SEMINAR ON
CONTENTS
Introduction
Composition
Types – Gray & White
Mixing time
Setting time
Solubility
Biocompatibility
Radiopacity
pH...
• Resorptive defect
Comparison of Ca(OH)2 & MTA
Neurotoxic Evaluation
Cytotoxic Evaluation
Histologic Evaluation
Cellular ...
INTRODUCTION
Independent analysis suggests that the material of Mineral Trioxide
Aggregate (MTA) is identical to Portland ...
• Gypsum (5%)
Composition includes
• Tricalcium silicate
• Dicalcium silicate
• Tricalcium aluminate
• Tetracalcium alumin...
Gray MTA White MTA
FeO - Present FeO – replaced with MgO
FeO (Black) MgO (White)
hue matched the color of teeth
Many of th...
Glass or paper slab used for mixing with – plastic / metal spatula. It
requires moisture to set. Once the mix is dry sandy...
methods of ISO (6) or ADAS # 30 (7), the test solubility of MTA had to
be modified.
Biocompatibility
Clinically MTA is a b...
pH
MTA has a high pH of 12.5 similar to calcium hydroxide cement,
which prevents the bacterial growth and maintains the lo...
Advantages
• Antimicrobial Activity
• MicroLeakage
• Cementoconductive
• Non toxic
• Non-mutagenic
• Cell adherence & grow...
Indications
• To preserve pulp vitality
• Prevent pathological changes in the peri - radicular tissues
• Mechanical pulp e...
(Bekir Karabucak et al: dental traumatology 2005)
For Partial Pulpotomy or Cvek Pulpotomy, Formocresol or
Calcium hydroxid...
Reparative dentin formed by MTA does not originate from severely
damaged odontoblasts, but from undifferentiated cells tha...
Root End Filling (Torabinejad et al - 1995 & 1997)
MTA has the ability to prevent the irritants in the root canal to
extru...
Root perforations can occur during root canal treatment, post space
preparation or as a consequence of internal resorption...
Comparison of Calcium Hydroxide & MTA
The hard tissue formed, as a calcific bridge with MTA was less
period of time compar...
• Poor viscosity
• Not easy to apply in RC
• Multiple step Apexification with
• Unpredictability of apical closure
• Patie...
Ca(OH)2 MTA
Hard tissue formation Not much Root-end induction
Calcific bridge Not Continuous Continuous with
dentin
Period...
Application Not easy to apply in
RC
easy
Resorption Rate vary with density No resorption
Apical barrier formn. Change rate...
Pitt Ford et al: 1996
Nakata et al: 1998
M Torabinejad et al: 1999
Toh et al: 2003
Bargholz: 2005
Colceriu: 2005
Neurotoxi...
MTA is less toxic compared to other root end filling materials.
In 24 hrs, at low concentrations the sequence of toxicity ...
increased with no inflammatory cells in periradicular tissues and reduced
bacterial leakage.
(Torabinejad et al JOE, 23(4)...
synthesis of cellular RNA and Protein and therefore they are coordinating
in bone metabolism.
MTA compared with IRM, the t...
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Indian Dental Academy: will be one of the most relevant and exciting training center with best faculty and flexible training programs for dental professionals who wish to advance in their dental practice,Offers certified courses in Dental implants,Orthodontics,Endodontics,Cosmetic Dentistry, Prosthetic Dentistry, Periodontics and General Dentistry.

