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    Articolo mta Articolo mta Document Transcript

    • The use of Mineral Trioxide Aggregate in clinical and surgical endodonticsArnaldo Castellucci, MD, DDS A significant problem in clinical denti- silicate, Tricalcium aluminate, respon- stry in general, and in restorative denti- sible for the chemical and physical pro- stry and endodontics in particular, is iso- perties of this aggregate22), which set lation of the operative field for moisture in the presence of moisture. Hydration control. The root canal system to be of the powder results in formation of obturated must be dry in order to obtain a colloidal gel with a pH of 12.5. The a good seal, and contamination with gel solidifies to a hard solid structure blood must be avoided. During a direct in approximately three-four hours. This pulp capping procedure, hemorrhage cement is different from other materials must be controlled. When attempting currently in use because of its biocom- to seal a root perforation, a dry field is patibility, antibacterial properties, mar- essential. Further, during apical surgery, ginal adaptation and sealing properties, the retropreparation must be absolutely and its hydrophilic nature.41 dry. In terms of biocompatibility, Koh et Recently, Torabinejad and colleagues 41 al.19,21 and Pitt Ford et al.25 demonstra- developed a new cement named Mineral ted the absence of cytotoxicity when Trioxide Aggregate (MTA; ProRoot MTA came in contact with fibroblasts MTA, Dentsply Tulsa Dental) (Fig. 1), and osteoblasts, and the formation of which appears to have all of the cha- dentin bridges when the material was racteristics of an ideal cement to seal used for direct pulp capping. Other stu- communication between the root canal dies 16,39,45,48 demonstrated the growth of system and the oral cavity (mechani- cementum, periodontal ligament, and cal and carious pulp exposures), and bone adjacent to MTA when used to seal between the root canal system and the perforations, as well as when employed periodontium (iatrogenic perforations, as a retrofilling material in surgical open apices, resorbed apices, root-end endodontics. preparations). Torabinejad et al.43 demonstrated that MTA is an endodontic cement that is the antibacterial properties of MTA are extremely biocompatible, capable of sti- superior to that of amalgam, IRM (a mulating healing and osteogenesis, and zinc-oxide eugenol cement reinforced is hydrophilic. MTA is a powder that with polymethyl methacrilate), and consists of fine trioxides (Tricalcium SuperEBA (a zinc-oxide eugenol cement oxide, Silicate oxide, Bismute oxide) and reinforced with aluminum oxide and other hydrophilic particles (Tricalcium with ethoxybenzoic acid). Nonetheless, its antimicrobial spectrum is limi- ted, and if bacterial contamination is suspected or if acute inflammation is present, it is advisable to raise the pH and disinfect the root canal using a calcium hydroxide paste for one week before MTA.38 Furthermore, the margi- nal adaptation and sealing properties of MTA are far superior to amalgam, IRM, and SuperEBA.2,3,11,48,53 Fig. 1 ProRoot MTA (Dentsply Tulsa As noted, the characteristic that distin- 1 Dental, Tulsa, Oklahoma). guishes MTA from other materials used Pag. - 2
    • to date in endodontics is its hydrophilic during manipulation and 12.5 after 3properties. Materials used to repair per- hours.41 In a previous article, Holland etforations, to seal the retro-preparation in al.16 demonstrated the presence of calcitesurgical endodontics, to close open api- cristals in contact with MTA implantedces, or to protect the pulp in direct pulp in rat subcutaneous tissue. Those cal-capping, are inevitably in contact with cite cristals attract fibronectin, whichblood and other tissue fluids. Moisture is responsible for cellular adhesion andmay be an important factor due to its differentiation. Therefore we believepotential effects on the physical proper- that the MTA mechanism of action isties and sealing ability of the restorative similar to that of calcium hydroxide,materials.39 As shown by Torabinejad et but in addition, MTA provides a supe-al, MTA is the only material that is not rior bacteria-tight seal.10affected by moisture or blood contami- For those reasons MTA is preferred tonation: the presence or absence or blood calcium hydroxide. Nevertheless, MTAseems not to affect the sealing