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LOGO
- DR SNEHA RATNANI
Mineral Trioxide
Aggregate
Introduction
 Mineral trioxide aggregate (MTA) was developed
at Loma Linda University (Loma Linda,
California, USA)
 Fir...
 Endodontic failures may occur as a result of
leakage of irritants into the periapical tissues.
Therefore, an ideal ortho...
COMPOSITION
MTA is a cement composed ofMTA is a cement composed of
Portland Cement
)75%(
• Tricalcium silicate
• Dicalcium...
-It also contains trace
amounts of
Silica,
calcium oxide,
magnesium oxide ,
potassium sulphate, and
sodium sulphate.
Difference between
WhiteWhite
MTAMTA
Secondary electron
image EDAX analysis
 Calcium
 Silicon
 Bismuth
 Oxygen
GreyGre...
WMTAWMTA GMTAGMTA
ElementElement Wt% conc.Wt% conc. Wt% conc.Wt% conc.
CaOCaO 44.2344.23 40.4540.45
SiOSiO22 21.2021.20 17...
 MTA is essentially Portland cement (used in the
building industry as a binder in concrete) with
4:1 proportions of bismu...
 MTA powder is Hydrophilic .
 It consists of two phases – Crystalline
material is essential calcium oxide and
amorphous ...
Calcium oxide (50-75%) + Silicone dioxide(15-
25%)+ Aluminum oxide
Tricalcium Silicate + Dicalcium Silicate +
Tricalcium A...
Kiln
 MTA is available either as a box of five 1-gram
single-use packets or as premeasured water
packs for easy manipulation a...
MIXING OF MTA
MIXINGMIXING
 The mixing time should be less than 4 minutes,
as prolonged mixing can cause dehydration of
the mixture.
 The mixture c...
MESSING GUN / AMALGAM
CARRIER WEST PERF REPAIR
INSTRUMENT
FLAT END OF SPOON
EXCAVATOR
AMALGAM CARRIER
SPINE TAP NEEDLE
Car...
Different types of Carrier for placement of MTADifferent types of Carrier for placement of MTA
Small plastic amalgam type...
The hydration reaction during setting occurs
between tricalcium silicate (3CaO SiO2) and·
dicalcium silicate (2CaO SiO2) t...
 A study comparing white MTA (White MTA, Dentsply;
Tulsa Dental Products) to white Portland cement
showed the cements to ...
 Difference in the particle size distribution.
 Portland cement exhibited a wide range of
sizes whereas MTA showed a uni...
 Results from characterization studies have
indicated PC cannot be recommended as a
suitable substitute of MTA for the fo...
• As opposed to PC, MTA is manufactured in
laboratories as a medical material and is
approved by the U.S. Food and Drug
Ad...
PROPERTIES
PHYSICAL STATE - solid (powder)
COLOR - grey/white
ODOR - no specific odor
BOILING POINT - >1000ºC
SETTING TIME : 2 hours 45 min – 4 hours
COMPRESSIVE STRENGTH: immediately after
setting - 40 Mpa
21 days after setting - 7...
Solubility
 MTA displays low or nearly no solubility,
which is attributable to addition of the
bismuth oxide.
  Chemical...
Antibacterial properties
 Results showed that the freshly mixed MTA was
effective in killing the tested fungi after 1 day...
Periradicular reaction
 As a root-end filling in vivo, less periradicular
inflammation was reported compared with
amalgam...
BIOCOMPATIBILITY
 Some studies considered that the
biocompatibility of MTA is attributable to the
release of hydroxyl ion...
Regenerative Potential and
Biological Activity
 MTA has the capacity to induce bone, dentin,
and cementum formation and r...
Radiopacity
 MTA has a mean radiopacity of 7.17 mm of
equivalent thickness of aluminum, which is
less than that of IRM, s...
Direct pulp capping
 Pulp capping is indicated for teeth with
immature apices when the dental pulp is
exposed & there are...
 Similarly to calcium hydroxide , initially
causes necrosis by coagulation in contact
with pulp connective tissue .
 Thi...
Operative Sequence for Pulp capping
 Anaesthesia
 isolation with a rubberdam
 the exposesd pulp is irrigated with sodiu...
Pulp Capping
Pulp Capping
Pulp Capping
Verification of the setting of
MTA at 48 h.
