CATEGORY AUSTRALASIAN DENTIST 71 CLINICAL as an erosion on the occlusal surface that would require further monitoring. The likely diagnosis for tooth 37 was reversible pulpitis. Differential diagnoses included irreversible pulpitis and cracked tooth syndrome for tooth 37. After evaluating treatment options ranging from the least interventive to the most invasive, and discussing the associated costs, the patient chose to proceed with a likely direct pulp capping using MTA vpt (VOCO GmbH, Cuxhaven, Germany). This choice was due to the extent of the cavity. This procedure would be followed by a direct composite covering layer with GrandioSO Heavy Flow (VOCO GmbH, Cuxhaven, Germany), to seal the MTA vpt plug, and the final filling with the universal adhesive Futurabond U (VOCO GmbH, Cuxhaven, Germany) and the chromo-adaptive nano-hybrid composite GrandioSO Unlimited (VOCO GmbH, Cuxhaven, Germany). The patient was advised that if there was no pulp exposure, an indirect pulp cap would be recommended to promote pulpal health. If symptoms worsen in the future, indicating irreversible pulpitis, the suggested procedures would be orthograde root canal treatment or the extraction of tooth 37. Treatment began with a thorough cleaning of the tooth. The appropriate shade for GrandioSO Unlimited was then determined on the still wet tooth using the shade guide provided with the system, which turned out to be A3. The ClusterShade-System of GrandioSO Unlimited simplifies the shade selection process, utilising just five shades to cover all VITA® classical shades. Its chromo-adaptive properties enable easy blending with the natural tooth colour gradient, ensuring a seamless and natural-looking restoration. The treatment area was isolated using a rubber dam to maintain a clean working environment. Excavation of the carious defect was performed using a speed increasing handpiece with coarse-grit diamond and tungsten carbide burs for caries removal (Fig. 3). The preparation was finished with fine-grit diamond burs following the caries’ course, necessitating the opening of the distal proximal box. Alumina air-abrasion (29 µm, 4.0 bar) was used at the amelodentinal junction (ADJ) to enhance adhesion of the restorative material (Fig. 4). During the final excavation, initial pulp exposure occurred, either from caries or iatrogenically, requiring direct pulp capping. A wooden wedge was used to seal the distal cervical margin, causing a tear in the rubber dam at the distal proximal area. Upon reassessment, it was deemed unnecessary to replace the rubber dam, as contamination control could be adequately managed using a small saliva ejector. Homogenously hand-mixed MTA vpt (VOCO GmbH, Cuxhaven, Germany) was applied as the first layer for direct pulp capping following excavation and haemostasis with local anaestheasia to promote mineralised bridge formation. MTA vpt has a bacteriostatic effect due to its high pH 12 and releases calcium and hydroxide ions that promote formation of tertiary dentine and remineralisation. For effective caries management, small areas of carious dentine close to the pulp must be tightly covered with MTA vpt. An MTA block with a thin burnisher was used to successfully place the MTA vpt onto the exposed pulp (Fig. 5-7). The mixed paste may have a slight blue tinge, however, this colouring disappears after curing, leaving the material white-opaque. MTA vpt is free of bismuth oxide and ferrous compounds, thus, showing no product-related discolouration of the tooth. Immediately after application, the MTA vpt was carefully covered with a thin, sufficient layer of GrandioSO Heavy Flow (Shade WO, white opaque) without pressure and light-cured for 40 seconds without prior conditioning or use of an adhesive (Fig. 8). The cavity was demarcated with a sectional metal matrix, and Futurabond U was applied as Figure 5: Hand-mixed MTA vpt shown in an MTA block to allow for an easier and measured pick-up of the material with an instrument Figure 9: Displaying building up of the distal wall of the restoration on 37 with GrandioSO Unlimited A3 Cluster shade Figure 7: Accurate placement of MTA vpt over the micro exposure on 37 at the base of the cavity Figure 11: Immediate post-operative result of the completed restoration on 37 Figure 6: Hand-mixed MTA vpt shown picked up on a narrow burnisher to allow for precision placement Figure 10: Displaying building up of the full restoration on 37 with GrandioSO Unlimited A3 Cluster shade and FinalTouch brown and white tints Figure 8: Illustrating precision placement of GrandioSO Heavy Flow WO to seal the MTA vpt immediately after application Figure 12: Post-operative intraoral periapical radiograph of 37. Displaying a very deep restoration showing the thin layer of MTA vpt placed at the base of the cavity and the restoration completed with GrandioSO Unlimited
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