Saving a Cracked Molar – A Case of Vital Pulp Preservation with Biodentine™

Teeth with cracks that exhibit symptoms of moderate to severe pulpitis have historically been treated by pulpectomy, root canal treatment and then restoration with full-coverage indirect restoration. With the success of pulpotomies using calcium silicate cements, many of these teeth have been able to retain their vitality and arguably increase their longevity.

The Patient Presentation

In 2018, a 59-year-old patient presented with vague, sharp pain in the upper left quadrant. He struggled to identify the exact tooth, but testing revealed something telling:

• Tooth 26 reacted intensely to cold, with pain lingering for nearly a minute – a classic sign of pulpal involvement.
• Biting on damp gauze triggered a sharp, non-lingering response, suggesting a crack.
• Radiographs showed no periapical radiolucency, but the composite restoration on tooth 26 revealed multiple crack lines once removed.

These cracks ran deep, extending from the lingual to the center and from the mesio-buccal to the center, with finer cracks under the buccal cusps.

The patient was given a choice:

• Direct composite restoration – conservative, but risky if cracks progressed.
• Full-coverage indirect restoration – more protective, but costly.

The patient chose the more conservative path, opting for direct composite restoration. He returned annually, and for several years, the tooth remained asymptomatic.

The Turning Point – 2024

Six years later, in 2024, the patient returned with a familiar pain. This time, the symptoms were more pronounced:

• Severe, lingering pain to cold, lasting nearly a minute.
• Occasional, spontaneous aches.
• Tooth 26 was slightly tender to percussion.
• Radiographs revealed a reduced pulp chamber, indicating chronic pulp response.

The situation had clearly progressed, but instead of rushing to RCT, the clinician decided to assess the pulp’s condition before making a final decision.

The Procedure

Here’s what the clinician did to give this tooth a second chance:

• Rubber Dam Isolation – Essential for contamination control.
• Access Cavity Preparation – Removed the old composite, revealing the full extent of the cracks.
• Pulp Chamber Exposure – Upon removing the chamber roof, vital pulp tissue was found, along with a pulp stone – a positive sign for pulpotomy.
• Hemostasis – A cotton pellet soaked in NaOCl was placed for 5 minutes, effectively controlling bleeding and confirming tissue vitality.
• Bio-Bulk Fill with Biodentine™ – The entire pulp chamber was filled with Biodentine™, creating a strong, bioactive core for future restoration.
• Provisional Coverage – The tooth was temporized to allow for symptom monitoring.

The Follow Up

12 weeks later, the patient returned – pain-free and symptom-free. With the pulp stable, the tooth was prepared for a ¾ zirconia crown, with the Biodentine™ serving as a robust core. The final crown was bonded, restoring the tooth’s function, strength, and aesthetics.

The Takeaway

The ability to use Biodentine™ in the Bio-Bulk Fill technique has a number of advantages in cases like the above. This case demonstrates the potential of vital pulp therapy in cracked teeth:

✔️ Pulp preservation without extirpation
✔️ Reduced treatment time
✔️ Strong, bioactive core support
✔️ Long-term success with conservative care

Next time you see a cracked tooth, think beyond the RCT. Preserve the pulp. Save the tooth.
Biodentine™ in Bio-Bulk Fill procedure as a core material for indirect restoration