Abstract
A 37-year-old female presented for a routine check-up without symptoms. During caries removal on the mandibular first molar (#36), a small perforation was detected. The defect was sealed with Mineral Trioxide Aggregate (MTA), followed by a protective layer of TheraCal. After complete excavation of caries, the tooth was rebuilt using an adhesive protocol with Dentsply bonding system, 3M Nano Flowable composite, Shofu Bulk-Fill composite, EverX Flow (GC), and EverX Posterior Capsule for reinforcement. The tooth was conservatively prepared, and a digital impression was taken for fabrication of an E.max overlay.
Prior to cementation, the intaglio surface of the restoration was treated with sandblasting, hydrofluoric acid etching, phosphoric acid etching, and silane application. The tooth surface was also conditioned with sandblasting, phosphoric acid etching, and bonding. The restoration was then cemented with dual-cure resin cement.
This case highlights the successful integration of biological management of perforation (MTA + TheraCal) with modern adhesive restorative protocols, demonstrating that E.max overlays can provide a conservative and durable solution for posterior teeth with complex clinical challenges.
Introduction
Deep carious lesions in posterior teeth may occasionally lead to iatrogenic perforations during excavation, creating a significant restorative challenge. Traditionally, such teeth were often considered for extraction or treated with extensive full-coverage crowns. However, advancements in biomaterials such as MTA and resin-modified calcium silicate liners, combined with the adhesive capabilities of modern resin composites and ceramics, now allow for a more conservative and biologically driven approach.
Lithium disilicate (E.max) overlays represent a minimally invasive alternative to full crowns. They preserve sound tooth structure, provide excellent mechanical and esthetic outcomes, and, when combined with proper adhesive protocols, achieve predictable long-term success.
This report presents the management of a molar with caries and perforation, restored using a biomimetic approach and finalized with an E.max overlay.
Case Report
Patient: 37-year-old female
Medical history: Non-contributory
Chief complaint: Routine dental visit, no symptoms
Clinical findings:
- Mandibular first molar (#36) with an old defective composite restoration and recurrent caries.
- During caries excavation, a perforation was observed.
Radiographic findings:
- Periapical status within normal limits.
- Carious involvement beneath the existing restoration.
Diagnosis: Secondary caries with accidental perforation, tooth #36.
Treatment Procedure
- Isolation
- Absolute isolation with a rubber dam.
- Perforation management
- Immediate sealing with MTA.
- Protective coverage with TheraCal.
- Tooth build-up
- Application of Dentsply bonding system.
- Layering sequence:
- 3M Nano Flowable composite (initial lining).
- Shofu Bulk-Fill composite (bulk dentin substitute).
- EverX Flow (GC) (fiber-reinforced layer).
- EverX Posterior Capsule (final reinforcement).
- Tooth preparation and impression
- Conservative overlay preparation, preserving enamel margins and rounded internal angles.
- Digital impression taken for fabrication of an E.max overlay.
- Restoration surface treatment
- Sandblasting of the intaglio surface.
- Hydrofluoric acid etching (9%, 20 s).
- Rinse, dry.
- Phosphoric acid etching (short application).
- Silane application (60 s, air-dry).
- Tooth surface treatment
- Sandblasting.
- Phosphoric acid etching (15 s enamel, 10 s dentin).
- Application of Dentsply bonding agent.
- Cementation
- Dual-cure resin cement applied to the restoration.
- Restoration seated under firm pressure.
- Excess cement removed with microbrush and floss.
- Light-curing for 40 s from multiple directions.
- Finishing and polishing
- Margins refined and occlusion adjusted.
Discussion
The case demonstrates a combined biological and adhesive restorative approach:
- MTA provided a reliable seal for the perforation, thanks to its biocompatibility and bioactive properties.
- TheraCal offered an additional protective barrier and supported adhesive procedures.
- The layered build-up technique (flowable, bulk-fill, fiber-reinforced composites) enhanced fracture resistance and restored proper anatomy.
- E.max overlay allowed for a minimally invasive alternative to a full crown, optimizing both structural preservation and esthetics.
Recent literature supports the long-term success of lithium disilicate overlays, reporting survival rates of over 90% in posterior teeth at 10-year follow-up, provided adhesive protocols are strictly followed.
Conclusion
The combination of perforation management with MTA and TheraCal and a conservative adhesive restorative workflow enabled successful rehabilitation of a structurally compromised molar. The use of an E.max overlay offered functional stability, durability, and excellent esthetics, reaffirming the value of minimally invasive adhesive dentistry in complex restorative cases.
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