Inside Dentistry

June 2017
Volume 13, Issue 6

The Protocols of Biomimetic Restorative Dentistry:

2002 to 2017
Increase the longevity of restorations with the biomimetic approach
David Starr Alleman, DDS | Matthew A. Nejad, DDS | Capt. David Scott Alleman, DMD

During the last 15 years, the restorative approach has steadily evolved, progressing from
mechanical retention to advanced adhesion. This transition was fostered by a wealth of scientific
publications, improvements in adhesive materials, and most importantly, worldwide dissemination of
the science and techniques of advanced adhesion. Collectively, the science, principles, and
techniques of advanced adhesive dentistry are known as biomimetic dentistry. At its core, the
biomimetic approach respects the simple philosophy that, to adequately restore teeth, we must
“mimic life” and understand the natural tooth in its entirety.1-3
Logically, conserving more of the intact tooth is paramount to this approach, which pairs perfectly
with adhesion. Similar to the intact natural tooth, an adhesively-restored tooth is better able to
handle and manage functional stresses. As a result, the biomimetically-restored tooth eliminates
gaps under restorations and cracks into dentin that develop as a result of deformation and stress
concentrations, reducing or eliminating postoperative pain and sensitivity and preserving vitality, as
bacteria are not able to invade and kill the pulp.4,5 The natural flexibility and fracture resistance of a
tooth are also enhanced when it is hydrated by the vital pulp. 4,6
The biomimetic protocols of today are founded on the “silent revolution” of adhesive dentistry that
developed during the 80s and 90s.7-9 This revolution was advanced by Japanese researchers who
identified two different layers of carious dentin that had two different characteristics of dentin
adhesion. These researchers were able to predictably bond to dentin by using the novel technology
of a caries detecting dye, which allowed an ideal caries removal end-point to be visualized in the all
important “peripheral seal zone.”6 On a dentin surface free of denatured collagen, a bond to dentin
could be established using newly developed polymerizable monomers that were both hydrophilic
and hydrophobic. With these two technological breakthroughs, Dr. Takao Fusayama and his team of
researchers at the Tokyo Medical and Dental University began the quest for conservative, long-
lasting adhesive restorations.10 For the next two decades, continued advances in materials and
techniques allowed for more extensive dental defects to be restored in both the anterior and
posterior regions of the mouth.3,11-13
Fast-forwarding to 2002, a landmark book was published that advanced major concepts in
biomimetic dentistry, including new information regarding the properties of natural teeth and their
behavior under function, preparation design principles, and the all important foundational biomimetic
concept of immediate dentin sealing.1,2 In the same year, a technique to reduce the effects of
polymerization shrinkage stress was published, referred to as a stress-reduced direct composite,
which allowed a biomimetic approach to a direct composite restoration.14-16 This article outlines the
biomimetic paradigms and protocols that are supported by these and other scientific publications
and practiced by biomimetic dentists around the world.
Biomimetic Paradigms
Biomimetic restorative dentistry is founded on these four basic paradigms:

1. Maximum bond strength. Reducing polymerization stress to the developing hybrid layer results in
a 300% to 400% increase in bond strength.17-20 Dentin bond strengths in the range of 30 MPa to 60
MPa are in the same range as the tensile strengths of enamel, the dentinoenamel junction, and
dentin.21 This strong bond allows the biomimetically restored tooth to function and handle functional
stresses like an intact natural tooth.
2. Long-term marginal seal. A strong and secure bond allows for a long-term marginal seal to be
established and maintained during functional stresses.3,22-25
3. Increased pulp vitality. By maintaining a highly bonded seal, the restoration will provide long-term
function without recurrent decay, dental fractures, or pulp deaths.3,16,26,27 A vital tooth is also three
times more resistant to fracture.28
4. Decreased residual stress. Residual stress, while hard to visualize, leads to cuspal deformation,
debonding, gaps, cracks, pain and sensitivity, and recurrent decay. Reducing residual stress while
maintaining the maximum possible bond strength is the ultimate goal of any biomimetic restorative
technique.29,30
Biomimetic Protocols
The biomimetic restorative protocols used to produce these results can be divided into two groups:
stress-reducing protocols and bond-maximizing protocols.

Stress-Reducing Protocols
The first group includes 10 key stress-reducing protocols, which promote stress reduction to the
developing hybrid layer as it is formed and throughout the life of the restoration under function:3,25
1. Use indirect or semi-direct restorations for the occlusal and interproximal enamel replacements.
An indirect technique is the most stress-reduced technique. It reduces the volume of shrinking
restorative material.3,11,22 This also reduces residual stress.22,29,30
2. Decouple with time. This protocol states that polymerization shrinkage stress to the developing
dentin bond of the hybrid layer should be minimized for a certain period of time (ie 5 to 30 minutes)
by keeping initial increments to a minimum thickness (ie less than 2mm). This minimal thickness
prevents the connection, or “coupling,” of deep dentin to enamel or superficial dentin before the
hybrid layer is matured and close to full strength. This procedure neutralizes the “Hierarchy of
Bondability,” which states that the shrinkage of composite moves toward (or “flows” toward) the walls
of the preparation that are the most mineralized and dry and flows away from the walls of the
preparation that are the most moist and organic.20,31-33
3. Restore the dentin with thin horizontal layers of composite that are 1mm or less.14,20 This ensures
that decoupling with time is properly achieved and that the flow of the composite is not moving away
from the deep dentin during the early stage of horizontal layer development. This is the solution to
the problem of a preparation’s complex geometry and the resulting configuration stresses, which are
known as “C-Factor” stresses.34,35 Small volume increments are always associated with small ratios of
bonded to unbonded surface areas; thus, high C-Factor stresses can be reduced to “micro C-Factor”
stresses. This is the basic protocol of the stress-reduced direct composite technique.14,15
4. For large restorations, place fiber inserts on pulpal floor and/or axial walls to minimize stress on
the developing bond strength of the hybrid layer.24,36 The fiber nets allow the composite on either side
of the net to move in different directions via micro shifting of the woven fibers. The polymer network
is still highly connected, but the polymerization shrinkage does not stress the hybrid layer.37
5. Use slow start and/or pulse activation polymerization techniques.14-16,26,38
6. Use dentin replacing composites with shrinkage rates of less than 3% and with a modulus of
elasticity between 12 GPa and 20 GPa.1-3,12,38

