Biomimetic Restorative Dentistry, Volume 1

Fundamentals and Basic Clinical Procedures

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Library of Congress Cataloging-in-Publication Data

Names: Magne, Pascal, author. | Belser, U., author.

Title: Biomimetic restorative dentistry / Pascal Magne, Urs Belser.
Other titles: Bonded porcelain restorations in the anterior dentition
Description: Second edition. | Batavia, IL : Quintessence Publishing Co.,
Inc., [2021] | Preceded by Bonded porcelain restorations in the anterior
dentition / Pascal Magne, Urs Belser. Chicago : Quintessence Pub. Co.,
c2002. | Includes bibliographical references and index. | Contents:
Understanding the Intact Tooth and the Biomimetic Principle -- Natural
Oral Design -- Ultraconservative Treatment Options -- Semi-Indirect
Approaches in Anterior and Posterior Teeth -- Esthetic Treatment
Planning and Diagnostic Approach -- Anterior Indirect Bonded Porcelain
Restorations -- Maintenance and Advanced Repair Techniques. | Summary:
“Applies the biomimetic principle to bonded restorations using composite
resins and ceramics, describing the broad spectrum of indications and
detailing the treatment planning, diagnostic approach, step-by-step
treatment, and maintenance for each”-- Provided by publisher.
Identifiers: LCCN 2021005708 | ISBN 9780867155723 (hardcover)
Subjects: MESH: Dental Bonding--methods | Dental Restoration
Repair--methods | Biomimetics | Esthetics, Dental
Classification: LCC RK652.5 | NLM WU 190 | DDC 617.6/95--dc23
LC record available at https://lccn.loc.gov/2021005708

A CIP record for this book is available from the British Library.
ISBN: 9780867155723

©2022 Quintessence Publishing Co, Inc

Quintessence Publishing Co, Inc

411 N Raddant Road
Batavia, IL 60510
www.quintpub.com

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All rights reserved. This book or any part thereof may not be reproduced, stored in a retrieval system, or trans-
mitted in any form or by any means, electronic, mechanical, photocopying, or otherwise, without prior written
permission of the publisher.

Editor: Leah Huffman

Design: Sue Zubek
Production: Sue Robinson

Printed in Croatia

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BIOMIMETIC
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RESTORATIVE
DENTISTRY
VOLUME 1
Fundamentals and Basic Clinical Procedures

Pascal Magne, pd, dr med dent

Urs Belser, dmd, prof, dr med dent

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PASCAL MAGNE

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Dr Pascal Magne is an Associate Professor with Foundation for Medical-Biological Grants and
tenure and the Don and Sybil Harrington Foun- was honored with the 2002 Young Investiga-
dation Professor of Esthetic Dentistry in the Divi- tor Award from the International Association for
sion of Restorative Sciences at the University Dental Research as well as the 2007, 2009, and
of Southern California Herman Ostrow School 2018 Judson C. Hickey Scientific Writing Awards
of Dentistry in Los Angeles. He graduated from (for the best research/clinical report of the year
the University of Geneva Dental School in Swit- published in the Journal of Prosthetic Dentistry).
zerland in 1989 with a Med Dent degree and He was also the recipient of the Distinguished
later obtained his doctorate in 1992 and his Privat Lecturer Award of the Greater New York Acad-
Docent degree in 2002. Dr Magne received emy of Prosthodontics in 2016. Dr Magne is the
postgraduate training in fixed prosthodontics and author of numerous clinical and research articles
occlusion, operative dentistry, and endodontics on esthetics and adhesive dentistry and is an
and was a lecturer at the same university begin- internationally known mentor and lecturer on
ning in 1989 until 1997. From 1997 to 1999, he these topics. The first edition of this textbook
was a Visiting Associate Professor at the Minne- has been translated into 12 languages and is
sota Dental Research Center for Biomaterials considered one of the most outstanding books
and Biomechanics at the University of Minnesota in the field of adhesive and esthetic dentistry. Dr
School of Dentistry. After concluding 2 years of Magne is a founding member of the Academy
research, Dr Magne returned to the University of of Biomimetic Dentistry and a mentor of the Bio-
Geneva Dental School and assumed the position Emulation think-tank group. In 2012, he launched
of Senior Lecturer in the Division of Fixed Pros­ a revolutionary approach to the teaching of
thodontics and Occlusion until he was recruited dental morphology, function, and esthetics (the
to the University of Southern California in Febru- 2D/3D/4D approach) for freshman students at
ary 2004. He is the recipient of multiple awards the Herman Ostrow School of Dentistry at USC.
from the Swiss Science Foundation and the Swiss

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can be scanned to access exclusive video content demon-
strating techniques or further explaining concepts. They
will be updated as new material becomes available.

