Every crisis presents an opportunity. During the summer of 2019, as demonstrations in the
city saw MTR closures and patient cancellations, I spent an increased amount of time browsing my Instagram. Aside from the obligatory cute puppy posts and viral dance steps, the algorithm was directing me more and more towards dentistry posts. I had been on IG a few years by then, and many of these newer clinical photos were not your standard juicy surgical shots, or 4-4 veneer cases (the ones where the post-op always looks 2/3rds of a stop brighter). These photos were unfamiliar to me for their novel cavity preparations (often completely non-retentive), red markings (what I now know to be caries detector dye) and heroic attempts to save teeth with huge carious lesions orcracks - teeth I would usually be readying my extraction forceps for. The more I went down this rabbit hole, the more I realised these weren’t isolated cases of someone “trying out” treatments - it was a group of dentists following a certain philosophy. They called it “Biomimetic Dentistry”. From this new wave of dental IG accounts, a couple in particular stuck out to me. They were a father-son duo of dentists from Utah in the United States, Drs David and Davey Alleman. Even though their pictures were not perfectly lit, and the rubber dams weren’t in that baby blue shade that soothes my OCD, the descriptions under each post elevated their accounts above all others. The science behind each clinical step was described in numbered bullet points. I felt myself gradually intrigued by their explanations as I trawled though the posts, yet still wanting to know more. I always wish to stay young at heart, so I did what any respectable millennial would - I hit them with a direct message.
They got back in touch with me promptly, and it just so happened that they were launching a “Mastership Programme” for Biomimetic Dentistry soon. They offered me a place on the inaugural class, scheduled to begin at the end of 2019. Now, this was a fairly sizeable sum being asked from me by someone I had never met, whose exchanges with me were completely limited to Instagram. I did some due diligence with Google searches, and a week later I decided to take the plunge.
The term was coined by Pascal Magne and it is the concept that the natural tooth structure provides ideal physical and functional
properties, and that the aim of restorative treatment should be to mimic the natural tooth as closely as possible. There is a strong emphasis on adhesive dentistry and a deliberate move away from traditional materials that rely heavily on mechanical retention(E.g. amalgam and gold). In order to mimic the natural tooth structure, Dr Alleman breaks it down into his “six lesson approach”:
• Establishing the concepts of caries removal (including the use of caries detector dye)
• Establishing the concepts of crack removal
• Optimising the adhesive complex with immediate dentine sealing and resin coating
• Reduction of stress, by controlling C-factor and use of deep margin elevation
• Preparation design and cementation principles for adhesive restorations
• Occlusal considerations
Simply put, you must first prepare the tooth to accommodate an ideally bondable surface, then take steps to ensure the hybrid layer is as secure as possible. Finally, we must recognise the factors that are most likely to stress and compromise the hybrid layer and tooth structure, and mitigate their effects.
I had been aware of the six lesson approach from reading through Instagram, but it still seemed quite vague to me. Having just enrolled on the course, I was sent some preparatory videos and articles and the concepts became easier to understand. With more than 10 other students from all over the world, the course was conducted purely online. This turned out to be a blessing - as we all know now, the world would become heavily affected by COVID shortly afterwards. Every fortnight we were given 10+ articles, which would help us better
understand the upcoming seminar topic. Each seminar would
be conducted on Zoom, and was based off each lesson from the six lesson approach. There was usually over an hour of Q&A after each seminar - I was at a particular disadvantage here as I never participated live, due to the time difference. However, students were also assigned monthly calls with Dr Alleman, and I saved up all my questions to ask him directly. In fact, the main bulk of information dissemination and learning was done through the WhatsApp chat group, so ideas and uncertainties could be addressed between students and the course leaders.
As I run a solo practice, I had free rein to implement Biomimetic Dentistry immediately. Especially whilst the course was ongoing, I documented my cases very closely with clinical photography and radiographs. There was definitely a steep learning curve, as many aspects of biomimetic dentistry involved relearning many of the most routine procedures (such as a simple class I restoration). The hard work implementing Biomimetic
Dentistry into my practice was that my dental assistants had to first
understand why we needed to alter the existing status quo, and the
adjustments necessary to achieve that. Wholesale changes to treatment
workflows, materials and scheduling all had to be undertaken in those
early days. Since then, I have consistently stuck to Biomimetic restorative
principles for all my patients. Seeing these cases 3 years on, I feel I have
addressed several issues with my pre-Biomimetic work. In the very least,
I have much more confidence in my caries and crack removal, moisture
control and adhesion. On the other hand, I have been providing far
more indirect restorations. As such, treatment times and lab fees have
increased and I have had to make adjustments with regards to fees.
Despite the rapid spread of Biomimetic Dentistry around the world,
thanks to social media and as a trending topic amongst hands-on
courses, Hong Kong has largely been insulated from this movement. At
the time of writing, 304 participants from 47 nations had undertaken the
Biomimetic Mastership by Drs Alleman since its inception in 2020. Aside
from myself, no other practitioners have been from Hong Kong and
China. Of course, there are other educational resources on offer for
Biomimetic Dentistry. However, a closer look into the locally available
continued professional education courses suggest that this trend hasn’t
carried over to our part of the world.
Given my personal experience, I would strongly recommend my
colleagues in Hong Kong to consider discovering more about
Biomimetic Dentistry. Certain controversies still exist for me. For
example, I would still like to see a lot more clinical data comparing
the outcomes of mineral trioxide aggregate pulp capping versus
the Biomimetic concept of deep caries removal endpoint. The
beauty of Biomimetic Dentistry is that there are many principles
that apply to various stages of restorative treatment - you do not
need to dive in at once. You can cherry pick and start off gradually,
slowly incorporating more into your daily practice as you see cases
come back and feel more comfortable with results. As mentioned,
there is a teething period, even if you are in a position to make all
the necessary decisions. It may be a bigger challenge for associate
dentists who must follow existing protocols at their clinic. I have
heard of many graduates of the Mastership programme opting for
a “Partially Biomimetic” compromise. With this in mind, I recently
offered a locum position to a young dentist, whose interest in
Biomimetic Dentistry had also been piqued through Instagram. I
acted as a mentor to explain the clinical steps. At the same time, he
had the appropriate materials, staff and cases to his disposable. In
the end, I felt it was a meaningful activity for both of us.
As an introduction, I would recommend following the Instagram
accounts of Dr David Alleman (david.alleman.dds) and Dr Davey
Alleman (davey_alleman_dmd). If you prefer printed press,
“Biomimetic Restorative Dentistry” by Magne and Belser is a
beautifully put together book on the subject. And once you are on
your Biomimetic journey, please contact your Peak salesperson to
find out the most suitable materials to help you on your way!