ability has only recently been introduced, andof the mineral trioxide aggregate.39 In no long-term studies on its efficacy havefact, MTA sets only in the presence of been published. Therefore, it is neces-water.22 sary to recall treated patients on a regu- lar basis to determine if treatment hasPulp capping with MTA been successful, or if root canal therapyAmong the materials available today for is needed.direct pulp capping,25 MTA is the mate-rial of choice. Pulp capping is indicated Operative sequence for pulp cappingfor teeth with immature apices when the After achieving anesthesia and isolationdental pulp is exposed, and there are no with a rubber dam, the exposed pulp issigns of irreversible pulpitis.38 In such irrigated with NaClO to control blee-cases the maintainance of pulp vitality ding. The MTA powder is mixed withis extremely important, and MTA is sterile water and the mixture is placedpreferred to calcium hydroxide. Recent in contact with the exposure using astudies have shown that MTA stimula- Dovgan carrier (Fig. 2). Compress thetes dentin bridge formation adjacent to mixture against the exposure site withthe dental pulp; dentinogenesis of MTA a moist cotton pellet. Place a moist cot-can be due to its sealing ability, bio- ton pellet over the MTA and fill the restcompatibility, and alkalinity.25 Faraco of the cavity with a temporary fillingand Holland, 10 demonstrated that in material. After four hours, the patientteeth treated with MTA all bridges weretubular morphologically and in somespecimens, the presence of a slight layerof necrotic pulp tissue was observed inthe superficial portion of these bridges.This suggested that the material, simi-larly to calcium hydroxide, initiallycauses necrosis by coagulation in con-tact with pulp connective tissue. This Fig. 2reaction may occur because of the pro- Dovgan carriers (Quality Aspirators, 2duct’s high alkalinity, whose pH is 10.2 Duncanville, Texas). Pag. - 3
    • AUTHOR PROFILE. Dr. Castellucci graduated in Medicine at the University of Florence in 1973 and he specialized in Dentistry at the same University in 1977. From 1978 to 1980 he attended Continuing Education Courses on Endodontics at Boston University School of Graduate Dentistry. He limits his practice to Endodontics. Dr. Castellucci is Past President of the Italian Endodontic Society (S.I.E.), Past President of the International Federation of Endodontic Associations, an active member of the European Society of Endodontology, an active member of the American Association of Endodontists, and a Visiting Professor of 3a 3b Fig. 3a Preoperative radiograph of the lower right quadrant. The young patient isonly six years old and the lower molar is erupted only with the mesial cusps. A deep decay is already present with a pulp involvement. The tooth is com- pletely asymptomatic. Fig. 3b After the removal of the decay, thepulp exposure was covered with MTA, a wet cotton pellet and a temporary cement. 3c 3d Fig. 3c Seven month recall. Fig. 3d Fifteen month recall. Fig. 3e Two year recall. Fig. 3fFour year recall. The pulp tests vital, iscompletely asympotmatic and there isno evidence of calcification in the pulp 3e 3f chamber. is seen again, the rubber dam is positio- lenges:30 1) to establish hemostasis, and ned, the temporary filling material and 2) to select a restorative material that is cotton are removed, and the set of the easy to use, seals well, does not resorb, material is assessed. Then, the tooth can and is biocompatible, supporting new be restored (Figs. 3a-f). tissue formation. Generally, a barrier is created to achieve Perforation repair with MTA a dry field, and prevent the extrusion of Recently, the prognosis of teeth with a the restorative material. On the other perforation has improved with the use hand, all of the restorative materials cur- of the operating microscope 29 and the rently used (amalgam, Super EBA, IRM, introduction of MTA.6 composite resins) require a dry field and When clinicians want to predictably do not promote a new tissue formation. repair a perforation, they face two chal- For the above reasons, and primarily Pag. - 4