7. When restoring pulp chambers in non-vital teeth, use dual cure composite with the chemical cure
mode active for the first five minutes.39 The volume of composite is not as critical for chemically
cured composites because the chemical initiation of the polymerization is very slow (4 minutes to 5
minutes).34,35 This slow polymerization allows sufficient time for the dentin bonding system to
mature into a strong hybrid layer.

8. Remove dentin cracks completely within 2mm of the dentinoenamel junction. This area is referred
to as the “peripheral seal zone.” Remove all dentin cracks inside of the peripheral seal zone to a
depth of 5mm from the occlusal surface and to a depth of 3mm interproximally from the axial wall.6 If
cracks into dentin are left under the restoration, micro-movements under function will allow the
cracks to get longer (ie crack propagation).4,5,40 Larger cracks propagate with smaller forces than
shorter cracks; therefore, it is recommended to remove as much of the cracked dentin as possible
without exposing the pulp.
9. Limit onlay cusps to thinner than 2mm after removal of decay and cracked dentin.1-3 This will
change the forces on the hybrid layer from predominantly tensile to predominantly compressive,
which helps reduce bond fatigue.25,41
10. Verticalize occlusal forces to reduce tensile stress to the restoration and the cervical region of
the tooth.41 This can be done by restoring anterior guidance with bonded composite to the lingual
surface of maxillary cuspids and/or the facial surfaces of mandibular cuspids.
Bond-Maximizing Protocols
The second group includes eight key bond-maximizing protocols, which, when implemented, can
help achieve the maximum possible bond strengths attainable when employing the stress-reducing
protocols:

1. Establish a caries-free peripheral seal zone. Achieve a caries-free zone 2mm to 3mm
circumferentially around the cavity without exposing the pulp. Inside of the peripheral seal zone,
caries excavation should be limited to a depth of 5mm, measured on the long axis from the cavo-
occlusal surface. Measuring from the proximal tooth, the depth of excavation should be limited to
3mm from the cavo-proximal surface.6
2. Air abrade surfaces. Air abrade composite surfaces for bonding/cementation. This will increase
bond strength to both normal and carious dentin.19,42 It will also change the failure mode to eliminate
failures in the hybrid layer.19 When bonding to the composite base of a biomimetic restoration, air
abrasion will maximize the composite-to-composite bond.12,43
3. Bevel enamel. Bevel enamel across enamel rods to increase bond strength.44
4. Deactivate matrix metalloproteinases. This prevents 25% to 30% of bond strength from being
degraded.45 Deactivation can be achieved by using a 30 second treatment with 2% chlorhexidine
(eg Consepsis, Ultradent), benzalkonium chloride (eg Micro-Prime B, Danville or Etch 37, Bisco), or
a dentin bonding system with the MDPB monomer (eg SE Protect, Kuraray).6
5. Employ gold standard bonding systems. Use a gold standard dentin bonding system that can
achieve a microtensile bond strength of 25 MPa to 35 MPa on enamel and 40 MPa to 60 MPa on flat
dentin surfaces. The available data indicates that three-step total etch dentin bonding systems and
two-step self-etch dentin bonding systems offer the best clinical performance.19,46
6. Utilize immediate dentin sealing. The application and polymerization of dentin bonding agents at
the time of preparation (and before an impression is taken) has numerous advantages and will
ultimately increase the microtensile bond strength by 400% when compared to the traditional
approach of bonding the dentin at the cementation appointment.17,18 This is fundamental to achieving
maximum bond strength.
7. Resin coat the immediate dentin sealing. This can be done with a flowable resin or a lower
viscosity restorative composite with a modulus of elasticity of around 12 GPa (ie the same as deep
dentin). This ensures that the dentin bonding system is fully polymerized even if the pressure of
pulpal fluid transudation (in conjunction with the air-inhibited layer) has made the adhesive too thin to
be polymerized due to air-inhibition. Once the dentin bonding system is resin coated and the resin
coating is light polymerized, the air inhibition and transudation stop. This step also creates a “secure
bond,” which means that if the onlay was ever dislodged from the resin coating, the resin coating
would stay bonded to the sealed dentin.13,47-49 A few dentin bonding systems have thicker and highly
filled adhesives (ie around 80 microns). These dentin bonding systems can act like a resin coating.
Examples include OptiBond FL (Kerr), All Bond 3 (Bisco), and PQ1 (Ultradent).
8. Achieve deep margin elevation. A sub-gingival box margin needs to be bonded and raised to a
supra-gingival position to obtain a biomimetic microtensile bond strength greater than 30 MPa. This
deep margin elevation, in conjunction with immediate dentin sealing, resin coating, and the
composite “dentin replacement,” is referred to as the “bio-base”—a term used by the Academy of
Biomimetic Dentistry for the stress-reduced, highly bonded foundation that the indirect or semi-direct
inlay or onlay will be bonded to.50,51
Case Presentation
In this case, which would present problems for dentists who perform treatments without biomimetic
restorative protocols, the caries are deep and the structure of the tooth is compromised (Figure
1 through Figure 10). For a traditional, full-coverage treatment, much of the intact tooth would have
to be sacrificed. However, employing biomimetic restorative protocols can solve many of these
problems by conserving tooth structure and promoting healing of the pulp. By combining the stress-
reducing and bond-maximizing protocols, biomimetic restorative dentistry is able to reconnect all
parts of the tooth with all parts of the restoration while maintaining a lifelike tensile/cohesive strength
in the 30 to 50 MPa range.
Lifelike Longevity
These two semi-direct biomimetic restorations (Figure 11) on teeth #3 DOLF inlay/onlay and #4 full
onlay (mirror reversed) are more than 15 years old now. The onlay on the bicuspid and the
inlay/onlay on the molar were restored using most of the protocols presented in this article with the
exception of fiber placement for stress reduction and deep margin elevation on the bicuspid. There is
a slight ditching of the flowable cementing resin on the molar, but no leakage is present. The onlays
were fabricated out of Z-100 (3M, St Paul, MN).
This 10-year-old stress-reduced direct composite restoration (Figure 12) included fiber placement for
stress relief. Only the cracks into the dentin were removed. The cracks into the enamel were
stabilized with biomimetic protocols to re-establish a tensile cohesive strength from side to side, front
to back, and top to bottom. As a whole, the tooth is now functioning again like a natural tooth. The
occlusal surface was restored with Majesty Posterior (Kuraray, Okayama, Japan).
These Empress inlay and Empress onlay restorations (Figure 13) are 17 years old. Replacing
occlusal and interproximal enamel, they are bonded to stress reduced bio-bases consisting of
immediate dentin sealing, resin coating, and dentin replacement with a composite (AP-X, Kuraray)
with a modulus of elasticity similar to dentin (16.7 GPa). The modulus of elasticity of the ceramic
enamel (Empress, Ivoclar) is around 80 GPa. This number is a little higher than the enamel that it
replaces, which has a modulus of elasticity of around 60 GPa. Composites with a modulus of
elasticity of 20 GPa, such as Z-100 and Majesty Posterior, have also been functioning biomimetically
for 10 to 20 years without breaking down.3
Conclusion
When performing a biomimetic restoration, it is vital to visualize the accomplishment of the protocols.
Magnification in the 5X to 8X range is highly recommended when performing a biomimetic
restoration.6 The use of a surgical microscope or high-powered loupes makes treatment very
predictable.
Beyond the biomimetic paradigms, stress reducing protocols, and bond maximizing protocols, there
are other principles that are related to biomimetic restorative dentistry. Minimally-invasive dentistry,
structural analysis of existing tooth structure, and polymerization dynamics of composites are
important topics that fully-trained biomimetic restorative dentists need to understand.34,35,40,52
The purpose of using biomimetic restorative concepts and protocols is to increase the longevity of
restorative dental treatments and to reduce or eliminate future cycles of retreatment. In addition,
conservation of tooth structure prevents periodontal complications and pulp death.27 Dentists and
patients who choose biomimetic dentistry enjoy these benefits every day.
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CE INFORMATION & QUIZ

Decoupling With Time

David Starr Alleman, DDS; Davey Scott Alleman, DMD; Simone Deliperi, DDS; Jorge Aravena Diaz, DDS;
Leandro Martins, DDS, MS, PhD; and Filip Keulemans, DDS, PhD

August 2021 Issue – Expires Saturday, August 31st, 2024

Inside Dentistry

Abstract

Polymerization dynamics, which govern the movement of composite restoratives as they cure, dictate
that shrinkage occurs in the direction of the most bondable surface or, in larger volumes, toward the
center mass of the material. When polymerizing, composite shrinks toward the wall or walls of the
preparation that are the most mineralized and dry and away from the walls that are the most moist and
organic as dictated by the hierarchy of bondability. Immediately sealing the dentin with a dentin
bonding system after preparation, applying a thin coating of resin, and allowing the developing dentin
hybrid layer to mature for an appropriate amount of time improves the overall bond strength
significantly and prevents the shrinkage stress created by larger overlying volumes of composite from
causing debonding in a process known as decoupling with time. Additional techniques, such as deep
margin elevation, stress-reduced direct composite layering, and the placement of fiber reinforcement
also leverage decoupling with time to improve bond strengths. This article explores the development
and use of these and other techniques to improve bond strengths to dentin, discusses the impact of the
hierarchy of bondability on composite failure, and presents the biomimetic restorative dentistry
protocols that incorporate this information to create restorations that possess a long-term seal to
prevent reinfection, maintain pulp vitality, maximize the preservation of tooth structure, and minimize
residual stresses in the tooth/restoration complex.