Disinfection of
exposure site by
rinsing with
5.25%
sodium
hypochlorite.
Pulp ...
Follow-up periapical radiograph at 11
months showing
maturogenesis of the root.
Final coronal restoration with composite.
...
Pulpotomy agent
 MTA has been proposed as a potential
medicament for pulpotomy procedures as well
as capping of pulps wit...
All irrigation should be performed
before the material is placed because
irrigation after placement will cause
significan...
Pulpotomy
Pulpotomy
Pulpotomy
Pulpotomy Procedure
Anaesthesia
 Isolation with a rubber dam.
 Caries should be removed using a
caries detector with a ...
 Place a wet ,thinned ,flattened cotton pellet over
the MTA.
 The cotton pellet provides the moisture MTA
requires for a...
Apexification
 Although MTA & Calcium hydroxide both exhibit
similar alkaline Ph levels, MTA also shows
excellent margina...
Apexification
Apexification
Apexification
 Rubber dam isolation
 Extirpate the pulp and clean the root canal
system using endodontic instruments and
5.25% Naocl i...
 Place MTA in the canals and condense to the
apical end of the root canal to create a 3-
4mm apical plug .
 Radiographic...
Apexification
Preoperative radiograph of the
maxillary left central incisor.
The patient is 55-years-old and
this tooth (w...
Perforation Repair with MTA
 Mta can today be considered the ideal material
to seal perforations .
 Cementum has been sh...
INTERNAL MATRIX CONCEPTINTERNAL MATRIX CONCEPT MODIFIED MATRIX CONCEPTMODIFIED MATRIX CONCEPT
LEMON 1992LEMON 1992 C.BARGH...
OVER INTERNAL MATRIX CONCEPTOVER INTERNAL MATRIX CONCEPT
NO PRESSURE REQUIREDNO PRESSURE REQUIRED
WET FIELDWET FIELD
BETTE...
GRANULATION TISSUEGRANULATION TISSUE
COLLAGEN MATRIXCOLLAGEN MATRIX
MTA APPLIED ALONG THE COLLAGENMTA APPLIED ALONG THE COLLAGEN
HEALING OF PERFORATIONHEALING OF PERFORATION
IMPORTANCE OF COLLGENIMPORTANCE OF COLLGEN
•HIGH DEGREE OF COMPATIBILITYHIGH DEGREE OF COMPATIBILITY
(KEISER et al-2000)(K...
Operative Sequence
First visitFirst visit
Isolation with a rubber dam .
Cleansing of the perforation site.
In case of b...
Second visitSecond visit
After 24 hours , removal of temporary
cement to check if MTA is set.
Completion of therapy
Furcal repair
Furcation
Perforation
Furcation
Perforation
Furcation
Perforation Repair
Use of paper
point to
locate the
perforation.
LATERAL PERFORATION AND STRIPLATERAL PERFORATION AND STRIP
PERFORATIONPERFOR...
Prep for Extra-Radicular
Perforation Repair
Extra-Radicular
Perforation Repair
Accidental Perforation
1 month Follow Up
ROOT END FILLING
 Establish a seal between the root canal space
and periapical tissues.
Acc to Gartner and DornAcc to Gar...
 Cements and sealers such as ZnOE, IRM, Super
EBA, cavit, zincpolycarboxylate, zinc phosphate
and glass Ionomer cements, ...
 MTA provides superior seal when
compared with Amalgam, IRM and
Super EBA. and
 Most characteristic tissue reaction
of M...
 With longer duration, new cementum was
found of the surface of the material.
 In a two year follow-up study with MTA as...
 Such studies support further development of
MTA to reduce the long setting time and
difficulty in manipulation for use a...
 MTA was able to induce apical healing even
when placed in infected canals.
 It may be assumed that neoformed cementum
d...
Root- end fillings
Costa et al JOE 2003 Mar
thickness of 4 mm is most adequate for the use of MTA as a root-
end filling m...
Treatment of Internal &
external Root resorption
 Moisture present in these preparations turns
the ‘MTA’ soupy & difficul...
 If MTA is placed from inside the tooth , a
moist cotton pellet or paper point should be
placed against it, because the p...
Root Resorption
The patient was referred with a large resorptive
lesion in the root of his maxillary right central
incisor...