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Prof Urs Belser graduated from the Dental Insti- dontics (EPA) from 2002 to 2003, and Visiting
tute at the University of Zurich in Switzerland. He Professor at Harvard University in the Depart-
received postgraduate specialty training in ment of Restorative Dentistry and Biomaterials
reconstructive dental medicine (board-certified Sciences (Prof Dr H. P. Weber) in 2006. Since 2012
specialist) at the University of Zurich and was an he has been Guest Professor in the Department
Assistant Professor and then Senior Lecturer in of Oral Surgery (Prof Dr D. Buser) and Department
the Department of Fixed Prosthodontics and of Reconstructive Dentistry (Prof Dr Urs Braegger)
Dental Materials there (Prof Dr Peter Schärer, MS) at the School of Dental Medicine at the University
from 1976 to 1980. He was also a Visiting Assis- of Bern. In 2013 he became an Honorary Fellow
tant Professor from 1980 to 1982 in the Depart- of The International Team of Implantology (ITI).
ments of Oral Biology (Prof Dr A.G. Hannam) and Between 2013 and 2017 he served as editor-in-
Clinical Dental Sciences (Prof Dr W. A. Richter) in chief of Forum Implantologicum (ITI), and in 2014
the Faculty of Dentistry at the University of British he became a lifetime honorary member of the
Columbia in Canada. Between 1983 and 2012, American College of Prosthodontists (ACP) and
Prof Belser acted as the Professor and Head of received the Lecturer of the Year Award. In 2018
the Department of Fixed Prosthodontics and he was presented the Morton Amsterdam Inter-
Occlusion at the University of Geneva School of disciplinary Teaching Award (together with Prof
Dental Medicine, serving as the president of the Dr D. Buser). Prof Belser’s research is focused
Swiss Association of Reconstructive Dentistry on implant dentistry, with special emphasis on
from 1984 to 1988. He was the recipient of the esthetics and the latest developments in the field
Scientific Research Award of the Greater New of CAD/CAM technology and high-performance
York Academy of Prosthodontics in 2002, Pres- dental ceramics, as well as on adhesive recon-
ident of the European Association of Prostho- structive dental medicine.

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Emerging concepts in biomimetic restorative BRD offers restorative solutions that balance
dentistry (BRD) provide the ability to restore the the functional and esthetic needs of the anterior
biomechanical, structural, and esthetic integrity of and posterior dentitions. A wide range of restora­
teeth with utmost respect for biologic structures tive techniques, from direct to semi-(in)direct and
(pulp and periodontal tissues). Adhesive tech- indirect approaches, are available to cover each
niques constitute the cornerstone of BRD, and patient’s specific needs. Combining ceramics
novel restorative designs are striking elements of and composite resin optimal stiffness, their wear
this nascent approach to tooth restoration. Indi- and surface characteristics, and the biomechani-
cations for bonded restorations have expanded cal strength achieved through high-performance
to include more advanced destructive conditions bonding enable the crown of the tooth as a
such as severely broken-down teeth, crown-­ whole to support masticatory function. By the
fractured teeth, and nonvital teeth. As a result, same token, the optical effects inherent in the
considerable improvements have been made tooth and the lifelike features of composite resins
both medicobiologically and socioeconomically: and ceramics make this restorative approach
More sound tissue is preserved, tooth vitality is the ultimate in esthetic satisfaction for both the
maintained, and treatment is less expensive than practitioner and the patient.
traditional and more invasive prosthodontics.

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Watch nature...
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Not manmade, not humanly inspired, but divinely designed …

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… and faithfully emulated.

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DEDICATION

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To my wife, Geibi, and my children, Erine and Santiago, the most precious gifts
from God in my life. To my brother, Michel, whom I love dearly and who shared
and brought to light his passion for God, for dentistry, and for dental technology.
To my sister, Marina, her husband, and my nephews, who were always present and
available despite the physical distance separating us. To my nieces, also distant but
always present in my heart. In memory of my mother, Agnès, who was taken from
us by cancer too early, and my father, Albin, who supported me and encouraged
me in all situations.

—PM

In memory of my mother, Heidi, and my father, Theodor. To my wife, Christine,

for her unfailing support and patience. To my children, Marc and Michèle, and
grandchildren.

—UB

Geneva, 2018

As iron sha rpens iron, so one person sha rpens a nother. —Proverbs 27:17

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CONTENTS
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VOLUME 1
Foreword by William H. Douglas  xxiv
Foreword by Panaghiotis K. Bazos  xxv
Preface  xxvii
The Four Elements  xx
Gallery  xxiv

1 Understanding the Intact Tooth and the Biomimetic Principle  1

1.1 Biology, Mechanics, Function, and Esthetics  2

1.2 Optimal Compliance and Flexibility  4
1.3 Rationalized Anterior Tooth Shape  6
1.4 Rationalized Posterior Tooth Shape  8
1.5 Mechanics and Geometry During Function  10
1.6 Physiologic Enamel Cracking and the DEJ  20
1.7 Natural Tooth Aging and Enamel Thinning  28
1.8 Biomimetics Applied to Mechanics  36
1.9 Copying vs Simulating Nature  52
1.10 Biomimetic Implant Restorations  54

2 Natural Oral Design  67

2.1 General Considerations  68

2.2 Fundamental Criteria  72
2.3 Esthetic Integration and Smile Balance  132
2.4 Morphology of Posterior Teeth  144
2.5 Didactic Steps to Dental Morphology  178
2.6 Drawing Models  184

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Ultraconservative Treatment Options  233

3.1 Chemical Treatments and Biomimetics  234

3.2 Nightguard Vital Bleaching  236
3.3 Microabrasion and Megabrasion  250
3.4 Remineralization and Resin Infiltration  254
3.5 Nonvital Walking Bleach Technique  258
3.6 Reattachment of a Tooth Fragment  272
3.7 Adhesive Restorative Materials and Armamentarium  278
3.8 Direct Restorations in Anterior Teeth  308
3.9 Considerations for Direct Restorations in Posterior Teeth  340
3.10 Deep Margin Elevation Technique  358