Twenty-three years ago, a team of researchers from the University of Minnesota set out to answer the
question, “Do dental composites always shrink toward the curing light?” and found that the answer was
“No.”1 Dental composites shrink toward the most bondable surface that they are connected to or
toward the center of their mass during the first 5 to 30 minutes after placement. Knowledge regarding
how composites move during curing is referred to as the science of polymerization dynamics. The
volume of a polymerizing mass of composite greatly influences the direction of its movement as it
shrinks. The larger the volume of a light-cure composite, the more the shrinkage is directed to the
center of its mass and away from the walls of the preparation.

A primary goal of biomimetic restorative dentistry protocols is to place small volumes of composite that
move toward the developing dentin hybrid layer during their maturation. This positive dynamic
movement can only occur if the initial volume of composite that is placed on top of the dentin bonding
system is kept very thin (less than 1.5 mm) during the first 5 minutes of its polymerization reaction. This
is one of the secrets to successful biomimetic restorative dentistry. Other protocols of biomimetic
restorative dentistry that take advantage of polymerization dynamics to achieve long-term success
include immediate dentin sealing, resin coating, deep margin elevation, stress-reduced direct composite
layering, and polyethylene fiber placement.

Dentin Sealing, Resin Coating, and Deep Margin Elevation

For every partial coverage restoration placed using biomimetic restorative dentistry protocols, there is a
fundamental direct restorative component-the immediate sealing of the freshly prepared dentin. In
immediate dentin sealing, the freshly prepared dentin is infiltrated with resin to create a hybrid layer
that mimics the dentinoenamel complex, protecting it from bacterial leakage and the remnants of
temporary cements. The companion concept of immediately placing a thin layer of microfilled flowable
composite to protect the underlying hybrid layer is referred to as “resin coating.” These two protocols
were introduced in Japan and Europe in the mid-1990s.2-4 Immediate dentin sealing and resin coating
procedures have been shown to increase the strength of the bond to dentin by 400%.5

Introduced in 1998 by Dietschi and Spreafico, deep margin elevation is another biomimetic restorative
dentistry protocol that leverages polymerization dynamics. Deep margin elevation is performed
immediately after immediate dentin sealing and resin coating to restore subgingival defects.6 By
executing deep margin elevation as a separate step, the volume of composite used subgingivally was
reduced and allowed to remain unconnected to any larger masses of composite for a period of time.
Deep margin elevation allows a strong bond to develop in this most difficult area to restore.7-10

The concepts of immediate dentin sealing, resin coating, and deep margin elevation have been used and
taught at the University of Geneva, Switzerland, for more than 20 years, and great successes using these
three fundamental protocols in partial coverage restorations have been documented and published
during that time.10 Why do these three techniques produce such a dramatic increase in the bond
strength to dentin and, subsequently, the longevity of adhesive dentistry? Because traditional
techniques used to bond partial coverage restorations (with or without subgingival defects) delayed the
dentin bonding procedure until the time that the final restoration was placed. This reduced the potential
bond strength by approximately 80% because it failed to allow the dentin hybrid layer enough time to
mature in a stress-free environment. Enamel hybrid layers develop quickly because enamel is dry.
However, dentin is moist and flexible, making it more difficult to encapsulate with the developing resin
polymers of the dentin bonding system being used. It requires roughly twice as much time to develop a
strong bond to dentin as it does to develop a strong bond to enamel,11 but when a mature bond to
dentin is established, it is roughly twice as strong as the bond to enamel.12

Decoupling With Time

Immediate dentin sealing, resin coating, and deep margin elevation all provide sufficient time for the
dentin bonding system to create a mature hybrid layer that is better able to resist any shrinkage stresses
associated with the resin cements or subsequent composite layers to which it is connected (ie,
“coupled”). Therefore, by delaying or “decoupling” the bonded connection between the dentin hybrid
layer and the subsequent restorative layers for a period of time, the maximum cohesive strength of the
tooth/restoration complex can be achieved. This concept of first establishing a bonded seal of the dentin
with a thin layer of resin and then, after a period of time, connecting or coupling the rest of the
restoration to it has been referred to in the literature as “decoupling with time.” Decoupling with time
can help overcome the differences among the multiple types of dental hard tissue involved in bonding
procedures. Those differences have been used to establish what is referred to as the “hierarchy of
bondability.”

The Hierarchy of Bondability

The hierarchy of bondability dictates the direction of shrinkage of composite layers and the amount of
stress that is concentrated on the developing dentin hybrid layer. When polymerizing, composite shrinks
toward the wall or walls of the preparation that are the most mineralized and dry and away from the
walls that are the most moist and organic.13

The hierarchy of bondability Is based on the science that has shown that preparations have multiple
types of dental hard tissues that can be hybridized. These hard tissues have different percentages of
mineral content, and that level of mineralization affects how easy or difficult it is to form a strong bond
to each of them. Commonly encountered dental hard tissues ranked in the order of their mineral
content from the most mineralized and dry to the least mineralized and moist include enamel, sound
superficial dentin, sound intermediate dentin, affected superficial dentin, affected intermediate dentin,
sound deep dentin, affected deep dentin, and infected deep dentin. The first six of these hard tissues
can establish bonds in the range of 30 to 50 MPa if C-factor stresses are eliminated or delayed and a
“gold standard” dentin bonding system is used.12,14,15 The last two hard tissues, affected deep dentin
and infected deep dentin, can only achieve a bonded seal in the range of 10 to 20 MPa.16-18 If the bond
strengths of immediate dentin sealing and resin coating are allowed to be established during the first 5
to 30 minutes, greater durability of the bond to dentin is achieved under occlusal loading.19