Internal Resorption
ROOT RESORPTIONROOT RESORPTION
Internal Resorption
Internal Resorption
Repair
Prophylactic treatment of Dens in Dente
Clinical view of the crown of the
maxillary right central incisor Preoperative rad...
A comparative study of selected properties of ProRoot
mineral trioxide aggregate and two Portland cements
G. Danesh IEJ 20...
Radiopacity:
Five samples per cement were produced.
 These samples were tested according to the
ISO standards to compare ...
Results
 After 28 days MTA was of low solubility(0.78%)
compared with CEM I (31.38%) and CEM II (33.33%).
 At exposure t...
The effect of mineral trioxide aggregate on the
apexification and periapical healing of teeth with
incomplete root formati...
 The other eight teeth in each animal were
divided into two experimental groups.
 The apical thirds of the canals of gro...
 Results
 Significant differences (P < 0.05) were found in
relation to the position of barrier formation
and MTA extrusi...
Effect of mineral trioxide aggregate on proliferation
of cultured human dental pulp cells
T. Takita IEJ2006
 To investiga...
Effect of mineral trioxide aggregate on proliferation
of cultured human dental pulp cells.
T. Takita IEJ2006
 To investig...
Results
 Mineral trioxide aggregate significantly
stimulated cell proliferation after 12 days,
whereas Dycal had no such ...
Ex vivo biocompatibility tests of regular and white
forms of mineral trioxide aggregate
D. A. Ribeiro,IEJ 2006
Aim
 To ex...
 and resuspended with fresh medium.
 Each individual treatment was repeated three times
consecutively to ensure reproduc...
Biological response of pulps submitted to different
capping materials
Andre briso 2006
 ABSTRACT:
 Pulp capping is a pro...
After sixty days, the animals were
killed and the specimens were
processed in order to be analyzed
with optic microscopy....
conclusion
 Collectively, these studies have shown that MTA is a
biocompatible material.
 Mineral Trioxide Aggregate is ...
Thank you
Mta - dr sneha
Mta - dr sneha
Mta - dr sneha
Mta - dr sneha
Mta - dr sneha
Mta - dr sneha
Mta - dr sneha
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PRESENTATION ON MTA

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Mta - dr sneha

  1. 1. LOGO - DR SNEHA RATNANI Mineral Trioxide Aggregate
  2. 2. Introduction  Mineral trioxide aggregate (MTA) was developed at Loma Linda University (Loma Linda, California, USA)  First described in the dental scientific literature in 1993 by Lee et al.  The chemical composition of MTA was determined by Torabinejad et al.  It received US Food and Drug Administration approval in 1998 and is commercially available as Pro-Root MTA by Dentsply International .  Initially recommended as a root-end filling material, it is currently being used for pulp capping, pulpotomy, apexogenesis and apexification, apical barrier formation, repair of
  3. 3.  Endodontic failures may occur as a result of leakage of irritants into the periapical tissues. Therefore, an ideal orthograde and/or retrograde filling material should seal the pathways of communication between the root canal system and its surrounding tissues; thus, this material should be biocompatible and dimensionally stable. This led to the development of mineral trioxide aggregate (MTA) materials possessing these ideal characteristics.
  4. 4. COMPOSITION MTA is a cement composed ofMTA is a cement composed of Portland Cement )75%( • Tricalcium silicate • Dicalcium silicate • Tricalcium aluminate • Tetracalcium aluminoferrite Gypsum (Calcium Sulphate) )5%( Bismuth Oxide )20%( MTA = Portland's Cement + Bismuth Oxide + Gypsum = Radio-opacity and Good Setting Properties Sarkar et al JOE 31 (2) Feb. 2005
  5. 5. -It also contains trace amounts of Silica, calcium oxide, magnesium oxide , potassium sulphate, and sodium sulphate.
