Case Title
Preservation of a Grossly Carious Posterior Tooth Using Pulp Capping and Direct Biomimetic Composite Restoration Under Strict Isolation
Case Overview
A posterior tooth presented with extensive carious destruction, deep dentin involvement, and proximity to the pulp. The primary objective was to preserve pulp vitality, restore structural integrity, and re-establish function using a strictly adhesive, minimally invasive approach, avoiding full coverage or endodontic overtreatment.
This case demonstrates that with proper isolation, magnification, controlled caries removal, and modern bioactive materials, even grossly compromised teeth can be predictably saved.
Diagnosis and Treatment Planning
Clinical and magnified inspection revealed:
- Extensive occlusal and proximal caries
- Soft infected dentin with localized pulpal exposure
- No signs of irreversible pulpitis
- Favorable periodontal and restorative prognosis
A vital pulp therapy approach was selected, consisting of:
- Selective caries removal
- Direct pulp capping with MTA under rubber dam isolation
- Immediate direct composite restoration using a reinforced biomimetic protocol
This decision aligns with current evidence favoring pulp preservation over prophylactic root canal treatment in restorable teeth.
Step-by-Step Clinical Protocol
1. Isolation and Field Control
Absolute isolation was achieved using a rubber dam, ensuring a contamination-free environment throughout the procedure. Isolation is critical for both pulp capping success and adhesive longevity.
Copper matrices were used to:
- Support missing walls
- Allow controlled composite packing
- Maintain proper emergence profile in deep cavities
2. Controlled Caries Removal
Caries removal was performed under magnification, following a selective excavation strategy:
- Infected dentin removed completely
- Affected dentin preserved near the pulp to avoid unnecessary exposure
This approach reduces pulpal trauma while maintaining biological respect.
3. Pulp Capping Under Microscope
A localized mechanical pulp exposure was encountered.
Protocol followed:
- Hemostasis achieved gently without excessive pressure
- Pulp evaluated under magnification
- Mineral Trioxide Aggregate (MTA) placed directly over the exposure
MTA was selected due to its:
- High biocompatibility
- Excellent sealing ability
- Proven dentin bridge formation
- Long-term pulp vitality outcomes
4. Base and Reinforcement Layer
After initial MTA placement:
- A protective layer was allowed to stabilize
- GC EverX Flow Posterior was used as a dentin replacement layer
EverX Flow was chosen for its:
- Fiber reinforcement
- Crack-stopping behavior
- Dentin-like modulus of elasticity
This step restores internal strength and reduces fracture risk in structurally compromised teeth.
5. Definitive Composite Restoration
The final restoration was completed using a packable composite layered anatomically to recreate:
- Cuspal form
- Occlusal anatomy
- Proper proximal contact
Layering was done incrementally to:
- Minimize polymerization stress
- Optimize adaptation
- Maintain marginal integrity
6. Finishing and Polishing
A multi-step polishing protocol was used to enhance surface quality and longevity:
- Initial contouring with fine finishing instruments
- Pre-polishing using appropriate discs and rubbers
- Final polish to achieve a smooth, plaque-resistant surface
Proper polishing is essential to reduce wear, marginal staining, and secondary caries risk.
Outcome
- Pulp vitality preserved
- Tooth structurally reinforced
- Occlusion restored
- Margins sealed under isolation
- Function and biology respected
This case highlights that gross caries is not an automatic indication for root canal treatment when modern protocols and materials are correctly applied.
Clinical Significance
This case reinforces the principles of conservative adhesive dentistry:
- Preserve biology whenever possible
- Replace only what is lost
- Use materials that mimic natural tooth behavior
- Prioritize isolation and technique over aggression
Such an approach aligns with contemporary minimally invasive and biomimetic dentistry philosophies.
References
- Bjørndal L, et al. Management of deep caries and the exposed pulp. Int Endod J. 2019.
- Mente J, et al. Mineral trioxide aggregate or calcium hydroxide direct pulp capping: long-term results. J Endod. 2010.
- Hilton TJ, et al. Vital pulp therapy: Current concepts. J Am Dent Assoc. 2013.
- Kunzelmann KH, et al. Fiber-reinforced composites in posterior restorations. Dent Mater. 2015.
- Opdam NJ, et al. Longevity of posterior composite restorations. J Dent Res. 2014.
- Magne P, Belser U. Bonded porcelain restorations in the anterior dentition. Quintessence.
- Style Italiano Group. Adhesive protocols for deep posterior restorations.
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