Because biomimetic restorative dentistry protocols that promote decoupling with time, including
immediate dentin sealing, resin coating, and deep margin elevation, make all of the resin coated dentin
surfaces equally bondable, the hierarchy of bondability is neutralized.20,21 The stresses from
subsequent composite layers will not be concentrated on the deep dentin hybrid layer until the deep
dentin hybrid layer’s strength has been maximized. This secures the bond to that most critical part of
the restoration. Immediate dentin sealing and resin coating result in a strong interface of two different
materials that mimics the dentinoenamel complex.22

Direct Decoupling Techniques

After immediate dentin sealing, resin coating, and deep margin elevation were introduced for indirect
and semi-direct approaches, other techniques were developed to create direct adhesive restorations
that had characteristics similar to those of the “biomimetic” indirect restorations. These new techniques
also incorporated decoupling with time in order to overcome the problems associated with the
hierarchy of bondability.

Separation

In 2000, Wilson and colleagues published a technique that introduced the word decoupling into the
literature.23 Intended to prevent sensitivity after class II direct composite restoration in the posterior
dentition, this decoupling protocol involved a permanent separation of the deepest 1-mm layer of
composite from the more superficial 2-mm layers through the addition of an unbonded separating layer.
The technique sealed the tooth and prevented the hydrodynamic movement of pulpal fluid that causes
pain after dental restorations.24 However, because the bottom of the restoration was disconnected
from the top, the biomechanical function of the tooth under loading was altered. This could lead to early
tooth fractures and required retention forms similar to those of traditional cavity preparations.

Stress-Reducing Direct Composite Layering

In 2002, Deliperi and Bardwell introduced what would become known as the stress-reducing direct
composite layering protocol.25 This technique also had the goal of preventing postoperative sensitivity,
but it eliminated the need for retention and resistance forms in preparations. In the protocol, the dentin
and the enamel were restored as two different substrates and in three different stages using a selective
composite technique.

After immediate dentin sealing, the first stage of composite layering involved the replacement of the
proximal/facial/lingual enamel shell. In the second stage, dentin replacement began with the placement
of a 0.5-mm to 1.0-mm layer of flowable composite on the floor of the preparation over the filled
adhesive of the bonding system used to hybridize the dentin. Then, after this initial thin increment of
composite was created, the rest of the dentin was replaced using the same small volume increment
technique to place 1.0-mm to 1.5-mm, wedge-shaped increments using slow-start pulse polymerization
protocols, decreasing the C-factor ratio. The third stage involved replacing the occlusal surface via a
successive cusp buildup protocol.

Although the stress-reducing direct composite layering protocol employed decoupling with time, the
layers of the restorations were ultimately coupled from top to bottom instead of being left disconnected
in the manner of the protocol developed by Wilson and colleagues. The stress-reducing direct composite
layering protocol could also be used for cusp replacing restorations.26
In 2004, a comparative study provided solid in vitro clinical evidence to support the use of decoupling
approaches to improve the strength of bonds to dentin.27 The results indicated that the thinner the
horizontal layers of composite placed, the higher the microtensile bond strength achieved in the
deepest floor of the preparations. According to the data, a 1-mm horizontal layer achieved a
microtensile bond strength of 30 MPa, whereas a 4-mm bulk-filled layer only achieved a microtensile
bond strength of 11 MPa.

Then in 2014, a team from Brazil produced more in vitro support for the concept of decoupling using
finite elemental analysis at the University of Tennessee.28 The conclusions of these studies reinforce
that maximizing the bond strength of the adhesive layers nearest the pulp is best accomplished by
placing multiple horizontal layers of small volume.

Polyethylene Fiber

Another decoupling technique involves placing ultra-high molecular weight woven polyethylene fibers
into the first thin 0.5- to 1.0-mm layer of flowable microfilled composite coupled to the dentin bonding
system. This innovation was developed at the Selçuk University in Turkey and the Tokyo Medical and
Dental University in Japan under the direction of Belli and Inokoshi, respectively.29-31 The technique
was shown to eliminate the stress to the dentin hybrid layer that causes microleakage. These
experiments were confirmed in 2007 by El-Mowafy and colleagues32 and in 2009 by Ozel and
colleages.33 By placing polyethylene fiber in the first 1 mm of composite, an effective decoupling of the
lowest sealing layers of composite from the overlying layers of composite was achieved. In 2008, Erkut
and colleagues used scanning electron microscope visualization to demonstrate the mechanism of stress
relief, which involved the fibers separating as the small intertwining masses of composite moved in two
different directions.34 In 2020, this technique of “decoupling with fiber” was confirmed by Sadr and
colleagues through in vitro tests that permitted real-time visualization of the fibers acting as a
decoupling mechanism using optical coherence tomography.35

Maximizing Dentin Bond Strength

Each of the aforementioned decoupling protocols adds to the time that it takes to complete the
restoration. This extra time for the polymerization reaction allows the dentin hybrid layer to mature in
its seal and its strength. Every restorative procedure takes time to perform, including both amalgam
placement and composite placement. Is delivering a direct adhesive composite restoration or an indirect
bonded restoration worth the added time that it takes to place? Only if there is a benefit to the patient
regarding better outcomes and greater longevity. This is the goal of the “post-amalgam era.”36