  6. 6. Difference between WhiteWhite MTAMTA Secondary electron image EDAX analysis  Calcium  Silicon  Bismuth  Oxygen GreyGrey MTAMTA Secondary electron imageSecondary electron image EDAX analysisEDAX analysis CalciumCalcium SiliconSilicon BismuthBismuth OxygenOxygen AluminumAluminum IronIron Camilleri et al -Dental Materials (2005) 21, 297–303
  7. 7. WMTAWMTA GMTAGMTA ElementElement Wt% conc.Wt% conc. Wt% conc.Wt% conc. CaOCaO 44.2344.23 40.4540.45 SiOSiO22 21.2021.20 17.0017.00 BiOBiO22 16.2316.23 15.9015.90 AlAl22OO33 1.921.92 4.264.26 MgOMgO 1.351.35 3.103.10 SOSO33 0.530.53 0.510.51 ClCl 0.430.43 0.430.43 FeOFeO 0.400.40 4.394.39 PP22OO55 0.210.21 0.180.18 TiOTiO22 0.110.11 0.060.06 HH22O+COO+CO22 14.4914.49 13.7213.72 Composition of MTA
  8. 8.  MTA is essentially Portland cement (used in the building industry as a binder in concrete) with 4:1 proportions of bismuth oxide added for radiopacity.  However Camilleri and co-workers have shown that MTA is composed primarily of tricalcium and dicalcium silicate, the main constituent elements of Portland cement, which on hydration produce a silicate hydrate gel and calcium hydroxide, not calcium phosphate as claimed by Torabinejad.
  9. 9.  MTA powder is Hydrophilic .  It consists of two phases – Crystalline material is essential calcium oxide and amorphous – Calcium phosphate.  Hydration of MTA powder result in the formation of a colloidal gel that hardens.  The Crystalline material has prisms that have 87% Ca , 2.47% Silica, and remainder oxygen.  Amorphous material 33% calcium , 2% Carbon
  10. 10. Calcium oxide (50-75%) + Silicone dioxide(15- 25%)+ Aluminum oxide Tricalcium Silicate + Dicalcium Silicate + Tricalcium Aluminate + (Tetracalcium Aluminoferrite)(Tetracalcium Aluminoferrite) Calcium silicate hydrated gel (Hardens on setting) Calcium Hydroxide contained in a silicateCalcium Hydroxide contained in a silicate matrixmatrix (Camilleri et al -(Camilleri et al -Dental Materials (2005) 21,Dental Materials (2005) 21, Clinkered in a Kiln On mixing with water
  11. 11. Kiln
  12. 12.  MTA is available either as a box of five 1-gram single-use packets or as premeasured water packs for easy manipulation and application.  ProRoot liquid microampules (sterile water) and a carrier are also provided with the packet.  It should be stored in closed sealed containers away from moisture.  The powder is mixed with supplied sterile water in a 3:1 powder/liquid ratio.
  13. 13. MIXING OF MTA
  14. 14. MIXINGMIXING
  15. 15.  The mixing time should be less than 4 minutes, as prolonged mixing can cause dehydration of the mixture.  The mixture can be carried with a plastic or metal carrier. The unused portion of MTA powder can be stored in sterilized empty film canisters.  MTA is uninhibited by blood or water, as moisture is required for a better setting of the material.
  16. 16. MESSING GUN / AMALGAM CARRIER WEST PERF REPAIR INSTRUMENT FLAT END OF SPOON EXCAVATOR AMALGAM CARRIER SPINE TAP NEEDLE Carriers Of MTA
  17. 17. Different types of Carrier for placement of MTADifferent types of Carrier for placement of MTA Small plastic amalgam type carrier. Small Spoon excavator. Amalgam pistolAmalgam pistol Messing gun Dovgan Carriers
  18. 18. The hydration reaction during setting occurs between tricalcium silicate (3CaO SiO2) and· dicalcium silicate (2CaO SiO2) to form a calcium· hydroxide and calcium silicate hydrate gel, producing an alkaline pH. The released calcium ions diffuse through dentinal tubules, and increase their concentration over time as the material cures. Upon hydration, the poorly crystallized and porous solid gel (hydrated forms of components) that is formed solidifies to a hard structure in approximately 3 to 4 hours (initial set), with mean setting time of 165 ± 5 minutes.
