New treatment strategies for direct pulp capping and pulpotomy have shown promising potentials for improved outcomes in immature teeth with extensive caries, traumatic pulp exposures, or anatomical anomalies. Preservation and protection of the dental pulp in developing teeth promote root maturation and extend tooth survivability by postponing or even preventing more complex endodontic and restorative care. Early intervention using hydraulic calcium silicate cements such as mineral trioxide aggregate (MTA) stimulates pulpal cell recruitment and differentiation, up-regulates transformation factors (gene expression), and promotes dentinogenesis. Calcium hydroxide, resin-modified glass ionomer cements, hydrophilic resins, and formocresol have been shown to be less effective as bioactive agents when used in vital pulp therapy. Improved treatment procedures for pulp preservation include the use of caries detector dye to preserve the remineralizable inner carious layer and the use of sodium hypochlorite as a hemostatic and diagnostic agent to differentiate reversible from irreversible pulpitis. Although stepwise excavation and the use of calcium hydroxide is still being advocated, pulp capping and pulpotomy procedures using calcium silicate-based cements are becoming widely accepted as more effective procedures. MTA and new hydraulic calcium silicate cements provide biocompatible environments that predictably promote reparative dentin bridge formation when placed under properly bonded and sealed composite restorations. Hydraulic calcium silicate cements appear to provide a promising future for the preservation of pulpal integrity in immature teeth when used with modified and conservative treatment protocols.