The average age of a large composite restoration in the United States is a little more than 5 years. Many
protocols utilizing biomimetic approaches have been developed during the last 25 years that have been
able to extend the life of large composite restorations to more than 20 years.10 By combining the best
decoupling techniques with the concepts of polymerization dynamics and time allowance for the hybrid
layer to mature, restorations can be created that act like natural tooth structure and that are strongly
connected from side to side, top to bottom, and front to back with cohesive strengths in the range of 30
to 50 MPa-the same as the natural tooth components.37

In a summary of biomimetic restorative dentistry protocols that was published in Inside Dentistry in
2017, the authors listed 18 different protocols that have been shown to maximize the bond to dentin in
the developing hybrid layer.20 Without employing stress reducing protocols that permit decoupling with
time, it is impossible to achieve long-term successes in structurally compromised teeth with large
defects from decay and fracture. Maximum dentin bond strengths are needed to achieve the goals of
biomimetic restorative dentistry, which include establishing a long-term seal of dental hard tissues to
prevent reinfection under the restoration, maintaining pulp vitality, maximizing the preservation of
tooth structure, and minimizing residual stresses in the tooth/restoration complex.

Composite Failure

Why do large non-stress-reduced composite restorations fail? They fail because of recurrent decay,
fracture of the tooth, and/or fracture of the restoration. All three of these failure modes are a
manifestation of the stresses of polymerization that in the first hours of placement resulted in either
weakening of the dentin hybrid layer, residual strain in the remaining tooth structure, internal stress in
the polymer networks in the large composite mass, or a combination of these conditions.38 Although all
of these failure modes require repair or replacement, recurrent decay often leads to pulpal infection,
which may cause pulpal necrosis. A major goal of biomimetic restorative dentistry is to prevent this type
of failure mode. Therefore, priority is given to avoiding polymerization stress on the maturing dentin
hybrid layer.

Adhesive dentistry in large defects could be expressed as a simple relationship between dentin bonds
and the polymerization stress caused by composite shrinkage. If a dentin bond can withstand the
stresses applied to it during its initial formation, then it can better withstand the stresses of occlusion.39
In 1984, Davidson and colleagues were the first to study the development of composite-dentin bond
strength in relation to polymerization shrinkage stress as a function of the polymerization time.40

By utilizing biomimetic restorative dentistry protocols from the published scientific literature,
occurrences of superficial clinical failure modes, such as the chipping of replaced enamel, can be
reduced greatly for decades, and the occurrence of catastrophic/biologic failure modes, such as those
involving dentin and pulpal vitality, can be almost completely eliminated.

Biomimetic Restorative Dentistry Protocols

There are seven main protocols used in biomimetic restorative dentistry that help to neutralize the
hierarchy of bondability and permit decoupling with time to maximize the bond strength to dentin41:

1. Create a peripheral seal zone inside the dentinoenamel complex that is free of carious dentin by
using caries detecting dye. The dye’s differential staining will allow the hard tissues that will
present the most difficulty in establishing the dentin hybrid layer to be visualized and then
treated in ways to maximize their seal and bonded strength.42

2. Use an immediate dentin sealing technique that can establish a hybrid layer with a microtensile
bond strength in the 30 to 50 MPa range.5

3. Resin coat the immediately sealed dentin with a 0.5-mm layer of microfilled or nanofilled
flowable composite to increase the thickness of the adhesive layer of the dentin bonding
system.4

4. Allow the dentin hybrid layer 5 to 30 minutes to mature before placing an overlying increment
with a thickness greater than 1.5 mm.25,43,44

5. When the amount of dentin to be replaced is greater than 1.5 mm in thickness, use a stress-
reducing direct composite layering technique to restore the dentin and then the enamel
separately.25,43,44

6. When vertical defects are deeper than 4 mm, use a deep margin elevation technique.6-9

7. Incorporate polyethylene and fiber glass fibers to relieve polymerization stresses to the hybrid
layer and improve fracture resistance under occlusal loading.30,31,45-48

The use of all or some of these protocols results in the development a highly bonded foundation. This
foundation, which has become known as the “bio-base” at the Academy of Biomimetic Dentistry in the
United States and in the Philippines, is an intrinsic part of every biomimetic restorative dentistry
restoration. The bio-base eliminates the need for traditional external ferrule.
All of the protocols that occur after immediate dentin sealing (ie, 3 through 7) take time to perform.
During the time that it takes to perform these five protocols, something very critical is happening. The
free radical polymerization reaction that is forming the hybrid layer in dentin is completing 80% to 90%
of its potential monomer conversion, which directly relates to it strength. The conversion of monomers
to oligomers, then to small polymers, and finally, to larger polymers takes 5 to 30 minutes.40,49,50 The
adhesive layer in the dentin bonding system needs to be a minimum of 80 µm thick to polymerize
because 10 to 20 µm of its thickness will be inhibited from conversion by the air inhibiting of the dentin
bonding system initiators that cause the start of monomer chain formation.51

Immediate dentin sealing may be performed with either a filled, lightly filled, or unfilled dentin bonding
system to achieve the goal of high bond strengths. However, the combination of a filled dentin bonding
system and a flowable composite for the resin coating creates an ideal gradient of elasticity that can
best absorb stresses from polymerization and occlusal loading. The concept of making an unfilled
adhesive layer thicker by adding a flowable composite as a resin coating or “filled adhesive” is a proven
biomimetic restorative dentistry protocol.4,29,38The process of resin coating also reduces the chance of
pulpal fluid transudations turning from nanoleakage into microleakage due to perforations of the
adhesive layer of the dentin bonding system.52

Discussion

For the overlying composite to not adversely affect the strength of the hybrid layer, the polymerization dynamics (ie, d

irectional movements) of the composite layers need to be understood in terms of the configuration of the tooth prepar

ation and the volume of the composite used. The configuration of the defect in the tooth and the overall volume of the

restoration both have an effect on the amount of stress associated with the polymerization of the different composite

layers in the restoration.