  19. 19.  A study comparing white MTA (White MTA, Dentsply; Tulsa Dental Products) to white Portland cement showed the cements to have similar constituent elements except for the bismuth oxide in the MTA.  MTA had less gypsum.  Decreased gypsum causes a reduction in setting time of the cement.  Higher level of toxic heavy metals and aluminium in Portland cement
  20. 20.  Difference in the particle size distribution.  Portland cement exhibited a wide range of sizes whereas MTA showed a uniform and smaller particle size.  Both MTA (Pro-Root) and Portland cement (Quikrete, Columbus, OH,USA) had similar physical, chemical and biological properties, and the biocompatibility of both materials was due to the similarity in constituents
  21. 21.  Results from characterization studies have indicated PC cannot be recommended as a suitable substitute of MTA for the following reasons: • The quality and composition is difficult to predict. Studies have shown that the arsenic content of PC is 6 times the amount of arsenic in GMTA. • The high solubility can lead to release of a toxic element and early degradation of the material, jeopardizing the long-term safety of PC. • Carbon dioxide in inflamed tissues readily
  22. 22. • As opposed to PC, MTA is manufactured in laboratories as a medical material and is approved by the U.S. Food and Drug Administration for use in humans. Although MTA is considered a refined form of PC material (parent compound), substitution with PC for MTA is discouraged for clinical purposes. Generally, researchers do not suggest that MTA and PC have the same clinical, biologic, and mechanical properties and do not co nsider PC to be a suitable replacement for MTA as an endodontic material
  23. 23. PROPERTIES PHYSICAL STATE - solid (powder) COLOR - grey/white ODOR - no specific odor BOILING POINT - >1000ºC
  24. 24. SETTING TIME : 2 hours 45 min – 4 hours COMPRESSIVE STRENGTH: immediately after setting - 40 Mpa 21 days after setting - 70 Mpa pH : 10.2 at start of mix rises to 12.5 after 3 hours. In experimental setting MTA is capable of maintaining high ph for long time. The high pH of MTA could be of clinical significance when used in apical barrier
  25. 25. Solubility  MTA displays low or nearly no solubility, which is attributable to addition of the bismuth oxide.   Chemical analysis and x-ray diffraction have demonstrated insolubility of 18.8% in water.  Although MTA forms a porous matrix characterized by internal capillaries and water channels with increased liquid/powder ratio— which can increase the porosity and the solubility further—the solubility levels of GMTA have been shown to be stable over time.
  26. 26. Antibacterial properties  Results showed that the freshly mixed MTA was effective in killing the tested fungi after 1 day of contact, whereas the 24-h set MTA was effective after 3 days of incubation. It was concluded that MTA (freshly mixed and 24-h set) was effective against C. albicans. Nazhan-Al Saad et alNazhan-Al Saad et al  Nine facultative bacteria and seven strict anaerobes. MTA was found to have an antibacterial effect on five of nine facultative bacteria but no effect on any of the strict anaerobes.
  27. 27. Periradicular reaction  As a root-end filling in vivo, less periradicular inflammation was reported compared with amalgam (Torabinejad et al.)  In addition, the presence of cementum on the surface of MTA (Loma Linda University) was a frequent finding.  It induced apical hard tissue formation with significantly greater consistency, but not quantity.  MTA (ProRoot) supported almost complete regeneration of the periradicular periodontium when used as a root end filling material on noninfected teeth
  28. 28. BIOCOMPATIBILITY  Some studies considered that the biocompatibility of MTA is attributable to the release of hydroxyl ions and formation of calcium hydroxide during the hydration process.   Other reports had observed the formation of a white interfacial material (precipitates) between GMTA and tooth structure within 1 to 2 hours when exposed to physiologic fluids (phosphate- buffered physiologic solution) in vivo or with simulated body fluids in vitro.   SEM and x-ray diffraction (XRD) analysis of these precipitates revealed the presence of chemically and structurally similar hydroxyapatite (HA)-like structure with a
  29. 29. Regenerative Potential and Biological Activity  MTA has the capacity to induce bone, dentin, and cementum formation and regeneration of periapical tissues (periodontal ligament and cementum).  MTA provides a good biological seal and can act as a scaffold for the formation and/or regeneration of hard tissue (periapical).  It is an osteoconductive, osteoinductive, and cementogenic (cementoconductive and cementoinductive) agent.  MTA stimulates immune cells to release
  30. 30. Radiopacity  MTA has a mean radiopacity of 7.17 mm of equivalent thickness of aluminum, which is less than that of IRM, super EBA, amalgam, or gutta-percha.   It has a similar radiodensity to zinc oxide eugenol and slightly greater radiopacity than dentin.
