The adhesive revolution – how new

biomimetic concepts are changing the

face of restorative dentistry
Maria Paula Paranhos* (DDS, MS), Visiting PhD student, School of Dentistry, USC

Since the early 1990’s, Dr Pascal Magne has focused his attention on “Biomimetic Dentistry”, which consists of
restoring the biomechanical, structural and esthetic integrity of the teeth in a conservative way. This conservative dentistry is
ruled by preservation of as much natural tooth structure as possible and can be predictably achieved due to improvements and
understanding of dental materials. Not only has Dr Magne been involved in spreading this concept and educating the dental
community, but also in proving the legitimacy of this conservative philosophy with his research. His book, “Bonded Porcelain
Restorations in the Anterior Dentition – A Biomimetic Approach”, has been a best seller since its publication in 2002, thus
supporting the importance of his work. Dr Magne is the Don and Sybil Harrington Professor of Esthetic Dentistry at USC and
runs The Center for Esthetics and Biomimetic Restorative Dentistry (CEEBRD). In the past years, this Center has received
various research collaborators from all over the world as well as predoctoral dental students, who have been developing cutting
edge research to find conservative solutions to restore teeth and dental implants within the biomimetic principle.
BIOMIMETIC RESTORATIVE DENTISTRY
Teeth, through their unique combination of natural materials - enamel, cement-enamel junction, and dentin -
constitute the perfect association of strength and resilience. The goal of adhesive restorative dentistry is to return all of the lost
dental tissues to full form and function. It can be achieved by means of restorative materials that recover the strength and
protect the remaining tooth structure when effectively bonded to both enamel and dentin. These adhesive techniques protect the
pulp and maximize preservation of tooth structure with minimal preparation and allow the long-term maintenance of their
vitality and natural appearance. Selecting which material to restore teeth is, therefore, critical and must be based on scientific
understanding and clinical experience. One of the goals of the research, developed under the supervision of Dr. Magne, is to find
out which materials and restorative techniques are more appropriate for specific clinical situations where the major rationale is
to preserve and protect teeth. In this sense, a variety of studies have been developed and published.

A PARADIGM SHIFT
Traditional prosthodontic principles (stabilization and retention) do not align with the biology (pulp survival), function
and mechanics of natural teeth. In the “biomimetic approach” all of the prepared dental tissues are returned to full function
through a hard tissue bond. This reconstruction allows functional stresses to pass through the tooth, drawing the entire crown
into the final functional, biologic and esthetic result. This is in sharp contrast to the porcelain-fused-to-metal or porcelain-
fused-to-zirconia technique, in which the stiff metal/ceramic coping makes the underlying tooth structure hypo-functional. New
biomimetic principles will ultimately result in less pulp damage and elimination of intraradicular posts or full coverage crowns.
It results in considerable improvements, comprising both the medical-biological aspect and the socio-economical context (i.e.
decrease of costs when compared to traditional and more invasive prosthetic treatments).

IMMEDIATE DENTIN SEALING (IDS) - The cornerstone

The core of adhesive dentistry is to achieve an ‘ideal’ bond to the tooth structure, especially to dentin, since bonding
to enamel is proven and predictable. In this way, Magne et al. (2005) have proposed a successful approach to benefit the bond
to dentin, the Immediate Dentin Sealing (IDS). This procedure involves the formation of a resin coating which both seals and
protects the dentin surface against bacterial leakage and sensitivity, maintaining the bond strength similar to freshly cut dentin
even in case of delayed restoration placement (Magne et al., JPD 2007). In this technique, the bonding agent is applied directly
to freshly cut dentin and polymerized before making an impression.

Fig 1 - Sample preparation for microtensile dentin bond strength test (Magne et al., JPD 2005)

Since the benefits of IDS are already well established, Dr. Magne has focused his research on the possible
interactions between impression materials and resin coated tooth surfaces. In a recently published study, with predoctoral
dental student Briklin Nielsen (2008 Dentsply Award in Research Day), it was demonstrated that the incompletely polymerized
resin coating can inhibit the polymerization reaction of impression materials. Immediate dentin sealing should, therefore, be
followed by air blocking and pumicing to generate ideal impressions with silicon-based impression materials. The clinical
significance of this study is that clinicians must be cautious when making impression after IDS.
 In order to find the best way to combine IDS with daily restorative procedures, other studies involving this technique
are being carried out at the CEEBRD laboratory. The combined use of opaquers and bonding agent to seal stained/dark dentin
is being evaluated using microtensile bond testing.