Configuration factor or "C-factor," which was established in the mid to late 1980s by Davidson, Feilzer, and de Gee, r

efers to the ratio of a restoration's bonded to unbonded surfaces.40,49,50 When composite was bonded to only one surfa

ce, the masses of composite shrank in mostly one direction and were not very stressful to the bond. However, when 3

D cavities were filled, the shrinkage toward multiple walls caused so much stress that the bonds of the dentin hybrid l
ayers established with dentin bonding systems that had strengths in the 18 MPa range failed. This caused gaps in the

deepest parts of the preparations that were closest to the pulp.40,49,50 None of the early dentin bonding systems were a

ble to achieve bonds to flat surfaces (low C-factor) in the biomimetic range of 30 to 50 MPa until the late 1980s and e

arly 1990s.

One technique pioneered by Fusayama in the 1980s demonstrated some success in higher C-factor preparations usi

ng a chemical cure dentin bonding system and a chemical cure composite that had a 5-minute gel point delay. This 5-

minute delay in the polymer formation allowed more time for the dentin bonding system to mature; therefore, the poly

merization stresses from the volume of composite were delayed.53,54 Unfortunately, the successes of this "directed shri

nkage" technique were not consistent, and there was reported sensitivity from sealed gaps filled with pulpal fluid, whic

h caused pain during function from hydrodynamic movement of the fluid.24

Why was the failure of these early techniques always associated with debonding at the pulpal floor and not at the ena

mel margin? Because the movement of the composite shrinkage was toward the enamel and away from the pulpal flo

or as dictated by the hierarchy of bondability. This occurred because it is easier for a hybrid layer to develop to highly

mineralized dental hard tissues such as enamel and superficial dentin than it is for it to develop to intermediate dentin

, deep dentin, and root dentin, which require more time to develop a strong bond.13

Dentin bonds can achieve strengths in the 50 to 60 MPa range, which are potentially twice the strong as bonds to ena

mel in the 25 to 30 MPa range. However, within the first 3 minutes of polymerization, the early bond strength to enam

el is twice as strong (16 MPa) as the early bond strength to dentin (8 MPa).11 Dentin is only approximately 50% hydro

xyapatite, whereas enamel is more than 95% hydroxyapatite, so it takes longer for the bond to dentin to mature. Denti

n is also approximately 30% collagen and 20% water, which makes it "slippery" and more difficult for the enveloping p

olymers to "grab ahold of" than the dryer enamel. If you connect or couple an overlying composite mass of a larger vo

lume too soon, then the dentin hybrid layer can be stretched to a weaker connection or even broken during the first h

ours of the polymerization reaction. This is because the polymerization of the overlying composite is stretching the de

ntin hybrid layer toward its center of mass and away from the dentin.

Another method developed during the 1980s that attempted to overcome the problem of polymerization shrinkage wa

s the "semi-direct" technique. This concept involved a composite inlay or onlay that was polymerized outside of the m

outh and then cemented into place using a dentin bonding system and a resin cement applied at the same time. 55 Re

moving the large volume of composite from the cavity during shrinkage was a good idea, but the clinical results were

not great. Again, this was due to the differences in the bondable surfaces when the dentin bonding system was applie

d to the semi-direct restoration at the same time as the resin cement. Delaying dentin bonding instead of immediately

sealing the freshly prepared tissues decreased the bond to dentin to less than 11 MPa.5 This is because the moveme

nt of the shrinking cement layer moved in accordance with the hierarchy of bondability. It shrunk toward the most bon

dable surface at the moment of coupling, which was the dry intaglio surface of the composite inlay or onlay. The weak

er surface was the moist and flexible dentin hybrid layer that was being developed at that time.

Although the directed shrinkage and semi-direct techniques that were developed were found wanting, new approache
s were being developed that were successful. The new techniques of immediate dentin sealing, resin coating, and de

ep margin elevation to seal the preparation before the impression was made were game changers that led to more pr

otocols that decoupled with time and neutralized the hierarchy of bondability. The resin coating or "dual bonding" tech

nique was shown to eliminate the gaps on the pulpal and axial walls of restorations2,3 and increase the bond strength t

o dentin by as much as 400% to the range of 50 to 60 MPa when using a gold standard dentin bonding system.5

Further testing revealed that delayed composite placement of the direct components of direct and indirect restoration

s were improved with decoupling with time because it takes time for the chemical reactions of the dentin bonding syst

em to occur.6,56-59 All biomimetic restorative dentistry techniques delay the coupling of the dentin hybrid layer to larger

volumes of shrinking composites for a period of time. The time that the dentin hybrid layer is allowed to mature can ra
nge from 5 minutes for shallow stress-reducing direct composite restorations to 2 weeks for indirect final restorations t

hat are bonded to bio-bases.