4 Semi-(In)direct Approaches in Posterior and Anterior Teeth  379

4.1 Historical Perspective and Classification  380

4.2 The Chairside CAD/CAM Age  386
4.3 Posterior CAD/CAM Restorations  388
4.4 Immediate Dentin Sealing  400
4.5 The Natural CAD/CAM Restoration  412
4.6 Endocrowns and CAD/CAM Assemblies  414
4.7 Luting Procedures in Posterior Teeth  416
4.8 Anterior CAD/CAM Restorations  424

Index

VOLUME 2

5 Esthetic Treatment Planning and Diagnostic Approach  447

5.1 Interactive Patient-Operatory-Laboratory Relationships  448

5.2 Patient Management  450
5.3 Photoshop Smile Design  452
5.4 Treatment Planning and Initial Therapy  454
5.5 Diagnostic Wax-up Step by Step  460
5.6 Diagnostic Mock-up  478
5.7 Special Cases  489
5.8 Biocorrosion/Wear and Tight Bites  514
5.9 Basics of Digital Dental Photography  542
5.10 Shade Documentation/Communication  548

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6 Anterior Indirect Bonded Porcelain Restorations  565
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6.1 History and Classification of Indications  566

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6.2 Type I: Teeth Resistant to Bleaching  570 u

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Type II: Major Morphologic Modifications  574 i n t e s s e n

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6.3
6.4 Type III: Extensive Restorations in Adults  588
6.5 Combined Indications  606
6.6 Types IV and V: Full-Coverage Crowns/Endocrowns  608
6.7 Biologic Considerations  612
6.8 Perspectives for Occlusal Veneers  616
6.9 Tooth Preparation Principles  620
6.10 Definitive Impressions  666
6.11 Provisional Restorations  672
6.12 Laboratory Procedures  682
6.13 Try-in and Adhesive Luting Procedures  730

7 Maintenance and Advanced Repair Techniques  769

7.1 BPRs: Maximum Performance, Reduced Maintenance  770

7.2 Routine Professional Hygiene  772
7.3 Complications and Repairs  776
7.4 Postbonding Crack Infiltration  790
7.5 Replacement of Class 3 Composite Resin Restorations   796
Adjacent to BPRs

αΩ The Whole Story: From La Chaux-de-Fonds to

Los Angeles  801

αΩ.1 Early Challenges: Setting the Stage  802

αΩ.2 Early Academic Life and the Brothers  804
αΩ.3 Touched by God  806
αΩ.4 The Minnesota Experience  811
αΩ.5 Geneva to Los Angeles  813

Index

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FOREWORD

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It is with considerable pleasure that I write the The approach is basically conservative and
foreword to Dr Magne and Prof Belser’s book, biologically sound. This is in sharp contrast to
which takes the science of esthetic dental the porcelain-fused-to-metal technique, in which
reconstruction to a new level both clinically and the metal casting with its high elastic modulus
academically. Dr Magne spent 2 years as a Visit- makes the underlying dentin hypofunctional. The
ing Associate Professor in the Minnesota Dental goal of the authors’ approach is to return all of
Research Center for Biomaterials and Biome- the prepared dental tissues to full function by the
chanics at the University of Minnesota, where creation of a hard tissue bond that allows func-
many of the ideas promulgated in this book were tional stress to pass through the tooth, drawing
hotly debated, refined, and tested in a modeling the entire crown into the final esthetic result.
and experimental environment. In this book, the I hope that this new edition of the book will
clinician will find all that he or she could wish receive a wide readership and that its principles
for in terms of indications and the classic clin- will be carefully studied and become fully estab-
ical steps for tooth preparation, laboratory as lished in teaching and research, as well as de
well as CAD/CAM procedures, adhesive luting rigueur in the practice of restorative dentistry.
procedures, and maintenance protocols. Those
who have heard Dr Magne lecture will not be William H. Douglas, bds, ms, phd
disappointed. In fact, they will find much more Former Director, Minnesota Dental Research
that is practically and intellectually satisfying. Center for Biomaterials and Biomechanics
The central philosophy of the book is the Former Chair, Department of Oral Science,
biomimetic principle—that is, the idea that the University of Minnesota
intact tooth in its ideal hues and shades, and Professor Emeritus, School of Dentistry,
perhaps more importantly in its intracoronal University of Minnesota
anatomy and location in the arch, is the guide to Minneapolis, Minnesota
reconstruction and the determinant of success.