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Mineral trioxide aggregate/ orthodontic courses by indian dental academy

  1. 1. SEMINAR ON
  2. 2. CONTENTS Introduction Composition Types – Gray & White Mixing time Setting time Solubility Biocompatibility Radiopacity pH Physical Properties Advantages / Disadvantages Indications / Contra-Indication Clinical Applications • Direct pulp capping • Apical plug • Root end filling • Root perforations • Furcation involvement 2
  3. 3. • Resorptive defect Comparison of Ca(OH)2 & MTA Neurotoxic Evaluation Cytotoxic Evaluation Histologic Evaluation Cellular Response to MTA Conclusion References 3
  4. 4. INTRODUCTION Independent analysis suggests that the material of Mineral Trioxide Aggregate (MTA) is identical to Portland cement. It is a new remarkable biocompatible material with exciting clinical applications pioneered by Dr. Mahmoud Torabinejad, Loma Linda University, in 1993. Its first description in the dental literature in 1993, by Lee & colleagues, that MTA has been used in both surgical and non – surgical applications, including root end fillings, direct pulp capping, perforation repairs in roots or furcations and Apexification. In 1998, MTA’s approval by U.S Food and Drug Administration led to widespread use. MTA cement provides a better sealing ability over Amalgam, GIC, IRM, ZOE, and Super EBA. It’s an ideal material for use against bone for the overgrowth of cementum, formation of bone and facilitates the regeneration of the periodontal ligament fibers. Chemical Composition (Sarkar et al – JOE 2005) MTA is a mechanical mixture of 3 powder ingredients: • Portland cement (75%) • Bismuth oxide (20%) 4
  5. 5. • Gypsum (5%) Composition includes • Tricalcium silicate • Dicalcium silicate • Tricalcium aluminate • Tetracalcium aluminoferrite • Calcium sulfate • Bismuth oxide MTA powder consists of fine hydrophilic particles. Tricalcium silicate, Tricalcium aluminate, Silica oxide and Tricalcium oxide are the major components and few other mineral oxides are responsible for chemical and physical properties of MTA. Bismuth oxide added for radio opacity. Types of MTA: There are two types of MTA Gray and White (Saeed Asgary et al JOE 2005) 5
  6. 6. Gray MTA White MTA FeO - Present FeO – replaced with MgO FeO (Black) MgO (White) hue matched the color of teeth Many of the transitional element (Cr, Mn, Fe, Cu), which have free d- electrons (electrons not involved in bonding) exhibit strong colors when in their oxide forms (because these d- electrons can be readily excited by light in the visible spectrum- that is the solid has a small band gap). By contrast, Oxides of the elements that do not have excited electrons (Mg, Al, Si,P, S, K, Ca, Ti) tend to be colorless or white (large band gap), where as heavier element Bismuth oxide has a yellow oxide. Mixing MTA Prepared immediately before use. Kept always in closed containers or free from moisture. Powder: Water = 3: 1 6
  7. 7. Glass or paper slab used for mixing with – plastic / metal spatula. It requires moisture to set. Once the mix is dry sandy form its ready for application. Setting Time MTA powder consists of fine hydrophilic particles. Hydration of MTA powder results in a colloidal gel that solidifies to a hard structure in ~ 4 hrs which has a long setting time. It is generally considered that a potential root end filling material should set as soon as placed in root end cavity without significant shrinkage. This condition would allow the dimensional stability of the material after placement and less time for an unset material to be in contact with vital tissues. In general, quicker a material sets more it shrinks. But MTA has long setting time with less shrinkage. Solubility Lack of solubility is an ideal characteristic of MTA as a root end filling material. Despite of some advantages of controlled long term clinical studies, because of its long setting time, the recommended 7
  8. 8. methods of ISO (6) or ADAS # 30 (7), the test solubility of MTA had to be modified. Biocompatibility Clinically MTA is a biocompatible material with good sealing ability should generate little or no inflammatory response in periradicular tissues, and encourage the formation of fibrous connective tissue and / or cementum covering the entire root end. Calcium & Phosphorus are the main ions present in this material, which are the principle components of dental tissues, hence MTA proved to be biocompatible when used in contact with cells and tissues. Radio Opacity Bismuth oxide added for radio opacity and it is more radio opaque than its surrounding structures. Shah et al in 1995 showed that the MTA is less radio opaque than Kalzinol- (7.97) and more radio opaque than GP (6.14), IRM (5.30), Super EBA (5.16), Dentin- (0.70). More radio opaque than GP & dentin are very much distinguishable on radiographs. 8
  9. 9. pH MTA has a high pH of 12.5 similar to calcium hydroxide cement, which prevents the bacterial growth and maintains the long lasting bactericidal potential. Induction of hard tissue formation / barrier in Apexification procedures and root end filling would minimize the interaction between material and host tissues Physical Property Compressive Strength is an important factor to be considered when a filling material is placed in a cavity that bears occlusal pressure. As a root end filling material do not bear direct pressure, the Compressive strength of this material is not as significant as materials used to repair defects in occlusal surfaces. Compressive strength in 21days ≈70 Mpa. Mechanical wear, an important factor in coronal restoration, MTA is not used as coronal restoration or not placed in functional areas. Erosion of restorative filling materials can occur either by acids generated by bacteria, acids present in food or beverages or by mechanical wear. 9
