containing dentin bonding system. Immediate dentin sealing increases bond strength immensely.
Of similar importance is resin coating the immediately sealed dentin with a low-viscosity composite resin material (this should have a modulus of elasticity similar to dentin). Composite resin should be placed in small increments, ideally no larger than 1mm.
Large composite restorations should have fiber inserts placed on the pulpal floor/axial walls to minimize polymerization shrinkage stress on the hybrid layer. Any deep margins should be raised to a supragingival position by the creation of a “bio-base” using the aforementioned composite-bonding techniques.
Beveling enamel to expose enamel rods also contributes to increased bond strength. Once these steps have been taken, a same-day indirect restoration fabricated via CAD-CAM can be confidently cemented into place. Following these same-day techniques can improve outcomes and create strong, aesthetic, functional restorations that last.
Other Dental Applications
An exciting recent application of biomimetic dentistry is in implants. Implant dentistry provides an ideal solution for individual tooth replacement, and dental implants can also support dentures for increased stability in the case of edentulous patients. The majority of dental implants being placed are made of a metal base. When an implant heals, it requires integration with the bone for stability (osseointegration). The largest cause of implant failure in dentistry is peri-implantitis, or the loss of bone surrounding an implant due to infection and inflammation.
In recent years, researchers have attempted coating the surface of implants with different biomaterials with the goal of increasing osteointegration and decreasing the incidence of peri-implantitis. Biomimetic coatings to improve osteointegration and speed healing include a hydroxyapatite layer, nanocomposites, growth factors, and extracellular matrix (eg collagen).
Anti-bacterial coatings include medications (eg antibiotic, bisphosphonate and statin), antimicrobial peptides, polysaccharides, and metals (eg silver, zinc, and copper) which are being used to decrease the incidence of peri-implantitis. Research is ongoing, but this is a promising new dental application of biomimetics which could have broad ramifications in both individual tooth replacement and denture stability.
Power of CAD/CAM and Biomimetic Dentistry
CAD/CAM is an extremely useful tool in biomimetic dentistry. Dentists now have the technology available to fabricate same-day indirect restorations that flawlessly imitate the function, aesthetics, and strength of natural teeth. As materials have improved, the minimal thickness required has decreased, facilitating minimal preparation requirements and maximizing the amount of natural tooth remaining following preparation.
Combined with immediate dentin sealing and improved bonding techniques, CAD/CAM allows for ideal biomimetic restorations to be placed on the same day as the preparation appointment. This saves valuable time and money for both the provider and the patient.
CAD/CAM is also an excellent driver of patient referrals. Many patients are amazed by (and even want to photograph) the technology being used to restore their teeth. When they leave an appointment happy and excited, they are more likely to refer their friends to the office, which is a win-win for patients and dentists alike.
Work with Stomadent Dental Lab
Stomadent Dental Lab utilizes state-of-the-art CAD/CAM technology and top-tier dental materials for all of your dental needs. Stomadent can help you fabricate the finest biomimetic indirect restorations such as porcelain onlays or inlays. We are also available to answer your questions regarding the best dental materials available for your strong, aesthetic, and functional restorations.
Do you have questions or are you ready to get started on your next case? Check out our website.
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