Dental Asia November/December 2023

CLINICAL FEATURE
Quadrant Dentistry: Managing
structurally compromised root
canal treated molar tooth using
biomimetic principles, fibre
reinforcement and adhesive
treatment By Dr Anand Narvekar
CASE HISTORY
A 35-year-old female complained of pain
during the consumption of hot and cold
beverages for several months. Due to the
COVID-19 pandemic, she delayed her visit
to the clinic.
Clinical examination revealed large carious
two walls defect on tooth 46. IOPA showed
the involvement of nerve with no signs of
periapical infection and widening for PDL
space. Tooth 47 showed marginal leakage
from old composite restorations and tooth
48 revealed a Class 1 defect (Figs. 1 and 2).
TREATMENT PLAN
Phase 1: Root canal treatment
Caries-driven access for root canal
treatment with complete removal of caries.
Canal shaping was done with Endostar
azure file system. 03 canal system with
02 mesials and 01 wide distal. Root canal
therapy was done in single visit.
Phase 2: Quadrant direct restorations and
overlay preparations
The patient was recalled after 15 days for
post-root canal build and direct restorations
for teeth 47 and 48.
Quadrant isolation was done from teeth 42-
48, with the placement of a wingless active
clamp on tooth 48. A heavy rubber dam was
selected for a better inversion and perfect
seal due to the structurally compromised
tooth 46 (Fig. 3).
When performing a quadrant treatment
approach in one setting, it is recommended
to start with the last tooth as the patient’s
jaw would close as time elapses, which
presents difficulty when working on the last
posterior tooth 7 or 8.
Old composite restoration was removed
from tooth 47 and caries were removed from
teeth 47 and 48, with the help of a caries dye.
Incremental morphological-driven cuspby-cusp
layering was selected to reduce the
C-factor as Class 1 defects produce a high
C-factor of 5, which leads to polymerisation
shrinkage and shrinkage stress.
The first layer was applied using Shofu
Injectable XSL, a 2nd Gen high compressive
strength composite. This layer must be
minimally 0.5mm as it will seal the uneven
dentine floor and protect the hybrid layer
from the polymerisation shrinkage stress.
The second layer was applied using the
Fig. 1: Reflected mirror view of mandibular right
quadrant showing large carious defect on tooth 46
involving mesial, buccal and lingual portion of the
tooth structure, along with leaky composite margins
on tooth 47
Fig. 2: Retracted mandibular right quadrant buccal
view showing large carious defect on tooth 46
involving mesial, buccal and lingual portion of the
tooth structure. IOPA showed involvement of the
nerve with no signs of periapical infection
Fig. 3: Rubber dam quadrant isolation from teeth
43-48 for restoring teeth 46-48. The small collage
photo showed the clean pulp chamber just before
obturation
DENTAL ASIA NOVEMBER / DECEMBER 2023 31