Direct Pulp Capping with BIOBulk technique

A clinical case by our Community member Dr Vincenzo Tosco

This article and its content are published under the Author’s responsibility as an expression of the Author’s own ideas and practice. Styleitaliano denies any responsibility about the visual and written content of this work.

In restorative dentistry, managing carious exposure in deep lesions is a common occurrence, especially in cases with no or mild symptoms. Various treatment options exist, including minimally invasive approaches to vital pulp treatment, such as direct pulp capping. Direct pulp capping, when conducted after a careful diagnosis, is generally an effective clinical procedure for treating teeth with deep decay and exposed pulp. Calcium silicate-based materials, called bioceramics, are commonly applied in direct contact with the pulp. These materials play a crucial role in eliciting a pulp response and promoting the formation of a reparative bridge of hard tissues, thereby preserving pulp vitality. Additionally, new bioceramics can serve as a dentin substitute, allowing for a one-step cavity filling with satisfactory adaptation to the cavity. This way, the procedure is simplified and the chair time required to complete the restoration is reduced, as they have excellent bonding properties with resin-based composites.
This clinical case shows and explains the basic concepts of the “BioBulk-fill” approach, using Biodentine XP material as dentin replacement, to perform the restoration in deep cavity lesion.
This case report is about Grace, 32 years old, who came to “fix the hole in her tooth”. The patient did not feel pain and the tooth was positive in the vitality test and negative to the percussion test. The radiological examination revealed no periodontal lesions, while upon clinical examination the tooth presented a cavity with dental caries without exposure of the pulp.

septodont biodentine XP style italiano styleitaliano
septodont biodentine XP style italiano styleitaliano
styleitaliano style italiano deep proximal cavity

Fig.1
Initial situation of deep carious lesion on second lower left premolar.

styleitaliano style italiano rubber dam isolation

Fig.2
After application of the rubber dam, high and low-speed burs were used at first to clean the cavity, then a manual tool to complete the removal of the infected and damaged tissue, in order to have more control and sensitivity.

styleitaliano style italiano deep cavity closer to the pulp chamber

Fig.3
Indeed, when the cavity begins to be deep and get closer to the pulp chamber, it is advisable to use manual tools such as a vanadium excavator.

styleitaliano style italiano clean cavity with pulp exposure

Fig.4
The lesion was deep and the pulp was exposed. At this point, one should wait for the bleeding to stop, or promote formation of the clot. Only after the bleeding has stopped it is possible to evaluate and decide whether to proceed with direct capping of the pulp. When it is not possible to stop the bleeding, it is advisable to perform an endodontic treatment.

styleitaliano style italiano injection of biodentine septodont

Fig.5
Therefore, I decided to perform a direct pulp capping, applying the Biodentine XP bioceramic material inside the cavity easily, directly in contact with the pulp.

septodont biodentine XP style italiano styleitaliano
septodont biodentine XP style italiano styleitaliano
styleitaliano style italiano hardening of bioceramic material before restoration

Fig.6
Then, depending on the humidity present inside the tooth, it is necessary to wait for the material harden, at least 15 minutes, to proceed with the bonding procedures to complete the restoration.

styleitaliano style italiano : shaping of the bioceramic lining before restoration

Fig.7
Once the material has hardened, it is possible to modify the shape of the Biodentine XP layer with burs or manual instruments in order to distribute the material homogeneously within the cavity.

styleitaliano style italiano selective enamel etching

Fig.8
A sectional matrix was positioned to transform class two into a class one cavity, and the enamel was selectively etched for 20 seconds.

styleitaliano style italiano bonding of class II cavity

Fig.9
During the application of the Scotchbond Universal Plus Adhesive, it is appreciated how the brush remained clean without removing the bioceramic material, a sign that the material had completely hardened and was hence, suitable for completing the restoration, protecting the pulp.

styleitaliano style italiano class I cavity was left ready to fill

Fig.10
The mesial wall was built, re-establishing the proper contact point. After removal of sectional matrix, a class I cavity was left ready to fill.

styleitaliano style italiano occlusal modeling of lower premolar

Fig.11
The restoration was completed using only one mass of bulk-fill composite (A3, One Bulk Fill Restorative, 3M) and the occlusal morphology was obtained following Essential Lines modeling technique. After completing the restoration and curing the material, glycerin was applied for a final oxygen-free curing cycle.

styleitaliano style italiano light curing under glycerin gel

Fig.12
Under glycerin air-block, the restoration was cured again for 40 seconds.

styleitaliano style italiano final restoration

Fig.13
The final situation after rubber dam removal.

styleitaliano style italiano final aspect of lower premolar restoration

Fig.14
The final aspect of the restoration after finishing and polishing procedures.

styleitaliano style italiano before and after cavity restoration

Fig.15
Initial and final situation of the treatment of the left second premolar.

styleitaliano style italiano restored lower premolars

Fig.16
After the second premolar was performed, the old restoration of the first premolar was also replaced, again following the Bulk and Go and Essential Lines techniques proposed by StyleItaliano.

styleitaliano style italiano xray before and after direct pulp capping

Fig.17
The check-up x-ray shows different radiopacities of the composite and Biodentine XP. After 6 months of follow-up, no radiographic signs of periodontal lesions are evident, and the vitality test is positive and the percussion negative, a sign of maintained vitality of the treated tooth.

Conclusions

This technique allows the clinician to simplify the direct posteriors restorations, including direct or indirect pulp capping, using a bioactive material, like Biodentine XP, as dentin substitute. The combination of Biodentine XP and body shade composite for filling the cavity and the Essential Lines for modeling the restoration, ensures a safe outcome in one single visit.

Bibliography

  1. Rajasekharan, S., Martens, L.C., Cauwels, R.G.E.C. et al. Biodentine™ material characteristics and clinical applications: a 3 year literature review and update. Eur Arch Paediatr Dent 19, 1–22 (2018). https://doi.org/10.1007/s40368-018-0328-x
  2. Falakaloğlu S, Yeniçeri Özata M, Plotino G. Micro-shear bond strength of different calcium silicate materials to bulk-fill composite. PeerJ. 2023 Mar 29;11:e15183. doi: 10.7717/peerj.15183. PMID: 37013141; PMCID: PMC10066686.
  3. Tosco V, Vitiello F, Furlani M, Gatto ML, Monterubbianesi R, Giuliani A, Orsini G, Putignano A. Microleakage Analysis of Different Bulk-Filling Techniques for Class II Restorations: µ-CT, SEM and EDS Evaluations. Materials (Basel). 2020 Dec 23;14(1):31. doi: 10.3390/ma14010031. PMID: 33374708; PMCID: PMC7793523.
  4. Chiodera G, Orsini G, Tosco V, Monterubbianesi R, Manauta J, Devoto W, Putignano A. Essential Lines: a simplified filling and modeling technique for direct posterior composite restorations. Int J Esthet Dent. 2021 May 10;16(2):168-184. PMID: 33969973.

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