  31. 31. Direct pulp capping  Pulp capping is indicated for teeth with immature apices when the dental pulp is exposed & there are no signs of irreversible pulpitis .  In such cases ,the maintenance of pulp vitality is extremely important , & MTA is preferred to calcium hydroxide .  Recent studies have shown that MTA stimulates dentin bridge formation adjacent to the dental pulp ,  Dentinogenesis of MTA can be due to its
  32. 32.  Similarly to calcium hydroxide , initially causes necrosis by coagulation in contact with pulp connective tissue .  This reaction may occur due to the products high alkalinity, as the Ph is 10.2 during manipulation and 12.5 after 3 hours.  Holland et al demonstrated the presence of calcite crystals in contact with MTA implanted in rat subcutaneous tissue.  Those calcite crystals attract fibronectin which is responsible for cellular adhesion & differentiation.  Therefore it is believed that MTA mechanism of action is similar to that of calcium hydroxide , but in addition ,MTA provides a
  33. 33. Operative Sequence for Pulp capping  Anaesthesia  isolation with a rubberdam  the exposesd pulp is irrigated with sodium hypochlorite to control bleeding.  MTA powder is mixed with sterile water & the mixture is placed in contact with the exposure using a dovgan carrier.  Compress the mixture against the exposure site with a moist cotton pellet.  Place a moist cotton pellet over the MTA & fill the rest of the cavity with a temporary filling material .  After 4 hours the patient is seen again, the rubber dam is positioned the temporary filling
  34. 34. Pulp Capping
  35. 35. Pulp Capping
  36. 36. Pulp Capping
  37. 37. Verification of the setting of MTA at 48 h. Disinfection of exposure site by rinsing with 5.25% sodium hypochlorite. Pulp exposure presenting with moderate bleeding. Immediate postoperative periapical radiograph showing pulp capping with MTA, cotton and temporary filling material.
  38. 38. Follow-up periapical radiograph at 11 months showing maturogenesis of the root. Final coronal restoration with composite. Follow-up periapical radiograph at 4 months presenting with continued root development.
  39. 39. Pulpotomy agent  MTA has been proposed as a potential medicament for pulpotomy procedures as well as capping of pulps with reversible pulpitis.  MTA was tested in dog s teeth as a pulp′ capping material and produced favorable pulp responses.  There are reports of complete dentine bridge formation when MTA was used as a pulp capping agent.  Hard tissue bridge deposition next to MTA
  40. 40. All irrigation should be performed before the material is placed because irrigation after placement will cause significant wash out of the material.  MTA was less cytotoxic and non- mutagenic. This further supports the superiority of MTA over formocresol as a pulpotomy medicament.
  41. 41. Pulpotomy
  42. 42. Pulpotomy
  43. 43. Pulpotomy
  44. 44. Pulpotomy Procedure Anaesthesia  Isolation with a rubber dam.  Caries should be removed using a caries detector with a slow speed round burs & spoon excavators. Once caries has been entirely removed, irrigate with 5.25% naocl for 5-10 minutes to achieve homeostasis and ensure complete debridement. Rinse out naocl and ensure that the chamber is debris free. Place a 1-1.5 mm thick layer of freshly
  45. 45.  Place a wet ,thinned ,flattened cotton pellet over the MTA.  The cotton pellet provides the moisture MTA requires for a proper set.  Temporize with either light cured Photocure ,IRM or other suitable material.  Recall after a week  Once proper setting of MTA has been ascertained , the tooth can be restored
  46. 46. Apexification  Although MTA & Calcium hydroxide both exhibit similar alkaline Ph levels, MTA also shows excellent marginal adaptability & is non- resorbable.  MTA allow apexification cases to be restored after approximately 2 weeks as opposed to traditional Calcium hydroxide therapy, where apexification may require many months .