    • Endodontics at the University of Florence Dental School. He is the Editor of “The ItalianJournal of Endodontics ” and of “The Endodontic Informer”, Founder and President of the“Warm Gutta-Percha Study Club” and of the Micro-Endodontic Training Center. An inter-national lecturer, he is the author of the text “Endodonzia”, which will soon be published inEnglish. He lives and practices in Florence, and can be reached at 39 055 571 114 or atcastellucci@dada.it Fig. 4a The screw post has caused a strip perforation of the mesial root of this lower left first molar. The furcal invol- vement is evident. 4a 4b Fig. 4b After the removal of the screw posts, the distal and mesiolingual canals have been retreated and obturated with warm gutta-percha. The mesiobuccal canal has been obturated with warm gutta-percha up to the level of the perforation. Fig. 4c The mesiobuccal canal has now been filled with MTA from the perforation up to the orifice. Fig. 4d 4c 4d Two year recall.because it is hydrophilic, MTA can me steps 4-7 at the second visit.today be considered the ideal material 4) application of 2-3mm of MTAto seal perforations. In fact, cementum 5) radiograph to check the correct posi-has been shown to grow over MTA, tioning of the materialallowing for normal attachment of the 6) application of a small wet cotton pel-periodontal ligament.26 Furthermore, let in contact with MTAMTA doesn’t require a barrier, is not 7) temporary cementaffected by moisture or blood contami- second visitnation, and seals better than any other 1) after 24 hours, removal of temporarymaterial in use today (Figs. 4a-d). cement to check if MTA is set 2) completion of therapy.Operative sequence for treatment ofa perforation Criteria for assessing successThe operative sequence to treat a perfo- To be able to state that success has beenration of the root or of the floor of the achieved following treatment of a perfo-pulp chamber is as follows: ration, the treated tooth must meet thefirst visit following requirements:351) isolation of the operative field with a 1) absence of symptoms, such as spon-rubber dam taneous pain or pain on palpation or2) cleansing of the perforation site percussion3) in case of bacterial contamination, 2) absence of excessive mobilityapplication of calcium hydroxide for 3) absence of communication betweenone week. If this step is performed, the the perforation and the oral cavity/ 6a 6bpatient goes home, then return to resu- gingival crevice Pag. - 5
    • The use of Mineral Trioxide Aggregate in clinical and surgical endodontics 4) absence of a fistula tinued root growth and apical closure 5) normal function in the presence of a periapical pathology 6) absence of a radiolucency adjacent to are explained on the basis of remnants of the perforation vital tissue in the area.4 However, a pro- 7) thickness of the periodontal ligament cedure that requires multiple appoint- adjacent to the obturating material no ments involving frequent dressing more than double the thickness of the changes and instrumentation may cause adjacent ligament. injury to the local tissue.49,50 If even only one of these criteria is For all the above mentioned reasons, lacking, therapy is not successful. and taking into consideration the work of Koenigs et al.18 and Roberts et al.28 Immature pulpless teeth (who demonstrated the efficacy of tri- Despite the demonstrated clinical suc- calcium phosphate in inducing apical cess of calcium hydroxide apexification, closure respectively in monkeys and in there are some disadvantages of this men), Coviello and Brilliant 8 suggested technique.15 The apical closure is unpre- a one-appointment procedure for obtu- dictable. The time necessary to achieve rating permanent teeth with nonvital the final result is variable, and for adults pulps and open apices, using tricalcium an acceptable result may never be achie- phosphate as an immediate apical bar- ved. The treatment time necessary for rier against which gutta-percha would induced apical closure in pulpless teeth be condensed. In their study, they found in humans has not been established.7,28 no statistical difference in the success This therapy requires multiple appoint- rate comparing the multi-appointment ments for either reapplication of calcium and one-appointment techniques; they hydroxide or to check its presence inside did not observe overfilling for teeth the root canal, and the time interval treated with the one-appointment tech- between visits is at least three months. nique; the procedure was faster; fewer This may lead to loss of the coronal seal radiographs were required; there was with consequent recontamination and less discomfort for the patient; and