CAD/CAM RESTORATIONS - The present and future

Novel designs of bonded restorations, the behavior of those restorations when submitted to repeated biting forces, and
how new dental materials can be used to the greatest effect have also been studied at the CEEBRD. The combination of those
new materials with new equipments, such as the computer-aided design/computer-aided manufacturing (CAD/CAM)
technology, has simplified the fabrication of indirect restorations. Particularly for research, the use of CAD/CAM technology
allows fabrication of standardized restorations with less confounding variables (mostly operator-related), which gives more
consistency to the results.
Dr. Magne has a series of publications where the influence of material selection – including CAD/CAM materials – in
the fatigue resistance of restored teeth is evaluated. Together with Dr. Knezevic, he assessed the influence of material selection
(porcelain versus composite resin) for overlay-type restoration and its effect on the fatigue resistance of endodontically treated
molars. Using sophisticated servo-hydraulics to simulate cyclic isometric chewing in an artificial oral environment, they found
that the CAD/CAM composite resin MZ100 increased the fatigue resistance when compared to CAD/CAM porcelain (Research
Day Award 2007). When interpreting those results, it should be taken into consideration not only the resistance of the materials
but also the failure mode. Both composite resin and porcelain seem to be suitable for clinical applications. The composite resin,
however, presents more “friendly” and reparable failures.

Fig 2 – Artificial chewing environment and fractured specimen after testing (Magne and Knezevic, Quintessence Int 2009)

CAD/CAM COMPOSITE RESIN AND PORCELAIN OCCLUSAL VENEERS - The conservative way
A recent application of CAD/CAM restorations has been proposed by Dr. Schlichting, who investigated the possibility
of fabricating ultrathin restorations. These novel design restorations provide alternative options to other conservative techniques
such as gold onlays. In their study, attempts were made to restore eroded posterior teeth in a very conservative way. The
influence of CAD/CAM restorative material (ceramic versus composite resin) on the fatigue resistance of thin (1.2 mm) and
ultrathin (0.6 mm) occlusal veneers was evaluated. They found that for 1.2 mm-thick non-retentive occlusal veneers, CAD/CAM
composite resins (MZ100) are indicated in posterior teeth with high load requirements. It is important to note that when using
ceramics for this purpose, lithium disilicate ceramic (e.max CAD) may provide better performance than leucite ceramic
(Empress CAD). For 0.6 mm-thick veneers, milled composite resins increased the fatigue resistance of ultra-thin occlusal
veneers when compared to ceramics. More interestingly, none of the teeth fractured during the experiment, only cracks were
observed in the occlusal veneers.
The mentioned studies led to other research projects that are being developed, such as the fractography analysis of
those occlusal veneers in order to understand the failure trend and also the finite element analysis, which will assist in
understanding the stress distribution within this novel design restoration.
 Fig 3 – Artificial load cusps prepared for the fatigue testing (Schlichting et al., 2009 – in preparation)

Fig 4 – Ultrathin occlusal veneer milled by the Cerec 3 CAD/CAM system (Schlichting et al., 2009 – in preparation)

CUSTOMIZATION OF CAD/CAM COMPOSITE RESIN ONLAYS – The “human” touch

The previously mentioned studies prove that the use if composite resin CAD/CAM restorations can be beneficial in the
posterior dentition. One limitation of the CAD/CAM technology is, however, the lifeless milled restoration. Well-defined anatomy
and stains are not present and characteristics of a natural tooth cannot be encountered in those restorations. To counteract this
issue, Dr. Magne has been investigating the effect of customization of such restorations in their long-term esthetic longevity.
This pioneering technique includes a cut-back of the areas where no occlusal contact is present, and characteristic grooves,
cusps, and cervical stains, as well as cusp slopes, are added to the restoration. Promising clinical outcomes using this
technique have already been observed.
 Fig 5 – Cerec 3 CAD/CAM composite resin onlay before and after customization (Courtesy Dr. Magne)

CAD/CAM RESTORATIONS AND FIBER-REINFORCED DENTIN BONDING – Creating a new DEJ

The use of polyethylene fibers patches associated with immediate dentin sealing and CAD/CAM composite resin inlays
and onlays is also being investigated under at the CEEBRD. Dr. Boff and Dr. Oderich have evaluated the fatigue resistance of
compromised teeth – large preparation with cracks under one of the cusps – restored with composite resin and fibers patches
in different locations (bottom or top of the preparation). This is a new project that already presents exciting results.