Conclusion
Having small volumes of composite move toward the dentin hybrid layer as they cure is the primary goal of biomimeti

c restorative dentistry protocols. This ensures that large layers of composite that are thicker than 1 mm are not conne

cted to the developing hybrid layer during at least the first 5 minutes of its polymerization reaction. The hierarchy of b

ondability dictates the direction of the movement of the composite. Thin layers move toward the tooth and improve th

e strength of the hybrid layer. Thick layers move away from the tooth and toward the center of their mass, which can

weaken or break the hybrid layer.1 When the dentin hybrid layer is allowed to fully mature by decoupling with time, the

n all of the surfaces in the hierarchy of bondability become as bondable as enamel and can establish high bond stren

gths in 3 minutes.21 With the hierarchy of bondability neutralized by decoupling with time, tooth restoration becomes v

ery predictable and all of the goals of biomimetic restorative dentistry can be achieved.
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 SLA
Alleman Nejad Alleman (2017)
Urabe Nakajima Sano Tagami(2000)
Alleman Alleman Deliperi Aravena-Diaz Martins Kuelemans(2021)
With these 3 articles the Six Lessons Approach to Biomimetic Restorative Dentisry
is framed: 1. Connect the restoration to the tooth like enamel is connected to
itself and like dentin is connected to itself and like enamel is connected to dentin.
That means a circumferential hard shell with a cohesive strength in the range of
30-50MPa.

2. the only way to make this happen is by using the Bond maximizing protocols
and the 10 stress reducing protocols that published science has identified..
3. The fundamental missing concepts that needed to be identified and
implemented are HOB&DWT.
With these concepts direct, semi-direct and indirect BRD restorative techniques
are all able to restore teeth for at least 2 decades without gaps, cracks or
reinfections under the restorations.
You need to know the researchers toKnow the science.Science is done by human
beings. Human beings have names.
Masters of BRD will know the names of the scientists that guide us in our
protocols.
Y Yosida
K Yoshihara
B Van Meerbeek
D Fukegawa
S Inokoshi
M Nakajima
J Tagami
H Sano
D Pashley
J DeMunck
We owe them a debt of gratitude for what they have done.For the dental
profession. Adhesive dental science is the foundation of BRD.Without science
dentistry stays a subjective art. With science it becomes a healing profession.
Art and science together brings joy to the practice of Dentistry.

Ivar Mjor 2002

Harold Stanley was Ivar Mjor’s mentor. Stanley did not “believe” in adhesive
dentistry’s potentetial to seal a cavity and help the pulp heal.At least Mjor
believed in the potential but unfortunately did not understand how to reconnect
a tooth.
Lesson 1
Lesson 2
Lesson 3
Lesson 4
All are needed to promote pulp healing.
The answers are in the literature but Stanley and Mjor did not find them.One of
their collegues at the Univ of Florida at Gainesville
Did find many of the right answers on how to “Stay Bonded”.
JF Roulet’s book “Adhesion: The Silent Revolution”(2000) is highly recommended
but of course it is not the Six Lessons.
I brought Roulet to the 2014 Academy of Biomimetic Dentistry to connect him
with more like minded clinicians.
Over the past 17 years many connections between Japan, Europe, North and
South America have been made in the search for the best ways to Diagnose and
Treat decayed and fractured teeth in the best ways.
 New protocols of the Six Lessons
Approach to BRD
There are 7 major protocols There are 11 minor protocols

All 18 protocols have technical questions that need to be answered by a thorougly trained mentor.

This system has been applied clinically for 24 years. It has been taught to practicing dentists for 20 years.

Get Bonded, Stay Bonded

Biomimetic Protocols that Promote DWT

1. There are seven main protocols used in BRD that overcome the HOB by DWT, securing the bond
to dentin
2. Create a peripheral seal zone (PSZ) inside the DEC free of carious dentin using Caries Detectin
Dye (CDD).The CDD differential staining will identify the HOB, visualizing the dental hard tissue
most difficult to bond.”
3. Use IDS to establish a hybrid layer with micro-tensile bond strengths in the 30-50 MPa
4. RC the IDS with 0.5mm of micro-filled or nano-filled flowable to increase the thickness adhesive
layer of the DBS.
5. Allow the hybrid layer 5-30 minutes to mature before overlying layers have a thickness than
1.5mm range Of the Great
6. When dentin replacement greater than 1.5 mm is needed, use a stress reducing technique to
the dentin and enamel replacements
7. When vertical defects are deeper than 4mm, utilize a DME technique. Place fibers to relieve
polymerization stresses to the hybrid layer and improve composite Fracture resistance under
occlusal loading

Steps #3-7 decouple with time, minimizing stress to the hybrid layer. The conversion of monomers to
oligomers, to small and larger polymers takes time (5-30 minutes). Time allow the free-radical
polymerization reaction of the hybrid layer to complete 80-90% of its availa monomer conversion BRD
promotes DWT, overcoming the HOB. This solves the adhes equation of increasing bonds by decreasing
stress. This is the biomimetic philosophy.

Conclusions

The HOB dictates the directional movement of composite. When the dentin hybrid layer is allowed to
mature by DWT, the dentin substrates are as highly bondable as enamel. (16) the HOB eliminated by
DWT, the bond strength of the restoration can mimic the connectio a natural tooth, making it
predictable.