  10. 10. Advantages • Antimicrobial Activity • MicroLeakage • Cementoconductive • Non toxic • Non-mutagenic • Cell adherence & growth • Alkaline phosphotase/ osteocalcin • Interleukin production • Periodontal ligament attachment to cementum growth • Dentinal bridge formation Disadvantages • More difficult to manipulate • Longer setting time • 10
  11. 11. Indications • To preserve pulp vitality • Prevent pathological changes in the peri - radicular tissues • Mechanical pulp exposures • Carious pulp exposures with immature apices Contra-indications • Irreversible pulpitis Clinical Applications • Direct Pulp Capping • Apical plug • Root End Filling • Perforation Repair • Furcation involvment • Resorptive Defects • Immature apices (apexogenesis/ Apexification) Pulpotomy 11
  12. 12. (Bekir Karabucak et al: dental traumatology 2005) For Partial Pulpotomy or Cvek Pulpotomy, Formocresol or Calcium hydroxide based materials has been recommended as a choice of material to conserve the healthy pulp. Due to its toxic /mutagenic /carcinogenic effect, MTA was tried for Pulpotomy or Cvek Pulpotomy. New matrix formation with cellular inclusions and dentin-like barrier at 3rd wk that found to be successful in preserving the pulpal vitality and continued development of tooth. Direct Pulp Capping In Exposed pulps, to preserve the pulpal vitality, MTA is used as a pulp capping material. It prevents Bacterial leakage with a high level of biocompatibility. MTA stimulates dentin bridge formation adjacent to dental pulp. Dentinogenesis of MTA due to its sealing ability, biocompatibility, alkalinity and other properties associated with this material. Dentin bridge formation that promotes healing. It formed a complete barrier at exposure site with free of inflammations. 12
  13. 13. Reparative dentin formed by MTA does not originate from severely damaged odontoblasts, but from undifferentiated cells that migrated from deep regions of pulp, which replaced the degenerated odontoblasts. Reparative dentin formed is regular and odontoblasts remain intact. 13
  14. 14. Root End Filling (Torabinejad et al - 1995 & 1997) MTA has the ability to prevent the irritants in the root canal to extrude into periradicular tissues. There is a less inflammation, with cementum formation and the regeneration of periradicular tissues. Apical Plug MTA indicated for Necrotic pulps and With open apices. MTA can be used as a material of choice fir apical plug and placed 3- 4mm in the apical plug. It creates a hard tissue formation or as an apical plug to prevent the extrusion of filling material during obturation of the canal with open apices. Retrograde Filling Jordan in 1998 MTA was tried as retro grade filling material. It was found that it Inhibits dye penetration with a Good sealing ability. (Nicholson et al: BDJ 2000 188(5); 266-268.) Root Perforations 14
  15. 15. Root perforations can occur during root canal treatment, post space preparation or as a consequence of internal resorption. MTA can be placed in the repair area as a reparative material. Repair can be achieved by Intracoronal / Extracoronal placement. Lee etal, 1993, found to have less leakage with least overfilling Nataka, 1997, found that there was least bacterial leakage than amalgam Pittford, 1995, found that perforated area had non-inflamed surroundings with cementum formation over MTA. Furcation Involvement No inflammation with no loss of periodontal attachment surrounding MTA. MTA forms cementum and is continuous with cementum and also forms a hard tissue bridges. MTA extruded into bony defect cementum formed around excess material and the periodontal ligament has a separated cementum from bone. Resorptive Defects MTA used for repairing the resorptive defects. There will not be inflammation surrounding it with continuous cementum formation. It forms a hard tissue bridges also with reduced ostoeclastic activity. 15
  16. 16. Comparison of Calcium Hydroxide & MTA The hard tissue formed, as a calcific bridge with MTA was less period of time compared with Calcium Hydroxide. MTA forms a thick dentinal bridge in the pulps capped and the dentinal bridge were continuous with dentin or dentinal tubules, that are close to pulp with no tunnel defects. The degree of inflammation is also less with MTA compared with Calcium Hydroxide. MTA sets hard and prevents recontamination and seals the pathways of communication between root canal system and the external surfaces of the teeth. Calcium hydroxide’s high pH inhibits essential enzyme activities: Metabolism, growth and cellular division. A high pH alters integrity of cytoplasmic membrane by disrupting organic components (proteins and phospholipids) and interferes with nutrient support. However, intestitial fluid via crown / apex, necrotic tissue and normal cellular respiration can partially dissolve Ca (OH)2. Resorption rate of Calcium Hydroxide paste will vary with density and a rapid barrier formation was related to both Calcium Hydroxide change rate and a narrow initial apical width. Though it has many advantages, its disadvantages includes, • Permeable to fluids • Soluble in periapical tissues 16