Fig 6 - Tooth with simulated weakened cusp and crack before (left) and after (right) application of a polyethylene fiber patch (Boff et al., 2009 – in preparation)

TYPE III VENEERS BONDED TO CUSTOM IMPLANT ZIRCONIA ABUTMENTS - Uncharted territories
In addition to all the studies involving the dental structure itself, the CEEBRD has also followed the trend towards the
implant realm. New approaches, combining custom abutments and adhesively placed veneers (Magne et al., JPD 2008), have
been evaluated. Since the interest for zirconium oxide (zirconia) ceramics has grown significantly in the past decade, a major
trend is the use of zirconia implants and implant abutments. Therefore, bonding to zirconia has represented a major focus in
research. The mechanical properties of zirconia, combined to its biocompatibility and optical properties, have justified its use as
a metal-free alternative for a wide array of applications. These applications include implant dentistry (fixtures and abutments),
prosthodontics, orthodontics (brackets), and restorative dentistry (intraradicular posts). One of the limitations regarding the use
of zirconia ceramic restorations is that it is not originally intended to be adhesively cemented. Reliable and stable bond to
zirconia, however, needs to be achieved in situations where retention of the restoration relies primarily on adhesion, such as
partial veneers and resin-bonded FPDs. Dr. Paranhos developed a series of studies where micromechanical (abrasion methods
and laser treatments) and chemical strategies (special zirconia primers) were tested in order to find the best adhesive protocol
to restore non-retentive zirconia abutments.
 Fig 7 – Scanning electron micrograph of zirconium oxide ceramics impacted with Nd:YAG laser (Paranhos et al., 2009 – submitted for publication)

Once the best resin-to-zirconia adhesive protocol was established, the fatigue resistance and failure mode of type III
CAD/CAM veneers (porcelain versus composite resin) bonded to non-retentive custom zirconia abutments was assessed. The
results of this study demonstrated that the type III CAD/CAM porcelain and composite resin veneers showed similar fatigue
resistance when bonded to non-retentive zirconia abutments. The most interesting finding in their study is that the resin-to-
zirconia bond strength was strong enough to cause cohesive failures in the abutment. Additionally, the composite resin
CAD/CAM restorations presented a higher percentage of “friendly” and reparable failures, protecting the abutment. Future
research following the same principle of custom abutments is being carried out by Dr. Oderich and Dr Boff, yet in posterior
teeth. They have been evaluating the fatigue resistance of onlays bonded to custom zirconia and composite resin abutments.

Fig 8 – Type III veneer restoration and custom zirconia implant abutment (Magne et al., 2009 – in preparation)

VIRTUAL PROTOTYPING AND SIMULATION – The fifth element

Finally, the CEEBRD, in a thorough collaboration with the industry, is also building significant in-roads in restorative
dentistry by combining the use of CT scan data, a medical interactive image control system (Mimics/3-matics, Materialise), and
advanced stress simulation software (MSC Marc/Mentat) to generate virtual models of teeth and restorative conditions. The
goal of this research, which uses tools from the aerospace and automotive industry, is to propose continued development
regarding the facilitation and acceleration of geometry acquisition/modification during the fabrication of virtual models of tooth
restorations. The presented method is based on stereolithography (STL) and surface-driven automatic meshing. Advances in
virtual prototyping not only facilitate optimization and understanding of biomedical devices but will soon allow to create patient-
specific numeric models from any body part using either MRI, micro-CT or cone beam CT data. For the restorative dentist, the
ability to predict tooth/restoration failure is an example of the diagnostic value of virtual prototyping.

