CLINICAL RESEARCH

Ceramic adhesive restorations

and biomimetic dentistry:
tissue preservation and adhesion
Gil Tirlet
Senior Lecturer, Department of Prosthetic Dentistry, Faculty of Dental Surgery,
Paris Descartes University, Paris, France
Private Practice Specializing in Esthetic Dentistry, Paris, France

Hélène Crescenzo
Ceramic Dental Technician, Espace Diamant, Cogolin, France

Dider Crescenzo
Ceramic Dental Technician, Espace Diamant, Cogolin, France

Panaghiotis Bazos, DDS

Emulation, Athens, Greece

Correspondence to: Gil Tirlet

234 Boulevard Raspail, 75014 Paris, France. Tel : +33 43204130: E-mail: [email protected]

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Abstract and dentin. Today, it is clearly possible

to develop preparations allowing for the
Thanks to sophisticated adhesive tech- conservation of the enamel and dentin in
niques in contemporary dentistry, and the order to bond partial restorations in the
development of composite and ceramic anterior and posterior sectors therefore
materials, it is possible to reproduce a limiting, as Professor Urs Belser from
biomimetic match between substitution Geneva indicates, “the replacement of
materials and natural teeth substrates. previous deficient crowns and devital-
Biomimetics or bio-emulation allows for ized teeth whose conservation are justi-
the association of two fundamental par- fied but whose residual structural state
ameters at the heart of current therapeu- are insufficient for reliable bonding.”1
tic treatments: tissue preservation and This article not only addresses ceramic
adhesion. This contemporary concept adhesive restoration in the anterior area,
makes the retention of the integrity of the ambassadors of biomimetic dentist-
the maximum amount of dental tissue ry, but also highlights the possibility of
possible, while offering exceptional clin- occasionally integrating one or two res-
ical longevity, and maximum esthetic torations at the heart of the smile as a
results. It permits the conservation of complement to extensive rehabilitations
the biological, esthetic, biomechanic- that require more invasive treatment.
al and functional properties of enamel (Int J Esthet Dent 2014;9:354–369)

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Introduction tistry. As Pascal Magne points out,3 the

concept of modern biomimetics can
Biomimetics is the reproduction or copy be summarized into three distinct, but
of a model or a standard.2,3 More pre- closely linked, categories:
cisely, the notion of biomimetics consists „Observation of nature, biology, its
of reproducing and artificially imitating role, its mechanical behavior, and
natural systems in living organisms. its optical characteristics
Biomimetics is an emerging interdisci- „Respect of nature in preparing a
plinary field in materials science, engi- minimal dental tissue
neering, and biology, in which lessons „Reproduction of nature using
learned from a biological standard form adhesion and modern biomaterials
the basis for novel technological ma- (composites and ceramics)
terial innovation. It involves the inves-
tigation of both structures and physi-
cal functions of biological composites Reference model:
of engineering interest, with the goal of
the natural tooth
designing and synthesizing new and
improved materials. Natural teeth are the physiological result
The term bio-emulation was intro- of a subtle association between enam-
duced as a new expression for the dis- el, rigid and breakable, and the dentin,
cipline of dentistry, corresponding to resilient and flexible. From a functional
the reproduction of the natural model point of view, dentin cannot exist if an
via spatial, structural and optical histo- enamel shell does not cover it.3 These
anatomic emulation.4 In contemporary two tissues are associated and joined
dentistry, the concept of biomimetics together by an incredibly rich anatom-
is a true synonym for natural integra- ical interface called the dentoenamel
tion,3 meaning biological, biomechan- junction (DEJ). It is capable, through
ical, functional and esthetic integration, the intermediary of large fasces of col-
which closely mimicks the physiological lagen fibers to deflect and to impede the
behavior of the natural tooth.3,5 spreading of crevices in the enamel due
Because of sophisticated adhesive to plastic deformation.3
techniques and the progress that has Thus, due to its role as a buffer and
been made in ceramic adhesives, today stress absorber, it is a reference model
it is possible to produce a biomimetic for adhesive systems and polymer adhe-
match between esthetic substitution ma- sives used for reinforcing the biomech-
terials and the anatomical substrates of anical integrity of dental crowns5 (Fig 1).
the natural tooth.
Biomimetics associates two funda-
mental attributes at the core of modern Substitution model: adhe-
care: tissue preservation and adhesion.
sive ceramic restorations
It Is undisputable that this concept has
had the most profound effects on the The replacement of the enamel shell with
paradigms of modern restorative den- a soft material, such as composites, only