  47. 47. Apexification
  48. 48. Apexification
  49. 49. Apexification
  50. 50.  Rubber dam isolation  Extirpate the pulp and clean the root canal system using endodontic instruments and 5.25% Naocl irrigation.  Place calcium hydroxide paste in the root canal system for one week to fully disinfect the canal system.  When the patient returns in one week rinse ca(oh)2 paste from the root canal system with naocl irrigation and dry with paper points. ProceduProcedu re:re:
  51. 51.  Place MTA in the canals and condense to the apical end of the root canal to create a 3- 4mm apical plug .  Radiographically, check the extension & quality of fill .  Place a moist cotton pellet or wet paper point in the canal & close the access cavity with IRM or Cavit .  The patient can return in one week for obturation rest of the canal or the final obturation delayed until healing completed
  52. 52. Apexification Preoperative radiograph of the maxillary left central incisor. The patient is 55-years-old and this tooth (with an open apex) has not responded to previous therapy with calcium hydroxide Intraoperative film with the Dovgan carrier in place Three millimeters of MTA have been positioned at the foramen to form the apical barrier After the MTA is set, the thermoplastic gutta-percha has been used to obturate the root canal.
  53. 53. Perforation Repair with MTA  Mta can today be considered the ideal material to seal perforations .  Cementum has been shown to grow over mta allowing normal attachment of the periodontal ligament .  Furthermore, mta dosen’t require a barrier & is not affected by moisture or blood contamination & seals better than any other material in use today.( Amalgam, super EBA ,IRM ,composite resins )
  54. 54. INTERNAL MATRIX CONCEPTINTERNAL MATRIX CONCEPT MODIFIED MATRIX CONCEPTMODIFIED MATRIX CONCEPT LEMON 1992LEMON 1992 C.BARGHOLZ 2004C.BARGHOLZ 2004 PROCEDURE :-PROCEDURE :- CLEANINGCLEANING 0.5% NaOCl0.5% NaOCl WORKING LENGTH DETERMINATIONWORKING LENGTH DETERMINATION COLLACOTE MATERIALCOLLACOTE MATERIAL RESTORATIVE MATERIALRESTORATIVE MATERIAL
  55. 55. OVER INTERNAL MATRIX CONCEPTOVER INTERNAL MATRIX CONCEPT NO PRESSURE REQUIREDNO PRESSURE REQUIRED WET FIELDWET FIELD BETTER SEALINGBETTER SEALING CEMENTOGENESISCEMENTOGENESIS
  56. 56. GRANULATION TISSUEGRANULATION TISSUE COLLAGEN MATRIXCOLLAGEN MATRIX
  57. 57. MTA APPLIED ALONG THE COLLAGENMTA APPLIED ALONG THE COLLAGEN HEALING OF PERFORATIONHEALING OF PERFORATION
  58. 58. IMPORTANCE OF COLLGENIMPORTANCE OF COLLGEN •HIGH DEGREE OF COMPATIBILITYHIGH DEGREE OF COMPATIBILITY (KEISER et al-2000)(KEISER et al-2000) •ROUGH SURFACE OF MTAROUGH SURFACE OF MTA (FRID LAND & ROSADO 2003)(FRID LAND & ROSADO 2003) •MTA IS NOT A HARD MATERIALMTA IS NOT A HARD MATERIAL (TORABINEJAD et al-1995)(TORABINEJAD et al-1995)
  59. 59. Operative Sequence First visitFirst visit Isolation with a rubber dam . Cleansing of the perforation site. In case of bacterial contamination , application of calcium hydroxide for 1 week . Application of 2 to 3 mm of MTA . Radiographs to check the correct positioning of the materials. Application of a small , wet cotton pellet in contact with MTA. Temporary cement.
  60. 60. Second visitSecond visit After 24 hours , removal of temporary cement to check if MTA is set. Completion of therapy
  61. 61. Furcal repair
  62. 62. Furcation Perforation
  63. 63. Furcation Perforation
  64. 64. Furcation Perforation Repair
  65. 65. Use of paper point to locate the perforation. LATERAL PERFORATION AND STRIPLATERAL PERFORATION AND STRIP PERFORATIONPERFORATION Radicular Perforation
  66. 66. Prep for Extra-Radicular Perforation Repair
  67. 67. Extra-Radicular Perforation Repair
  68. 68. Accidental Perforation 1 month Follow Up
  69. 69. ROOT END FILLING  Establish a seal between the root canal space and periapical tissues. Acc to Gartner and DornAcc to Gartner and Dorn 1) able to prevent leakage of bacteria & their byproducts into the periradicular tissues. 2) nontoxic 3)noncarcinogenic. 4)biocompatible. 5)insoluble in tissue fluids. 6)dimensionally stable. 7)unaffected by moisture during setting. 8)easy to use. 9)radiopaque.
