ضرسان بعد سبع سنوات: علاج عصب بدون تلبيس، وحشو يحافظ على العصب

Two teeth, two strategies: 7-year follow-up

• Tooth 1: maxillary left first premolar (#24). Pre-endodontic build-up, root canal treatment and direct cuspal-coverage composite (direct overlay).
• Tooth 2: mandibular molar. Partial (selective) caries removal to preserve pulp vitality, then a direct composite with the proximal wall built first.

Tooth 1: maxillary first premolar

• Deep proximal caries extending subgingivally, with pulp involvement.
• Rubber dam isolation.
• Pre-endodontic build-up with deep margin relocation: Bioclear Biofit matrix, Bioclear Diamond Wedge and Bioclear Twin Ring.
• Snowplow technique at the cervical floor: an uncured layer of flowable composite, with the paste composite pushed into it and both light-cured together.
• Root canal treatment, obturation with a resin-based sealer.
• Definitive direct composite with cuspal coverage (direct overlay).

Tooth 2: mandibular molar

• Deep caries close to the pulp, vital pulp, no signs of irreversible pulpitis.
• Multiple-tooth rubber dam isolation.
• Partial (selective) caries removal: peripheral dentine and enamel margins cleaned to hard tissue, soft dentine left over the pulp to avoid exposure.
• Proximal wall built first with the snowplow technique, using a TOR VM sectional matrix and a Bioclear ring.
• Occlusal anatomy built up, occlusion checked, finished and polished.

Materials

• 3M Filtek Z350 XT composite
• 3M Scotchbond adhesive
• Resin-based endodontic sealer (tooth 1)

Rationale

• Build-up before endo: a predictable rubber-dam seal, a stable reference for working length, and a sealed chamber between visits. Relocating the deep margin follows the deep margin elevation principle, with 95.9% survival reported up to 12 years (Bresser et al., 2019).
• Direct overlay instead of a crown: preserves sound tooth structure. In a randomized trial on endodontically treated premolars, failure rates of direct composite were not significantly different from full crowns (Mannocci et al., 2002). Bruxism is a major risk factor, so case selection matters (Abu-Awwad et al., 2025).
• Coronal seal: the quality of the coronal restoration strongly influences periapical health (Ray & Trope, 1995).
• Partial caries removal: avoiding pulp exposure is the key to keeping the pulp vital. International consensus recommends selective removal in deep lesions (Schwendicke et al., 2016). In a 5-year randomized trial, restorations placed over soft dentine survived as well as those after stepwise excavation (Jardim et al., 2020).
• Longevity: posterior composites show annual failure rates of 1.8% at 5 years and 2.4% at 10 years (Opdam et al., 2014).

Clinical tips

• Rubber dam at every step, including multiple-tooth isolation when restoring adjacent teeth.
• In deep vital teeth, protect the pulp: clean the periphery, not the floor.
• Build the proximal wall first, then the occlusal anatomy.
• Snowplow at the cervical floor for adaptation.
• Use cuspal coverage when the walls are thin.
• Check the occlusion carefully, and recall regularly.

References

• Opdam NJ, et al. Longevity of posterior composite restorations: a systematic review and meta-analysis. J Dent Res. 2014;93(10):943–949.
• Mannocci F, et al. Three-year clinical comparison of survival of endodontically treated teeth restored with either full cast coverage or with direct composite restoration. J Prosthet Dent. 2002.
• Abu-Awwad M, et al. Direct restorations versus full crowns in endodontically treated molar teeth: a three-year randomized clinical trial. J Dent. 2025;156:105699.
• Bresser RA, et al. Up to 12 years clinical evaluation of 197 partial indirect restorations with deep margin elevation in the posterior region. J Dent. 2019;91:103227.
• Ray HA, Trope M. Periapical status of endodontically treated teeth in relation to the technical quality of the root filling and the coronal restoration. Int Endod J. 1995;28(1):12–18.
• Schwendicke F, et al. Managing carious lesions: consensus recommendations on carious tissue removal. Adv Dent Res. 2016;28(2):58–67.
• Jardim JJ, et al. Restorations after selective caries removal: 5-year randomized trial. J Dent. 2020;99:103416.