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allows for a partial restitution of the rigid-

ity of the dental crown. From this point of
view, the choice of ceramics allows for a
faithful restitution of this rigidity.2,3
Furthermore, aging is synonymous
with the volumetric reduction of the
enamel layer, and thus, an increase in
the flexibility of the tooth due to its de-
creasing rigidity.
The restitution of the original volume
of the enamel thus represents an esthet-
ic as well as a biomechanical approach. Fig 1 View of the natural incisors photographed
in transmission, allowing for the observation of dif-
Adhesive bonding technology and ce-
ference in thickness between the enamel (of the cer-
ramics have the ability to reverse and vical on the edge of the incisor) and the dentin, as
resist the effects of aging on teeth.3 For well as the amelodentin junction.
the aforementioned reasons, a rational
selection of restorative materials proves
to be essential.
Another essential point is the mater- erage ceramic adhesive restorations in
ial to combination ratio. The CER/COMP the anterior sector.
ratio should ideally be superior to 3. This The recognition of the importance of
is of great importance, due to the con- the integrity of dental tissue is the focus
tracting of polymers in the bonding com- of biomimetics. An analysis of these last
posite, and the differences in thermal points is critical following the removal of
expansion between the two materials. a prior restoration, trauma, or the elimi-
Thus, for an average bonded joint den- nation of a decayed lesion, in order to
sity of 100 mm, the ideal density of the economize hard tissue removal.
veneer should be a minimum of 300 mm. This analysis must be conducted in
A ratio inferior to the critical level of 3 will conjunction with the occlusion scheme
have important consequences in terms at hand, with emphasis on the presence
of potential failure rates of the restoration or absence of horizontal and/or oblique
(fissures and cracks in the ceramic ad- stress, the latter being the most detri-
hesive restoration).3 mental for teeth (eg, supraocclusion,
Therefore, the changing of paradigms dental wear, parafunctions, poor align-
must be accompanied by the progres- ment).
sive passage from full coverage ce- Composites – in part due to their in-
ramic restorations to partial coverage herent low elastic modulus – appear to
ceramic restorations.6 The latter may be challenged by mechanical stresses,
take the form of inlays, onlays, overlays, both masticatory and occlusal, when
veneerlays in the posterior sector and replacing large anterior coronal defi-
in veneers, half veneers or chips in the ciencies.7 In conjunction, the thermal
anterior sector.6 The scope of this article conduction mismatches them, and hy-
aims to address the various partial cov- groscopic expansion renders them even

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more vulnerable over time.7 Additionally, This article will illustrate four clinical
composites require relatively frequent, cases, three of which deal with vital teeth
meticulous clinical maintenance in or- and one with a non-vital tooth. The clinic-
der for them to reach their approximate al situations have been chosen in order
10-year life expectancy. Swift, with a pan- to demonstrate that beyond the biomi-
el of experts, concluded that the more metic approach (the chosen path for al-
complex the restoration, the shorter the most 20 years of “French” conservative
longevity.8 This statement partially con- and esthetic dentistry, today considered
firms the deficiency in stiffness attain- to be modern), the practitioner must de-
ment by composite, in order to recover ploy all modern therapeutic possibilities
the original rigidity – that of enamel. in order to not only treat the damaged
Thus today, in our clinical approach, tooth or teeth but also take into consider-
the stratification of anterior composites ation the targeted esthetic requirements
may increasingly give way to partial cov- of their patients, particularly in regards
erage ceramic adhesive restorations in to the therapeutic gradient.12
cases of large anterior coronal deficien-
cies, which are most often required in
adults in situations where stable high Case studies
esthetic requirements and longevity are
demanded.9-11 These types of restor- Case 1
ations embody the conservative doc-
trine, undisputedly placing them as the A 65-year-old woman, concerned about
therapeutic ambassador for modern her central upper incisors, presented for
biomimetic dentistry. an esthetic consultation. Her chief com-

Fig 2 Initial situation. Fig 3 Clinical view of preparation with post and
core (POM, Ivoclar/Vivadent on 12) and Partial
preparations with conservation of maximum enamel
on 11 and 21. The thickness of the preparation was
between 0.4 and 0.6 mm thus creating an optimal
enamel surface for bonding.

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plaint was that she disliked the shape

and the position of 21 and 11 (Fig 2).
The following treatment plan was pro-
posed to the patient: the rehabilitation of
her smile by a new crown on 12 (she pre-
sented gingival inflammation induced
by the actual prosthesis’ overcontour),
as well as two resin-bonded partial-cov-
erage ceramic restorations. Tooth 22 Fig 4 Preparation
dictated the esthetic outcome and guid- after curing of the ad-
hesive system on 11.
ed this minimally invasive rehabilitation
(Figs 3 to 7). No crown lengthening in or-
der to correct the gingival margin archi-
tecture was performed since the patient
preferred to avoid additional surgery.
Although a lack of symmetry among the
anterior teeth can be observed, the pa-
tient’s smile is still harmonious and natu-
ral (Figs 8 to 11). 
Fig 5 View of the
ceramic adhesive
restoration at bond-
ing. The adhesive
used was Optibond
Solo plus (Kerr).