the exposure of the healing tissues to bacte- results were predictable.8 ria. In these cases an acute exacerbation Buchanan 5 in 1996 suggested the use and delayed healing response may occur. of freeze-dried demineralized bone to be For these reasons, many clinicians advo- packed to the end of the immature root cated obturation of teeth with open canal to create a one-visit biocompatible apices without inducing a natural apical apical matrix. The use of an operating barrier.8,14,27,32,33,51 In fact, the concept of microscope in such cases was extremely obturating teeth with immature apices helpful, as it allows the clinician to without first inducing a natural apical observe to the areas of the apex or bone barrier is not new; several investiga- graft matrix. tors9,12,23,34 have likewise indicated that MTA has been suggested as an ideal success is attainable with this approach, material to promote the formation of which does not require repeated applica- an apical barrier in a one-visit procedu- tions of calcium hydroxide. re.38 According to recent studies, when The apex of a tooth should be conside- compared to calcium hydroxide and to red as a dynamic area, capable of self the osteogenic protein-1, MTA induced repair.23,54 Occasional instances of con- the same amount of apical hard tissuePag. - 6
    • formation, and without an inflammatory enough to prevent overfilling; neverthe-response.32 Other studies demonstrated less, there is no contraindication to thenewly formed bone, periodontal liga- use of a resorbable matrix (Collacote),ment, and cementum in direct contact against which MTA could be condensedwith MTA. 39,45 Therefore, because it to the apex. For this purpose, the pre-provides a good apical seal (better than fitted Schilder pluggers, as well as paperwas observed with amalgam, IRM, points, can be used. The thickness of theand Super EBA),1,3,11,24,37,39,46,47,48,53 its apical plug must be 3-4 mm. In orderantimicrobial properties,43 biocompati- not to have voids, the use of ultrasonicsbility,17,19,20,40,42,43,44,45 and hydrophilic is suggested (while slightly condensingproperties, and taking into considera- the MTA with the plugger, the assistanttion the successful clinical cases reported is asked to touch the plugger with thein the literature, 6,13,31,38,52 MTA should ultrasonic tip). After completion, thenow be considered the material of choice extension of the apical plug is checkedfor the apical barrier technique in the radiographically. If the apical plug istreatment of pulpless teeth with open not satisfactory, the MTA is removed viaapices. saline solution irrigation, and the filling procedure is repeated.Operative sequence for pulpless When the radiographic appearanceteeth with open apices looks ideal, a wet paper point is placedAfter application of the rubber dam and in direct contact with the MTA and thepreparation of an adequate access cavity, access cavity is closed with a temporarythe root canal system should be cleansed seal, and allowed to set for 3-4 hours. Atwith copious irrigation using sodium the next visit the rubber dam is placed,hypochlorite (which can be delivered the temporary seal and paper point areultrasonically for enhanced activation). removed, the hardness of the material isThe root canals require only minimum checked, and then root canal therapy isshaping, and because of their size and completed by filling the root canal withthe thinness of the dentinal walls, they warm gutta-percha (Figs. 5a-d). If theneed to be cleansed more than shaped in canal walls appear to be thin and fragi-order not to increase fragility. le, it has been suggested that the rest ofTo improve disinfection of the canals, the root canal be completely filled withTorabinejad38 suggests using an intraca- adhesive composite resin (without usingnal medication with calcium hydroxide gutta-percha) to strengthen the rootfor one week. After rinsing calcium structure.15hydroxide from the root canal with As stated previously, the use of the ope-irrigation and drying with paper points, rating microscope is essential in thesethe MTA powder is mixed with saline or cases. Furthermore, to facilitate thesterile water and the mixture is carried positioning of the material, the clinicianto the apical area with the pre-fitted can carry the dry powder to the site.Dovgan carrier. MTA must be posi- Touching the MTA powder with a wettioned exactly at the foramen, as the paper point will, by capillary action,material must be in direct contact with provide the necessary hydration.periapical tissues. Overfilling should The apical barrier technique using MTAbe avoided (Figs. 4a-d). In general, the is indicated for adult patients with pul-resistance of the periapical tissues is pless teeth and immature apices. Using Pag. - 7