Minneapolis, 1998

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FOREWORD

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In today’s 24/7 media culture, everyone strives A polymath in every sense, Dr Pascal Magne
to become an expert, but not everyone realizes has the disposition of a perioral architect simul-
what it actually takes in order to reach the level taneously operating like an intraoral engineer.
of a master. True mastery requires enormous To marvel, wonder, and attempt to decode the
amounts of work, persistence, and perseverance. divine design of our Creator has become his
It requires time and discipline. It requires fortitude passion, his vocation, his calling.
and effort. It requires setbacks and failures. Yet the simplicity and profundity of his message
From 2005 to 2007 while teaching alongside is to observe and preserve the harmony of the
Michel Magne and Dr Pascal Magne at the USC dental structures and, only when absolutely
Herman Ostrow School of Dentistry, I witnessed necessary, to intervene with the utmost respect
mastery personified in their pursuit of excellence. and care to the natural dental substrates, utilizing
Nothing was left to chance, from the special- biomimetic principles and analogous restorative
ized equipment utilized in order to test his null biomaterials in such a modality as to ultimately
hypotheses to the research and development conserve and reinforce the remaining sound
carried out by his talented postdoctoral students, tissue structures.
to continually optimize protocols enabling the First do no harm; then try to prevent it at all
dental community to achieve the highest quality costs.
of work for their patients.
From the start and over the years Pascal has Panaghiotis K. Bazos, dds, mclindent orthodontics,
become a revered mentor and cherished friend, morth rcs (Edin.)
and he ever remains a distinguished colleague Founder and CEO, Bio-Emulation
of mine. The authenticity in his didactic approach Private Practice in Restorative Dentistry and
paired with his common-sense clinical meth- Orthodontics
odologies have inspired a new generation of Aigio, Greece
adhesively driven restorative dentists to further
explore the science and art of dentistry in order
to faithfully bioemulate nature.

Los Angeles, 2007

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BRD gave rise to a new generation of multital- for sharing their collective experience and tacit
ented dentists and dental technicians, intently knowledge, by freely exchanging ideas and
enthusiastic for advancing the concept further by conceptualizations. Special appreciation and
diving deeper into understanding the archetype gratitude for my fellow Bio-Emulator, esteemed
of the natural tooth. The Bio-Emulation move- colleague and dear friend, Dr Javier Tapia-Guadix
ment has become a beautiful fruit of this labo- (Madrid, Spain), one of the most inspirational and
rious endeavour. If there is a single word that instrumental members of the group. His amaz-
makes creative people different from others, it ing creativity and undeniable talent in CGI and
is the word simplicity. Many minds that are inter- mesmerizing animations are on full display in
connected by one universal mindset that allows chapters 1 and 2.

xvi
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PREFACE

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The most exciting developments in dentistry biologic “composites” and the design of new
have emerged within the past decade. Digitally and improved substitutes. Biomimetics in dental
guided implant dentistry, guided tissue regener- medicine has increasing relevance. The primary
ation, adhesive restorative dentistry, and CAD/ meaning for dentistry refers to processing mate-
CAM restorations are strategic growth areas both rial in a manner similar to that by the oral cavity,
in research and in clinical practice. However, the such as the calcification of a soft tissue precursor.
many advances in dental materials and technol- The secondary meaning refers to the mimicking
ogy have generated a plethora of dental prod- or recovery of the biomechanics of the original
ucts in the marketplace. Clinicians and dental tooth by the restoration. This, of course, is the
technicians are faced with difficult choices as goal of restorative dentistry.
the number of treatment modalities and techno- Several research disciplines in dental medi-
logic tools continues to grow. Further, changes in cine have evolved with the purpose to mimic
technology do not always simplify technique or oral structures. However, this nascent principle is
decrease treatment costs. Prudence and wisdom applied mostly at a molecular level, with the aim
need to be combined with knowledge and prog- to enhance wound healing, repair, and regenera-
ress when it comes to improving our patients’ tion of soft and hard tissues.2,3 When extended to
welfare. In this perplexing context, no one will a macrostructural level, biomimetics can trigger
contest the need for less expensive, satisfactory, innovative applications in restorative dentistry.
and rational substitutes for current treatments. Restoring or mimicking the biomechanical, struc-
The answer emerged from an interdisciplinary tural, and esthetic integrity of teeth is the driving
biomaterial science called biomimetics.1 This force of this process. Therefore, the objective of
concept of medical research involves the inves- this book is to propose new criteria for esthetic
tigation of the structure and physical function of restorative dentistry based on biomimetics.

xvii
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Biomimetics in restorative dentistry starts Acknowledgments