Fig 6 Final result at 1-week follow-up. Note the Fig 7 One-month follow-up with contrastor.
biological and morphological appearance. This
view perfectly illustrates the biomimetic concept
using the “enamel substitution,” allowing the total
recovery of the intrinsic strength of the teeth.

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Fig 8 One-year follow-up (with two lateral softbox). Fig 9 One-year follow-up. Image taken with con-
At this time, we can notice a little gingival injury (me- trastor (with two lateral soft boxes).
sial side on 12) caused by severe tooth brushing.

Fig 10 One-year follow-up: left lateral view of the Fig 11 One-year follow-up: right lateral view of
smile. The asymmetry in the shape and the dental the smile.
composition remains the principal key to the smile’s
expression.13

The composite restoration was fixed

Case 2
with a stainless steel post and core,
A 17-year-old patient consulted in or- which characterizes conventional den-
der to re-evaluate previous endodontic tistry based on mechanical concepts
work on tooth 21 that was completed 3 (Fig 13). An initial radiograph was taken,
years previously following a trauma – it which displayed the high quality of the
was discolored due to a root canal. The endodontics (Fig 14). The composite
therapeutic choice in this case only took restoration and the stainless steel post
into consideration the biological, bio- and core were removed (Fig 15).
mechanical and esthetic rehabilitation A dental dam was applied. The crown
of tooth 21 per the patient’s esthetic re- presented very good residual tissue. After
quest (Fig 12). sandblasting, etching and the placing of

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Fig 12 Initial clinical situation. Fig 13 The composite restoration is fixed with a
stainless steel post and core.

Fig 14 An initial radio-

graph exhibits the high
quality of the endodontics.

Fig 15 Clinical view following the removal of the

composite restoration and prior to the removal of the
stainless steel post and core.

the adhesive system, flow micro hybrid

composite was applied at the base of
pulpal chamber preceding the placement
of the restoration composite (UD2, Enamel
HRi, Mycerium). A post was not necessary
in this situation due to the important ferrule
effect – the result of the conservation of
residual tissue (Fig 16).
The ceramic adhesive restoration
(e.max MO1, Ivoclar Vivadent) on the
buccal side was prepared, increasing
the enamel surface. A metallic matrix was Fig 16 Clinical view of 21 with dental dam.

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Fig 17 Preparation of the ceramic Fig 18 Completion of the buccal

adhesive restoration on the buccal preparation with an Acteon/Satelec
side. insert.

Fig 19 Final occlusal view with the palatal exten- Fig 20 View of the Emax MO1 ce-
sion going beyond the cingulum. ramic adhesive restoration.

Fig 21 View of the

ceramic adhesive res-
toration at the moment Fig 22 Radiograph fol-
of bonding. The adhe- lowing bonding that dem-
sive used was Optibo- onstrates the perfect fit
nd Solo plus. and seal of the restoration.

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connected to a plastic corner (Fender

wedge, Pred), which protected the ad-
jacent teeth. The buccal preparation
was completed with an Acteon/Satelec
insert for finishing two diamond grits: 76
microns and 46 microns to perfectly fin-
ish the margins (Figs 17 to 19). The ce-
ramic adhesive restoration was bonded
(Figs 20 and 21) and a radiograph at-
tested for a good adaptation (Fig 23).
Figures 23 to 26 show the final result and
biomimetic integration after bonding. Fig 23 Clinical view one week after bonding.

Figure 27 shows the clinical result at the

3-year follow-up.

Fig 24 Black and white picture to appreciate Fig 25 One-week follow-up (with contrastor).
brightness of the single restoration.

Fig 26 Smile integration. Fig 27 Three-year follow-up.

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Case 3

A 34-year-old man had a large compos-

ite on the left central incisor (21). The
patient refused proposed orthodontic
treatment. He preferred to find another
esthetic solution to restore his tooth. The
suggested treatment consisted of re-
placing the composite restoration with
a ceramic bonded partial restoration
(Fig 28).
Fig 28 Initial situation.

Fig 29 The clinical view of the preparation for the Fig 30 The final step in preparation with diamond
ceramic half veneer. Excellent tissue preservation ultrasonic insert.
can be observed.

Fig 31 The preparation following placement of Fig 32 Ceramic half-veneer

the dam before bonding. restoration before bonding.

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Fig 33 Final biomimetic result. Fig 34 Final situation (with two lateral soft box).

