Title
Quadrant Dentistry Under Absolute Isolation: Endodontic Management and Biomimetic Class II Composite Restoration with Predictable Contacts
Case Overview
A grossly carious posterior tooth presented with deep dentinal involvement and pulpal exposure risk within a compromised quadrant. The treatment objective was to preserve tooth vitality where possible, control contamination, and restore function and anatomy using an adhesive, minimally invasive approach.
A quadrant dentistry protocol was followed to ensure optimal isolation, moisture control, and efficient workflow for both endodontic and restorative phases.
Step-by-Step Clinical Protocol
1. Quadrant Isolation and Field Control
Treatment began with full rubber dam isolation of the quadrant, ensuring complete control over saliva, blood, and sulcular fluids.
- Heavy-gauge rubber dam was used to enhance retraction and visibility
- Adjacent teeth were isolated to allow predictable proximal contact formation
- Floss ligatures and clamps ensured cervical seal integrity
Rationale:
Absolute isolation is mandatory for adhesive dentistry and endodontics. It improves bond durability, reduces bacterial contamination, and directly impacts long-term success.
2. Caries Removal and Pulp Assessment
Caries excavation was performed under magnification with a selective caries removal strategy:
- Infected dentin removed completely
- Affected dentin near the pulp preserved to avoid unnecessary exposure
- Pulpal status assessed clinically after excavation
A localized pulpal exposure was encountered with controlled bleeding, indicating a favorable prognosis for vital pulp therapy.
3. Direct Pulp Capping Under Microscope
A direct pulp capping procedure was carried out under magnification:
- Hemostasis achieved using gentle pressure and biocompatible irrigants
- Mineral Trioxide Aggregate (MTA) placed directly over the exposure site
- Care taken to avoid contamination during setting
Why MTA:
MTA provides superior sealing ability, biocompatibility, and induces dentin bridge formation, making it the gold standard for direct pulp capping in mature permanent teeth.
4. Endodontic Treatment (Same Quadrant)
For the endodontically involved tooth in the same quadrant:
- Access cavity prepared under rubber dam
- Working length established and verified radiographically
- Cleaning and shaping performed using a conservative approach
- Obturation completed with a dense, three-dimensional fill
Key principle:
Performing endodontics under quadrant isolation allows immediate adhesive restoration without reinfection or interim leakage.
5. Matrix Selection and Proximal Wall Reconstruction
To restore a deep Class II defect:
- Copper matrices / sectional matrix system used to manage missing proximal walls
- Proper wedging achieved to control gingival fluid and create separation
- A tight, anatomically correct proximal wall was established before bulk buildup
This step converted the defect into a controlled Class I cavity, improving predictability.
6. Adhesive Protocol and Composite Placement
A strict adhesive protocol was followed:
- Selective enamel etching
- Universal adhesive applied according to manufacturer guidelines
- GC EverX Posterior (flowable and packable) used as a dentin replacement in high-stress zones
- Incremental composite layering to reduce polymerization stress
Occlusal anatomy was rebuilt using a biomimetic approach, respecting cusp inclines and contact areas.
7. Finishing, Occlusion, and Contact Verification
- Occlusion checked in static and dynamic movements
- Contacts verified with floss for tightness and passivity
- Margins refined and polished to ensure plaque resistance
Final restoration showed excellent marginal adaptation, proper anatomy, and functional integration within the quadrant.
Outcome
- Tooth preserved with minimal biological cost
- Vital pulp protected using evidence-based materials
- Endodontically treated tooth sealed immediately
- Tight proximal contacts and stable occlusion achieved
- Patient left with a fully functional quadrant restored in a single controlled workflow
Clinical Takeaways
- Quadrant dentistry dramatically improves efficiency and outcomes
- Rubber dam isolation is non-negotiable for adhesive success
- MTA remains the material of choice for direct pulp capping
- Proper matrix selection is key for predictable Class II restorations
- Biomimetic principles outperform traditional bulk restorations in longevity
References
- Bjørndal L et al.
Management of deep caries and the exposed pulp.
International Endodontic Journal, 2019.
- Mente J, Geletneky B, et al.
Mineral trioxide aggregate or calcium hydroxide direct pulp capping: clinical outcome.
Clinical Oral Investigations, 2014.
- Schwendicke F, Frencken JE.
Managing carious lesions: consensus recommendations.
Advances in Dental Research, 2016.
- Van Meerbeek B et al.
Adhesive dentistry: principles and techniques.
Dental Materials, 2020.
- Opdam NJM et al.
Longevity of posterior composite restorations.
Journal of Dental Research, 2014.
- Bastos JV et al.
Effect of rubber dam isolation on bond strength.
Operative Dentistry, 2016.
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