Conservative Endodontic–Restorative Rehabilitation Using Adhesive Dentistry Principles
From Controlled Caries Removal to Composite Onlay Reconstruction
Author: Dr Hamza Zahid
Clinic: Dr Hamza Dental Center, Lahore, Pakistan
Category: Endodontics | Adhesive Restorative Dentistry | Biomimetic Dentistry
Abstract
This case report describes the management of a deeply carious posterior tooth using a conservative endodontic–restorative approach rooted in adhesive and biomimetic dentistry principles. The treatment sequence focused on strict rubber dam isolation, controlled caries removal, predictable endodontic sealing, and cuspal reinforcement through an adhesive composite onlay. Modern resin materials, anatomical layering, and meticulous finishing protocols were used to restore function, strength, and long-term biological stability while preserving maximum sound tooth structure.
Introduction
The contemporary management of deep carious lesions demands a shift away from aggressive mechanical preparation towards biologically respectful, adhesive-driven protocols. When endodontic treatment is indicated, the restorative strategy must be planned from the outset to reinforce remaining tooth structure and reduce the risk of catastrophic failure.
This case highlights a restoration-driven endodontic workflow, integrating rubber dam isolation, conservative access design, adhesive sealing, and cuspal coverage with a direct composite onlay.
Case Presentation
A posterior mandibular molar presented with:
- Extensive occlusal caries undermining dentin
- Clinical symptoms consistent with irreversible pulpitis
- Structurally weakened cusps with high fracture risk
Radiographic evaluation confirmed deep dentinal involvement approaching the pulp with no advanced periapical pathology.
Clinical Procedure (Step-by-Step)
Step 1: Isolation and Field Control
Following local anaesthesia, full rubber dam isolation was established. Clamp selection ensured cervical seal without gingival trauma. Proper isolation was critical for moisture control, adhesive predictability, and procedural clarity.
Clinical relevance: Isolation is not optional in adhesive and endodontic dentistry; it directly impacts bond strength, microbial control, and long-term outcomes.
Step 2: Conservative Caries Removal
Caries removal was performed in a selective and controlled manner, preserving affected dentin where appropriate and avoiding unnecessary removal of structurally important tissue. Peripheral enamel and dentin were cleaned to hard sound margins.
Biological objective: Preserve dentin elasticity and reduce pulp stress while eliminating infected tissue.
Step 3: Endodontic Access and Canal Management
A conservative access cavity was prepared, maintaining pericervical dentin. Root canal treatment was carried out under rubber dam isolation with emphasis on:
- Minimal taper shaping
- Chemical disinfection
- Preservation of radicular dentin
Obturation was completed using a single-cone technique with resin-based sealer, ensuring a dense apical and coronal seal.
Step 4: Immediate Coronal Seal
Immediately following obturation, the pulp chamber was sealed to prevent coronal leakage. This step is critical in preventing reinfection and improving endodontic prognosis.
Step 5: Adhesive Foundation and Stress Management
The cavity was conditioned and bonded using a universal adhesive system under strict isolation. A stress-absorbing composite base was placed where required to:
- Reduce polymerisation stress
- Improve adaptation to deep dentin
- Create a stable foundation for cuspal build-up
Step 6: Cuspal Coverage with Direct Composite Onlay
Given the extent of cuspal undermining, a direct composite onlay approach was selected. Incremental layering was performed using enamel and dentin shades to replicate natural morphology and biomechanical behaviour.
Anatomic cusps, fissures, and marginal ridges were sculpted to restore:
- Occlusal stability
- Functional load distribution
- Tooth stiffness comparable to intact enamel–dentin complex
Step 7: Characterisation and Surface Texture
Subtle internal characterisation was achieved using ochre stains to enhance fissure depth and visual realism without compromising strength. Surface anatomy followed natural enamel line angles rather than artificial over-contouring.
Step 8: Finishing and Polishing Protocol
A multi-step polishing sequence was used:
- Pre-polishing with Enhance system
- High-gloss refinement with Diashine
- Final enamel-like lustre using Lucida polishing system (Style Italiano protocol)
This ensured:
- Reduced plaque adhesion
- Improved wear resistance
- Long-term surface stability
Outcome
The final restoration demonstrated:
- Excellent marginal adaptation
- Anatomically correct occlusion
- Natural enamel gloss and texture
- Functional cuspal reinforcement
Radiographic evaluation confirmed:
- Adequate obturation
- Proper coronal seal
- Absence of voids or overextensions
The tooth was returned to function with restored strength, aesthetics, and biological integrity.
Discussion
This case illustrates how adhesive dentistry can replace aggressive full-coverage approaches in selected posterior teeth. By combining conservative endodontics with biomimetic restorative principles, it is possible to:
- Preserve tooth vitality where possible
- Reduce structural sacrifice
- Improve fracture resistance
- Maintain reparability over time
Cuspal coverage does not always mandate indirect restorations. When isolation, material selection, and technique are optimised, direct composite onlays remain a powerful and conservative solution.
Conclusion
Conservative adhesive dentistry allows clinicians to restore deeply compromised teeth while respecting biology, function, and long-term prognosis. A restoration-driven endodontic approach, combined with meticulous isolation and modern composite systems, delivers predictable and durable outcomes without unnecessary invasiveness.
References
- Magne P, Belser UC. Bonded porcelain restorations in the anterior dentition: A biomimetic approach. Quintessence Publishing; 2002.
- Ferrari M, et al. Immediate dentin sealing and its influence on bond strength. J Adhes Dent. 2004;6(3):195–202.
- Dietschi D, Spreafico R. Adhesive metal-free restorations: Current concepts. Quintessence Int. 1998;29:409–420.
- Opdam NJM, et al. Longevity of posterior composite restorations: A systematic review. J Dent Res. 2014;93(10):943–949
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