with an understanding of hard tissue structure
and related stress distribution within the intact We should always remember that a key element
tooth, which is the focus of the opening chap- for successful and predictable restoration is
ter of this book. It is immediately followed by a teamwork, and an essential ingredient for team-
systematic review of parameters related to natu- work is humility—to consider others better than
ral oral esthetics. Because the driving forces of oneself. We must try to serve each other rather
restorative dentistry are maintenance of tooth than expect to be served. I would have been
vitality and maximum conservation of intact unable to achieve this work without the valued
hard tissues, the next chapters describe the collaboration of other dentists, dental techni-
ultraconservative treatment options and arma- cians, specialists, and researchers, all mentioned
mentarium that can precede a more sophisti- below.
cated treatment. The description of semi-(in)direct In 2003, Dr Harold Slavkin, as a Dean, along
approaches concludes Volume 1 of the book; with Dr Cherilyn Sheets, had a vision that included
those techniques can be considered when recruiting me to the University of Southern Cali-
direct techniques are challenging to apply (eg, fornia (USC), thus initiating our amazing journey
large restorative volume with cervical margins in to the United States in 2004. The numerous
dentin) and when indirect technique costs are not visiting scholars in my research laboratory as
justified or simply not affordable by the patient. well as all graduate dental students have been
The core of Volume 2 of the book centers enlightening my daily academic activities. They
on the application of the biomimetic principle have been a constant source of fresh air and
in the form of anterior indirect bonded porce- the breath of my life at USC. Our research works
lain restorations using composite resins and have been possible thanks to the unconditional
ceramics. The broad spectrum of indications of gifts of various colleagues, in particular Dr Parto
anterior indirect bonded porcelain restorations is Ghadimi. I also want to thank all the companies
described, preceded by detailed instruction on who provided their materials for research with
the treatment planning and diagnostic approach, no strings attached.
which is the first step for every case. Proposed There are numerous ceramists and labora-
treatments are described step by step through- tories who have inspired me much and offered
out both book volumes, including tooth prepa- support in one way or another. Special thanks
ration and impression, laboratory and CAD/CAM to Willi Geller, Klaus Müterthies, Claude Sieber,
procedures related to the fabrication of compos- Enrico Steiger, Naoki Hayashi, Sascha Hein,
ite resin and ceramic workpieces, and their final August Bruguera, Giuseppe Romeo, Milos Mila-
insertion through adhesive luting procedures. dinov, and Sam Alawie, among others.
CAD/CAM techniques are also included as perti- Witnessing the birth of The Academy of Bio-­
nent tools for the achievement of the biomimetic mimetic Dentistry with Dr David Alleman as well
principle. Volume 2 ends with discussion of the as The Bio-Emulation group with Dr Panaghiotis
follow-up, maintenance, and repair of bonded Bazos, Javier Tapia Guadix, and Gianfranco
restorations. Politano have been among the most memorable

xviii
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moments of my journey. Their members have book, and the private practitioners who donated
been instrumental in stimulating my mind and extracted teeth for the studies and illustrations.
pushing the boundaries of my creativity. Special thanks to Mr William Hartman and the
I feel so blessed to have studied under Prof Quintessence Chicago team—Leah Huffman,
Urs Belser; his teaching and guidance have been Sue Zubek, and Sue Robinson—for pushing the
invaluable to me and his support always uncon- envelope of my creativity and rendering this work
ditional. Life lessons have been learned thanks in the most exquisite way. A particular thought
to him. He is my first mentor. goes to the late Mr Peter Sielaff from Quintes-
I extend my endless appreciation to my sence Berlin who had been instrumental to the
brother, Michel Magne, MDT, my second mentor, making of the first edition of the work.
for his significant contributions to the chapter on Finally, I give honor and glory to my Lord
laboratory procedures and for his skills in fabri- and Savior, Jesus Christ, my mentor above all
cating the ceramic restorations for most of the mentors, who has made all of my projects possi-
cases in this book. Our brotherly “BOND” is to be ble through his gracious love. He also provided
compared to a perfect resin-ceramic bond that my soul mate, Geibi, and two additional gifts, our
has overcome the numerous storms of life. Our children Erine and Santiago. None of this work
synergy is also that of a perfectly bonded porce- would have been possible without them.
lain restoration: “Michel, delicate and fragile like I hope that you will enjoy reading this work
porcelain but strong once bonded. Pascal, more and applying its content for the good of your
resilient like composite resin but made beautiful patients and the joy of practicing biomimetic
by Michel’s skills.” restorative dentistry.
Special thanks go to Dr William Douglas, my God bless you!
third mentor, but also Drs Ralph DeLong, Maria
Pintado, Antheunis Versluis, and Thomas Korioth References
at the University of Minnesota for their help and
1. Sarikaya M. An introduction to biomimetics: A structural
friendship during my 2-year research scholarship
viewpoint. Microsc Res Tech 1994;27:360–375.
there that led to my PhD. They expanded my 2. Slavkin HC. Biomimetics: Replacing body parts is no lon-
ger science fiction. J Am Dent Assoc 1996;127:1254–1257.
vision and knowledge of scientific research in
3. Mann S. The biomimetics of enamel: A paradigm for
biomaterials and biomechanics. organized biomaterial synthesis. Ciba Found Symp
I also acknowledge my precious patients, 1997;205:261–269.

who directly contributed to the making of this

Pascal Magne

xix
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The Four Elements…

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1. SCIENCE. Science comes from the work of men.

Hence, science can be flawed. Humans make mistakes, and during the many steps in the making of a
scientific work, imperfections can be cumulated. Scientific interpretation adds to the widening of the
prediction values. While science is undeniably necessary to the growth of knowledge, it may become
much less valuable if not paired with common sense.

2. EXPERIENCE. Experience is YOUR story.

It is made of the practical knowledge, skill, or elements that you accumulated from direct observation
or participation in events or in a particular activity. Experience may be considered as part of science
but is not accepted per se as scientific, which is a contradiction because experience is truly priceless.

3. COMMON SENSE. Common sense is placed by God in your heart.

Common sense is the ability to make a good decision. It is based on wisdom (knowing what to do)
and discretion (knowing when and where to do it). Common sense triggers further investigation of
scientific facts that do not add up. Common sense allows you to look at situations the way God does.

Proverbs 3:21–22
Dear friend, guard clear thinking and common sense with your life;
don’t for a minute lose sight of them. They’ll keep your soul alive
and well, they’ll keep you fit and attractive.

4. THE PATIENT!
Science, common sense, and experience may lead to a specific therapeutic approach. The patient,
however, through informed consent, must be the major decision maker. Timing, affordability, culture, and
history might preclude the chosen therapy and call for a different approach. The patient’s constraints
and preferences must always be respected.

