Vital pulp therapy using Biodentine XP and adhesive restorations: a three-year case series

Vital pulp therapy (VPT) has become a predictable biologically driven alternative to root canal treatment for the management of deep carious lesions and limited pulp exposures, particularly with the advent of hydraulic calcium silicate cements (hCSCs). The novelty of this case series lies in the use of Biodentine XP as a bioactive dentin substitute combined with immediate or staged adhesive restorative protocols in posterior permanent teeth, with a 3-year clinical and radiographic follow-up. Three patients presenting with deep carious lesions and signs consistent with reversible pulpitis were treated under rubber dam isolation, involving a total of four posterior teeth. Direct pulp capping was performed in two patients, respectively in a mandibular premolar (Case 1) and a mandibular first molar (Case 2) after pulp exposure during caries removal, whereas indirect pulp capping was performed in two mandibular molars of the same patient (Case 3) affected by deep carious lesions. Diagnosis was established through clinical examination, pulp sensibility testing, percussion, and periapical radiographic assessment, which confirmed deep dentinal involvement without apical disease. After complete caries removal and hemostasis assessment when required, Biodentine XP was applied using a bio-bulk fill approach. In the direct pulp capping cases, treatment was completed in a single visit with immediate adhesive composite restoration using a 10-MDP-based universal adhesive. In the indirect pulp capping case, Biodentine XP was initially used as a temporary restoration and subsequently maintained as a definitive dentin substitute during final direct or indirect adhesive rehabilitation. At 6 months, 1 year, and 3 years, all treated teeth remained asymptomatic and responsive to pulp sensibility testing, while periapical radiographs showed stable conditions without signs of pathology or treatment failure. Restorations also demonstrated satisfactory marginal integrity and structural stability over time. These cases suggest that a bioactive-adhesive approach based on rapid-setting hCSCs and immediate or staged coronal sealing may represent a clinically reliable and minimally invasive strategy for preserving pulp vitality in selected posterior teeth. Given the descriptive nature of this three-case series, these findings should be interpreted with caution and require confirmation through larger prospective studies.