Fig 9 - Virtual model of a restored tooth and stress distribution comparisons in simulation software (Magne, JPD 2009 - submitted for publication)

CEEBRD team, left to right: Dr. Pascal Magne, Dr. Luis Henrique Schlichting, Dr. Maria Paula Paranhos, Dr. Elisa Oderich, and Dr. Luis Boff.

*Dr Paranhos is a PhD student at the Pontifical Catholic University of Rio Grande do Sul, Porto Alegre, Brazil
CAPES Foundation Brazil – Grant number BEX-1184-08-3

REFERENCES
MAGNE P., BELSER U. Bonded Porcelain Restorations in the Anterior Dentition – A Biomimetic Approach. Quintessence Publishing Co. (Chicago), 2002
MAGNE P. Immediate dentin sealing: a fundamental procedure for indirect bonded restorations. J Esthet Restor Dent 17:144-155, 2005
MAGNE P., KIM T.H., CASCIONE C., DONOVAN T.E. Immediate dentin sealing improves bond strength of indirect restorations. J Prosthet Dent 94;511-519, 2005
MAGNE P. 3-D rapid finite element analysis of dental restorative procedures using micro-CT data. Dent Mater 23:539-548, 2007
MAGNE P., SO W.S., CASCIONE C. Immediate dentin sealing supports delayed restoration placement. J Prosthet Dent 98:166-174, 2007
MAGNE P., MAGNE M., JOVANOVIC S.A. Novel esthetic solution for single-implant restorations – Type III porcelain veneer bonded to screw-retained custom
abutment: a clinical report. J Prosthet Dent 99:2-7, 2008
MAGNE P. TAN D.T. Incisor compliance following operative procedures: a rapid 3-D finite element analysis using micro-CT data. J Adhesive Dent , 10:49-56, 2008
MAGNE P., KNEZEVIC A. Simulated fatigue resistance of composite resin vs. porcelain CAD-CAM overlay restorations on endodontically-treated molars.
Quintessence Int 40:125-133, 2009
MAGNE P., OGANESYAN T. Premolar cuspal flexure as a function of restorative material and occlusal contact location. Quintessence Int, 40;363-370, 2009.
MAGNE P, OGANESYAN T. CT-scan-based finite element analysis of premolar cuspal deflection following operative procedures. Int J Periodontol Rest Dent,
29;361-369, 2009 (English), 29:337-345, 2009 (German)
MAGNE P., KNEZEVIC A. Influence of overlay restorative materials and load cusps and on the fatigue resistance of endodontically treated molars. Quintessence
Int, 40:729-737, 2009
MAGNE P., KNEZEVIC A. Thickness of CAD-CAM composite resin overlays influences fatigue resistance of endodontically-treated premolars. Dent Mater, 25;1264-
1268, 2009
MAGNE P, NIELSEN B. Interactions between impression materials and immediate dentin sealing. J Prosthet Dent, 102:298-305, 2009
MAGNE P, PARANHOS MP, BURNETT-JR LH. New zirconia primer improves bond strength of resin-based cements. Dent Mater (in press).
PARANHOS MP, BURNETT-JR LH, MAGNE P. Can Nd:YAG laser treatment increase the resin bond strength to zirconia ceramic? Int J Prosthodontics (submitted).
MAGNE P, SCHLICHTING LH, PARANHOS MP. Influence of material selection on the risk on inlay fracture during pre-cementation functional occlusal tapping. Dent
Mater (submitted).
MAGNE P. Virtual prototyping of adhesively-restored endodontically-treated molars. J Prosthet Dent 2009 (Submitted).
MAGNE P, PARANHOS MP, MAGNE M, BURNETT-JR LH, BELSER U. Fatigue resistance of type III porcelain and composite resin veneers bonded to screw-retained
customized CAD/CAM zirconia abutments (in preparation).
MAGNE P, SCHLICHTING LH, BARATIERI LN, MAIA HP. CAD/CAM composite resin increases the fatigue resistance of thin bonded posterior occlusal veneers. (in
preparation)
SCHLICHTING LH, MAIA HP, BARATIERI LN, MAGNE P. Novel-design ultra-thin CAD/CAM composite resin and ceramic occlusal veneers for the treatment of
enamel erosion. (in preparation)