Albert Einstein confides, “I want to know God’s thoughts ... the rest a re deta ils.”

xxi
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Science, experience, common material tested and the control method), particu-
sense, and the patient larly with clinical studies, which by default have
a majority of confounding variables. As such, the
It is undeniably true that we live in very intense combined studies of numerical simulation and in
times in the history of humanity. The times to vitro tests represent considerably advantageous
come do not promise to be easy, so it is more research tools because of the extreme possibili-
important than ever to remain in the faith. A faith ties of standardization.1,2 Unfortunately, however,
that will prove that this fragile mosaic that we the latter are not part of the official hierarchy of
form (each of us as a piece of broken glass) evidence-based medicine.
has the power to transform itself into an eternal
work of art. In this context, which challenges our 2. Experience: It has been shown that one of the
beliefs, we also try to be high-level professionals. significant variables of clinical practice is repre-
And it must be admitted: In dentistry the plethora sented by the clinician themself and their ability
of materials and techniques at our disposal is to master a particular approach. In medicine, for
not without challenges for our “dental faith.” As example, a study of carotid stenting has clearly
a practitioner trying to find one’s way through shown that patients of experienced operators
an avalanche of new dental products, new have less risk of complications.3 Similar data exist
technologies, conflicting scientific publications, with respect to dental bonding performance both
etc, it is more important than ever to examine in vitro and in vivo.4,5 Clinicians who participate in
one’s beliefs, values, ​​and the foundations that many training courses and develop these skills
will enable one to make the most appropriate will therefore tend to produce more reliable
choices. There are four synergistic components results.6
involved in the decision for the optimal treatment
plan: 3. Common sense: It is established that many
acts of daily practice lack high-level scientific
1. Science: The scientific method is a priori a evidence. The scientific community itself recog-
fundamental basis according to which a hypoth- nizes the existence of a “talking pig.”7 It is a
esis is tested with various levels of evidence parable explaining that common sense must
(expert opinion, in vitro test, clinical case be recognized even in the scientific method.
presentations, case series, cohort and random- According to this parable, a researcher trained a
ized controlled trials, systematic reviews, and pig to speak. “Is it madness?” you say to yourself.
meta-analyses). The scientific approach is unfor- But we bring this pig to speak in front of you and
tunately not without flaws. The conditions of the pig says, “Good evening,” and proceeds to a
study do not always represent the daily clinical summary of the news of the day for you. We hope
reality. Due to medical ethics, it is not possible to you would be surprised by this phenomenon and
standardize all clinical conditions. A multitude of would not be necessarily interested in a random
confounding variables, such as the operator, the selection of 100 pigs to verify this. The fact that
nature of the clinical situation, the habits of the any pig can talk is what is important. By the same
patient, etc, “adulterate” the results. Therefore, principle, it is possible to ask whether a random-
it is not uncommon for the null hypothesis to be ized study is necessary to prove that the use of
confirmed (no difference between the method or a parachute can prevent death in the event of

xxii
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an airplane disaster.8 These examples of “talking to the same therapeutic solution. However, the
pigs” demonstrate that common sense must be patient may find it impossible to choose this
used in every situation. It is not uncommon for solution, for example for economic reasons or
conflicting scientific data to be produced, which availability. A segmentation of the treatment or
then requires a decision based on experience a “low cost” alternative must then be explored,
and common sense. which does not necessarily correspond to the
ideal solution proposed by the health care team.
4. The patient: Finally, it is quite possible that Each patient presented in this book has been
science, experience, and common sense all point treated with the FOUR elements in mind.

References

1. Korioth TW, Versluis A. Modeling the mechanical behav- 5. Kemoli AM, van Amerongen WE, Opinya G. Influence of
ior of the jaws and their related structures by finite ele- the experience of operator and assistant on the survival
ment (FE) analysis. Crit Rev Oral Biol Med 1997;8:90–104. rate of proximal ART restorations: Two-year results. Eur
2. Magne P, Versluis A, Douglas WH. Rationalization of in- Arch Paediatr Dent 2009;10:227–232.
cisor shape: Experimental-numerical analysis. J Prosthet 6. Bouillaguet S, Degrange M, Cattani M, Godin C, Meyer
Dent 1999;81:345–355. JM. Bonding to dentin achieved by general practitioners.
3. Calvet D, Mas JL, Algra A, et al; Carotid Stenting Trialists’ Schweiz Monatsschr Zahnmed 2002;112:1006–1011.
Collaboration. Carotid stenting: Is there an operator ef- 7. Bandolier, “Evidence based thinking about health care.”
fect? A pooled analysis from the carotid stenting trialists’ On knowledge and pigs (editorial). http://www.bandolier.
collaboration. Stroke 2014;45:527–532. org.uk/band44/b44-1.html.
4. Unlu N, Gunal S, Ulker M, Ozer F, Blatz MB. Influence of 8. Verkamp J. Why we should stop proving a parachute
operator experience on in vitro bond strength of dentin works in a RCT. Eur Arch Paediatr Dent 2010;11:216.
adhesives. J Adhes Dent 2012;14:223–227.