    • The use of Mineral Trioxide Aggregate in clinical and surgical endodontics5a 5b 5c 5d Fig. 5a the traditional technique that employs carrier and gently compacted with aPreoperative radiograph of the upper left central incisor. The patient is 55 calcium hydroxide will not be effective small plugger. The best instruments for years old and the open apex is not for these cases. Further, patients may this purpose include the use of amal-respopnding to previous therapy with find the calcium hydroxide approach gam carriers like the Messing gun (R. calcium hydroxide. unacceptable due to the multiple visits Chige, Inc., Boca Raton, Florida), or the Fig. 5b that are required. new Dovgan MTA carriers which are Intraoperative film with the Dovgan The same technique using MTA is also straight, bendable, or pre-bent (Quality carrier in place. indicated in the young patient, only if Aspirators, Duncanville, Texas). Fig. 5c the traditional access cavity will allow Another method of comfortably car-Three millimeters of MTA have been a perfect visualization of the apical fora- rying MTA into the cavity is by using a positioned at the foramen to make the apical barrier. men using the operating microscope. carrier descibed by Edward Lee 23 (Figs. If this is not obtainable and a further 6 a-g). The material remains attached Fig. 5d removal of crown structure should be to a small spatula, as we were used to After the MTA is set, the thermopla- stic gutta-percha has been used to necessary, in this case the traditional using with SuperEBA. This method obturate the root canal. technique with calcium hydroxide has the advantage of being less cum- remains the treatment of choice. bersome and therefore allowing easier access even to small cavities on posterier Root end filling teeth,without the long wait necessary Due to its sealing properties, biocompa- for the mixing and therefore the setting tibility, and hydrophilic nature, MTA is with SuperEBA (a delay generally in the considered the best choice for a retrofilling region of 8-12 minutes, before being material.2,3,6,11,17,36,37,38,39,40,41,43,4445,46,47,48,53 able to carry out the completion). Its handling characteristics are consi- The material should be kept relatively dered to be excellent. In particular, the dry so it does not readily flow, yet moist material can be used in the presence of enough to allow manipulation and a blood.36 workable consistency. If the assistant touches the plugger with an ultrasonic Operative sequence for root end filling tip during the placement process, voids After the preparation of the root end are eliminated, the density of the fill is has been completed with ultrasonic better, and radiopacity is increased. instruments, the MTA is placed with a The working time of MTA is approxi- Pag. - 8
    • Figs. 6a-g6a 6b Use of the carrier described by Lee.6c 6d6e 6f accompanies other materials. Finishing of MTA is accomplished by simply car- ving away excess material with a spoon excavator to the level of the resected root end. The moisture necessary to achieve the final set is from the blood, which fills the crypt after surgery (Figs. 7a-d). Conclusion6g Mineral Trioxide Aggregate (MTA) is a relatively new material that has becomemately two hours, and this eliminates the material of choice for certain endo-problems related to rapid setting that dontic applications. This article has Pag. - 9
    • The use of Mineral Trioxide Aggregate in clinical and surgical endodontics Fig. 7aPreoperative radiograph of the lowerleft first premolar. The previous surgi- 7a 7b cal procedure is failing. Fig. 7b A fistolous track is present. Fig. 7c Postoperative radiograph after thesurgical retreatment. The old amalgam has been removed and the retroprep has now been filled with MTA. Fig. 7d The one year recall is showing acomplete healing, with the lamina dura surrounding the end of the root. 7c 7d described those applications, including the operative sequence for specific pro- cedures. Pag. - 10
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