When the preparation for the ceramic Case 4

half veneer was carried out, excellent
tissue preservation could be observed. A 35-year-old woman came to our prac-
The tooth was then prepared with a di- tice because of a bike trauma (Fig 35).
amond ultrasonic insert (Fig 29 to 31). We diagnosed crown fractures from me-
A rubber dam was applied before the dium to severe on teeth 11, 21 and 22
bonding of the ceramic half-veneer and also had to plan endodontic treat-
(Figs 31 and 32). Figure 33 and 34 ment. A temporary composite build
(1 year and 6 months follow-up with two up was performed on the three teeth.
lateral soft boxes) shows the final biomi- Preparations were guided by mock-ups
metic results. (Figs 36 to 38). Figures 39 to 43 show
the biomimetic results. Figure 44 shows
a radiograph to control apical healing

Fig 35 Initial situation: emergency. Fig 36 Preparation driven by mock-up.3,14 The

wax-up permitted the creation of a mock-up with
a silicone index use during the preparation stage.

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Fig 37 Mock-up just after preparation. (Luxatemp Fig 38 View of four preparation for ceramic ad-
Star, DMG) hesive restorations. No post or crown in this case
even on non-vital teeth and preservation of maximal
enamel.

Fig 39 Final view: one-week follow-up after Fig 40 Black and white picture to appreciate
bonding. brightness of the four restorations.

Fig 41 Polarized view with Polar_eyes (Emulation). Fig 42 Lateral view of smile: right side.

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Fig 43 Intra buccal view: right side. Fig 44 Radiograph with complete apical healing
on four anterior teeth.

Fig 45 Buccal view at one-year follow-up. Note Fig 46 Buccal view at two-year follow-up (with
the biomimetic integration and especially the bio- two lateral soft boxes).
logical integration with the gum.

and demonstrates a lack of Post and thetic, biomechanical and functional

core (Endodontic treatment: Dr Anne properties of enamel and dentin.
Laure Simon, Paris). Figures 45 and 46 Provided there is diligent implemen-
show the results at a two-year follow up tation and management of modern
with two lateral soft boxes). dental technology, dental adhesive sys-
tems have proven to be reliable over
time, thus imparting a secure bond
Conclusion between the tooth and the restoration.
Nonetheless, deep knowledge of bio-
In choosing partial coverage ceramic mechanical principles and techniques
adhesive restorations, biomimetics per- of conservative tooth preparation are
mits the imitation of the biological, es- essential to create optimal conditions

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for the implementation of a favorable tissue. It is important to take this major

oral restitution. evolution of biomimetics into considera-
The timelessness, the ideal surface tion in our respective practices.
characteristics and biomechanical inter- In conclusion, Pascal Magne at the
action that are ensured by a high per- Brussels Conference, December 2011,
formance dynamic bond to the tooth as perfectly illustrated this concept: “Get
a whole, classify ceramics as the ideal bonded, stay bonded.”15
restorative materials and the best choice
in terms of esthetic satisfaction. Optimal
rigidity in delicate areas, excellent chew- Acknowledgments
ing capacity, biocompatibility with peri-
odontal tissues, combined with excel- I would like express my most sincere
lent continuity between the material and gratitude to my advisor Professor Michel
enamel after bonding, bestows them Degrange for all that he has taught me,
with the ability to act as a true enamel both clinically and scientifically, and
replacement. It is important, however, to express my utmost admiration for
to be attentive in order to conserve the all that he has contributed to adhesive
maximum amount of enamel by imple- dentistry throughout his career and life. I
menting contemporary protocols, such would also like to warmly thank my other
as preliminary wax-ups, mock-ups and mentor Dr Pascal Magne for all that he
volumetric driven matrix guided reduc- has brought me over the past 20 years
tions. through his clinical and scientific work.
Partial coverage ceramic adhesive His place at the summit of contemporary
restorations can be utilized as the re- dentistry remains for me an absolute ex-
storative treatment modality in a variety ample and reference.
of clinical cases, vital and/or non-vital I would also like thank to my “brother”,
teeth provided that fundamental bond- Dr JP Attal for sharing in this exceptional
ing requirements can be met. human and professional adventure at
The goal of this article is not only to the university and the hospital, as well
showcase the said restorative modality as through GRF’s biomimetic workshops
in the anterior dentition, as a strong pro- over the past seven years.
ponent of biomimetic dentistry, but also I also extend my warmest thanks to
to highlight the possibility of achieving my new professional “family,” the Bio-
a seamless integration of restorations at Emulation Group, through whose daily,
the heart of the smile as a contrast to ex- challenging exchanges I continue to
tensive and invasive rehabilitations that progress ever more.
would require more invasive treatment. I finally thank Maris Harrington for her
Today the possibility exists to estheti- invaluable help in the writing and editing
cally reconstruct teeth while preserving of this article.

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