Dr. Ma gne, tha nk you for providing top-notch qua lity of ca re and work-
ma nship for the next genera tion of dentists. I love the work you do.
Pa tient

xxiii
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UNDERSTANDING THE
INTACT TOOTH AND THE
BIOMIMETIC PRINCIPLE

M
imicry in the field of science involves reproducing or copying a model—a
reference. Dental professionals who want to replace what has been
lost need to agree on what is the correct reference. The accepted frame of
reference must be the same for the entire profession, and it should be timeless
and unchanging. Once this is established, appropriate research designs, valid
concepts, and rational dental treatment plans can be constructed, devised, and
created. For the restorative dentist, the unquestionable reference should be the
intact natural tooth. Remains of Inca civilization in South America as well as
mummies in Egypt1 or even so-called “Stone Age” specimens2 demonstrate this
age-old principle: The original number, dimensions, and structure of teeth have
not changed. While the pattern of oral diseases (infections, wear, parafunctions)
has been influenced by the ever-changing human lifestyle, the original structure
of enamel and dentin appears to be the same today as it was 5,000 or 6,000
years ago. In this context, it seems commendable to study and understand the
marvelous design of natural teeth before considering any further concepts in
restorative dentistry.

1
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BIOLOGY, MECHANICS, FUNCTION, AND ESTHETICS ntessen

Physiologic performance of intact teeth is the other), which are covered extensively in chap-
result of an intimate and balanced relationship ter 3. Yet a critical question can be raised: What
between biologic, mechanical, and functional would have been the outcome if, instead of being
parameters (Fig 1-1a). Esthetics should not be intact, these central incisors had been previously
the driving force of treatment but only the result restored by two rigid and extremely resistant
of this relationship—“the cherry on top.” Biol- full crowns (eg, porcelain-fused-to-metal [PFM]
ogy is undoubtedly the dominating element in or reinforced ceramics)? We know from impact
this equation, and all efforts should go to the experiments that a more profound fracture (root
preservation of tooth vitality. Endodontically involvement), which would be problematic to
treated teeth, no matter how they are restored, restore, is encountered when stiff and unyielding
will always present a compromised prognosis (ie, crowns are used.5 This contrasts with the behav-
a higher risk of fracture) compared to vital teeth.3 ior of the more fragile cemented jacket crowns,
The most educational situations supporting which often shatter, leaving the remaining tooth
the complex interactions between biology, func- substance intact. A partial crown fracture might
tion/mechanics, and esthetics are found in cases be preferable if one considers that the energy
of traumatic injuries like that illustrated in Fig 1-1. dissipated during fracture can prevent further
The price of an injury can be paid in the form of biologic damage or root injury.
either a mechanical failure (hard tissue involve- In consideration of the above-mentioned
ment) or a biologic failure (pulpal involvement). parameters, it is of primary importance to ask
In both cases, the influence on the esthetic and ourselves: Is it better to pursue the develop-
functional parameters is observable. Fortunately ment of strong and stiff restorations or to find
for the patient in Fig 1-1, simple and economical treatment modalities that reproduce the biome-
treatment strategies could be used4 (ie, fragment chanical behavior of the intact tooth? Stronger
reattachment on the left central incisor and root and stiffer might not always be better.
canal therapy and internal bleaching on the

FIG 1-1 Physiologic performance of teeth. (a ) Performance of teeth is the

result of an intricate physiologic puzzle including biology, mechanics, func-
tion, and esthetics. (b to h) Illustrative case: The maxillary left central incisor
fractured following trauma that involved both maxillary central incisors (b). The
tooth fragment was recovered (c). The situation was potentially compromised
by pulpal exposure (d). After direct capping under rubber dam, the tooth
fragment was rebonded to the remaining tooth substance (see Fig 3-24). A
1-week postoperative view reveals the favorable situation (e). One month
later, the unfractured right central incisor showed signs of pulpal damage
(f). The severe organic discoloration was completely removed by internal
bleaching (“walking bleach technique,” see Figs 3-17 to 3-19) after root canal
treatment was accomplished. (The root canal therapy was indicated only by
the presence of symptoms and radiographic evidence.) The tooth was slightly
overbleached to anticipate the initial color relapse (g). The 5-year postop-
1-1a erative view shows stable results (h). (Parts b to g reprinted with permission
from Magne and Magne.4)

2 CHAPTER 1: UNDERSTANDING THE INTACT TOOTH AND THE BIOMIMETIC PRINCIPLE

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1-1c

1-1b 1-1d

1-1e 1-1f 1-1g

5Y
1-1h

BIOLOGY, MECHANICS, FUNCTION, AND ESTHETICS 3

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OPTIMAL COMPLIANCE AND FLEXIBILITY ntessen

The previous section calls for a strong and natu- compared to teeth restored with different types
ral protection concept present in natural teeth of crowns. Although resilience promotes protec-
called compliance or flexibility. This is an essen- tion against impact through energy absorption,
tial quality6 that enables a structure to absorb the excessive elasticity might also render a structure
energy of a force. In other words, a compliant too “floppy” for its purpose (Fig 1-2b, left). The
structure will cushion a sudden impact by bend- dentin core alone would be functionally inade-
ing elastically under a given load. Up to a certain quate without its rigid outer shell of enamel (Fig
point, the more compliant or resilient a structure 1-2b, right).
is, the better. This ability to store energy with-
out undergoing permanent damage is inherent In this respect, natural teeth, through the opti-
to intact teeth and can be considered a refer- mal combination of enamel and dentin, demon-
ence. Dentin is the key element in this capability. strate the perfect and unmatched compromise
Figures 1-2a and 1-2b show the exact shape and between stiffness, strength, and resilience.
structure of this essential “resilient” component. Restorative procedures and alterations in the
It was demonstrated by Stokes and Hood5 that structural integrity of teeth can easily violate
during impact, an anterior intact tooth is able this subtle balance.
to absorb the highest energy of fracture when