  17. 17. • Poor viscosity • Not easy to apply in RC • Multiple step Apexification with • Unpredictability of apical closure • Patients follow up • Delay in the completion of treatment MTA is an Insoluble matrix of silica that maintains the integrity even in contact with water. MTA is itself apical barrier material with good sealing ability properties and a high degree of biocompatibility. MTA has root-end induction capacity by producing an apical hard tissue formation with significant greater consistency. MTA is capable of maintaining high pH during a long time and forms an apical barrier that creates a favorable environment for cell division and matrix formation. Its advantages over calcium hydroxide are One- visit Apexification. Shortens the treatment time. Pt’s recall visit is less. 17
  18. 18. Ca(OH)2 MTA Hard tissue formation Not much Root-end induction Calcific bridge Not Continuous Continuous with dentin Period of time More Tunnel defects Less No tunnel defects Biocompatibility Low High Degree of inflammation High Less Sets Not hard Hard Seals the pathways of communication Better Good pH High High Solubility Partially dissolve Less soluble Permeable to fluids impermeable Soluble in periapical tissues insoluble viscosity Poor viscosity good 18
  19. 19. Application Not easy to apply in RC easy Resorption Rate vary with density No resorption Apical barrier formn. Change rate / initial narrow apical width Less / wide Apexification step Multiple One Apical closure Unpredictability Good Patients follow up More Less Treatment Delay Shortens Sealing Ability Evaluation Steve Dazey et al: 1990 Luke Moloney et al: 1993 Seung Jong Lee et al: 1993 Mahmoud Torabinejad et al: 1993 Christopher Bates: 1996 John D Welch et al: 1996 Roberto Holland: 1999 Roberto Holland: 2001 Bargholz: 2005 Sarkar et al: 2005 Leakage Evaluation M Torabinejad et al: 1995 Pitt Ford et al: 1995 19
  20. 20. Pitt Ford et al: 1996 Nakata et al: 1998 M Torabinejad et al: 1999 Toh et al: 2003 Bargholz: 2005 Colceriu: 2005 Neurotoxic Evaluation (Yahshid Asrari: JOE 29(11); Nov 2003.) Effects of root end filling materials on neurons in primary cortical cell cultures. Neurons are highly sensitive system to study toxicity. Neurons are highly susceptible to free-radical-mediated injury, metabolic injury and environmental toxins. They are much more sensitive than fibroblasts. Root end materials may absorb by the body, causing systemic toxicity. There is also possibility that these materials may cause local neurotoxicity when they are placed near the local nerves and nerve endings. Cytotoxic Evaluation (karl Keiser et al : JOE 26 (5); May 2000) 20
  21. 21. MTA is less toxic compared to other root end filling materials. In 24 hrs, at low concentrations the sequence of toxicity was Super EBA > MTA / Amalgam After 24- hrs, at high concentrations, the sequence of toxicity was Super EBA > Amalgam > MTA Histologic Evaluation (Torabinejad et al JOE, 21(12), Dec 1995.) MTA as a root end filling material does not prevent regeneration of dental and osseous tissues and induced cementoblasts to produce matrix for cementum formation over the MTA. The presence of cementum formation over the MTA in canals obturated with gutta percha either with or with out a root canal sealer indicated the superior sealing ability of MTA and its biocompatibility with periradicular tissues. There was an enhanced cementogenesis, due to its sealing ability or by activation of cementoblasts to produce cementum formation or by the release of substances that activate the cementoblasts to laid down a matrix for cementogenesis. Due to its alkaline pH, the formation of fibrous connective tissue that was as calcified as the post surgical time interval 21
  22. 22. increased with no inflammatory cells in periradicular tissues and reduced bacterial leakage. (Torabinejad et al JOE, 23(4), Apr 1997) MTA has the ability to stimulate the cytokine release from bone cells and promotes hard tissue formation rather than being inert or being irritant as a root end filling material. A Thick layer cementum over MTA was continuous with dentin incremental lines & cell inclusions. Some of the cementum surface was characterized by fiber insertion, mimicking sharpeys fibers. The New cementum was attached to the original cementum. Two possibilities for the source of the new cementum either derived from the remaining periodontal ligament or from ingrown connective tissue from bone. If the cementum had grown lateral aspects, incremental lines run diagonally from the cementum rather than parallel. Cellular response to MTA [Eng Tiong Koh et al: JOE 24(8); Aug, 1998] Cytokines, are soluble substances that are capable of activating other cells are released by variety of cells. They are low – molecular wt glycoproteins secreted as a result of cellular stimulation and are extremely potent. They interact with cell receptors, leading to a change in 22
  23. 23. synthesis of cellular RNA and Protein and therefore they are coordinating in bone metabolism. MTA compared with IRM, the tissue response was characterized by marked rounding of cells and depletion of cell numbers indicating IRM is toxic. MTA at 1 & 3 days, the cells observed were normal morphology, growing in intimate contact with cement and a new hard tissue formation by measuring the release of cytokines from the bone cells. Small amounts of IL-1a, IL-1b, IL-6 produced by cells in contact with MTA. The major Cytokines include ILs and colony stimulating factor. Most ILs cause T and/or B cell proliferation, and can stimulate by mature Osteoblast. Cytokines involved in bone formation divided in two groups: first includes stimulate bone cell proliferation and inhibit mature osteoblasts and second includes stimulate precursor proliferation and mature osteoblasts activity. Conclusion Thanks to Dr Torabinejad for remarkable material for use in endodontics. MTA with high biocompatibility, alkalinity, sealing ability provided hermetic seal. MTA is Panacea for pulpal / periodontal diseases. 23
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