1-2a

FIG 1-2 Resilient component of teeth. An extracted tooth was specially acid treated to eliminate the enamel shell
(a ) and expose the dentin core (left, proximal view; right, palatal view). The lost enamel volume is evident in part b.
The dentin core alone is weak, and bending under 5 kg can be perceived with the naked eye (b, bottom left; incisal
edge displacement about 0.5 mm). The enamel shell provides the tooth crown with sufficient resistance to bending
(b, bottom right; incisal edge displacement about 0.1 mm). (The bottom diagrams in b were produced with the finite
element method; see also Figs 1-5 to 1-9.)

4 CHAPTER 1: UNDERSTANDING THE INTACT TOOTH AND THE BIOMIMETIC PRINCIPLE

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DENTIN DENTIN + ENAMEL

50 N 50 N

DENTIN DENTIN + ENAMEL

1-2b

Optimal Compliance and Flexibility 5

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RATIONALIZED ANTERIOR TOOTH SHAPE ntessen

Starting in the posterior segment and moving lobes rising from the cingulum interrupt the pala-
in the anterior direction within the dental arch, tal concavity. The portion of the crown featuring
the process of “incisivization” takes place (Fig the thinnest enamel layer, namely the cervical
1-3a), whereby the occlusal table is gradually third, is also the area of maximum thickness
replaced by an incisal edge that has the obvious of dentin. Inversely, the thick incisal enamel is
function of cutting. supported by a thin dentin wall.
Canines display a different morphology. The
Anatomically, incisors show a distinct contrast cingulum is large and the marginal ridges are
between facial and palatal surface morphology. strongly developed. All of these convex elements
The labial aspect of the crown features smooth are confluent, and there is no major palatal fossa
and mainly convex contours, whereas the pala- (Figs 1-3b to 1-3d). The peculiarity of such archi-
tal surface displays a deep concavity extending tecture will be explained later in view of the
axially from the dental cingulum to the incisal specific functional requirements of this strategic
edge and laterally between the two pronounced tooth.
proximal ridges (Fig 1-3b). With this shape, the Detailed aspects of anterior tooth shape are
incisal edge is designed like a blade, which also presented in chapter 2 (section 2.2, criterion
undoubtedly plays a major role in the cutting 8, Figs 2-5 and 2-6).
efficiency of the tooth. In some instances, vertical

1-3a

INCISI VIZATION

6 CHAPTER 1: UNDERSTANDING THE INTACT TOOTH AND THE BIOMIMETIC PRINCIPLE

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1-3b

1-3c

FIG 1-3 Basic anatomy of the

anterior dentition. Comparative
views showing functional surfaces
of extracted teeth. Palatal surfaces
of canines (a , center; b, right; c a nd
d) display soft and convex curva-
tures compared to the concavities
of incisors (b, left).

1-3d

RATIONALIZED ANTERIOR TOOTH SHAPE 7

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RATIONALIZED POSTERIOR TOOTH SHAPE ntessen

While the anterior teeth play a major role in at the interface with the dentinoenamel junction
shearing and cutting food, the primary function (DEJ).7 The contours of dentin, on the other hand,
of posterior teeth is the comminution of food are concave and sharp-edged. While the enamel
into small swallowable and digestible fragments. surface is marked with deep developmental
The process of mastication is made possi- grooves and fissures, the surface of dentin at
ble through interdigitating cusps (Fig 1-4a). The the DEJ is rather smooth (Figs 1-4b to 1-4d).
robust macrostructure of each cusp is given by Detailed aspects of posterior tooth shape are
the contours of the enamel surfaces, rounded also presented in chapter 2 (section 2.4, Figs 2-21
and clearly convex, both at the outer surface and to 2-28).

1-4a

FIG 1-4 Basic anatomy of the posterior dentition. (a , left) Antagonistic posterior teeth in maximum intercuspal
position. Note the thicker biconvex enamel at the level of the supporting cusps (dotted a rrows), both maxillary
and mandibular, as well as the sharp edges of the underlying dentin at the cusp tips. (a , right) Maxillary premolar:
Interdental (top) and buccal (bottom) views with and without enamel. (b a nd c) Mandibular molar obtained from 3D
reconstruction based on microCT data. Note the wide base of the supporting cusps and concave cusp slopes of the
dentin. (d) Maxillary premolar obtained from 3D reconstruction based on microCT data. (Figures in part a reprinted
with permission from Bazos and Magne.7)

8 CHAPTER 1: UNDERSTANDING THE INTACT TOOTH AND THE BIOMIMETIC PRINCIPLE

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1-4b 1-4c

1-4d

RATIONALIZED POSTERIOR TOOTH SHAPE 9

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GALLERY
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GALLERY xxv
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GALLERY xxvii
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GALLERY xxxi
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GALLERY xxxvii
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