  70. 70.  Cements and sealers such as ZnOE, IRM, Super EBA, cavit, zincpolycarboxylate, zinc phosphate and glass Ionomer cements, mineral trioxide aggregate, calcium phosphate cement and bone cement have also been employed for retro- fillings.  Other commonly used materials are - composite resin (with and without bonding agent) and gutta-percha.  The less commonly used materials are laser, citric acid demineralization, ceramic inlay, teflon, mixture of powdered dentin & sulfathiazole and
  71. 71.  MTA provides superior seal when compared with Amalgam, IRM and Super EBA. and  Most characteristic tissue reaction of MTA was the presence of connective tissue after the first postoperative week.  Studies have shown that osteoblasts have favorable response to MTA as compared to IRM and amalgam. MTA Angelus (120 days). H.E. 40 X. Presence
  72. 72.  With longer duration, new cementum was found of the surface of the material.  In a two year follow-up study with MTA as root- end filling material resulted in a high success rate.
  73. 73.  Such studies support further development of MTA to reduce the long setting time and difficulty in manipulation for use as a root-end filling material.  Studies evaluating MTA as a retrofilling material have shown less periapical inflammation, presence of a fibrous capsule and formation of new cementum layer in contact with the material surface in many cases.
  74. 74.  MTA was able to induce apical healing even when placed in infected canals.  It may be assumed that neoformed cementum deposition on the entire material surface (biological sealing), as observed with MTA,was an important histopathologic event to be considered because it isolated the content remaining within the intracanal space and root- end filling material from the apical tissues.
  75. 75. Root- end fillings Costa et al JOE 2003 Mar thickness of 4 mm is most adequate for the use of MTA as a root- end filling material.
  76. 76. Treatment of Internal & external Root resorption  Moisture present in these preparations turns the ‘MTA’ soupy & difficult to condense.  Moisture can be drawn out of the MTA after placement with a dry paper point or cotton pellet  MTA is often pressed into the desired location & not condensed.  All irrigation should be performed before the MTA is placed .  Any irrigation after placement will cause significant washout of the material  The preparation or resorptive defect does not have to be perfectly dry, but most of the fluid has to be removed.
  77. 77.  If MTA is placed from inside the tooth , a moist cotton pellet or paper point should be placed against it, because the presence of moisture is essential for the material to set.  The access cavity is then closed .  Most internal repairs with MTA requires a second visit to complete the root canal therapy or restoration.
  78. 78. Root Resorption The patient was referred with a large resorptive lesion in the root of his maxillary right central incisor. A pulpectomy was performed and progressive débridement of granulation tissue was accomplished by monthly irrigation with sodium hypochlorite and placement of calcium hydroxide. After three months, débridement of the lesion was complete. The calcium hydroxide was removed, the canal was dried and the resorptive defect was repaired internally with MTA. The clinician placed a post that extended apically to the resorptive defect and restored the tooth with resin composite in preparation for placement of a crown.
  79. 79. Internal Resorption ROOT RESORPTIONROOT RESORPTION
  80. 80. Internal Resorption
  81. 81. Internal Resorption Repair
  82. 82. Prophylactic treatment of Dens in Dente Clinical view of the crown of the maxillary right central incisor Preoperative radiograph. Note the periapical radiolucency, the unusual anatomy, and the wide open apex. Intraoperative radiograph. Note the thickness of MTA without any overfilling. Postoperative radiograph Two-year recall.
  83. 83. A comparative study of selected properties of ProRoot mineral trioxide aggregate and two Portland cements G. Danesh IEJ 2006  Aim To compare solubility, microhardness and radiopacity of ProRoot MTA with two Portland cements (PC: CEM I and CEM II). Methodology  Solubility: for standardized samples (n ¼ 12/group) ring moulds were filled with the cements. These samples were immersed in double distilled water for 1 min, 10 min, 1 h, 24 h, 72 h, and 28 days.  Mean loss of weight was determined.  Microhardness: five samples of each cement were produced.
  84. 84. Radiopacity: Five samples per cement were produced.  These samples were tested according to the ISO standards to compare their radiodensity to that of an aluminium step wedge (1–9 mm).  Differences between the three materials with respect to their solubility, microhardness and radiopacity were analysed using anova and Student– Newman–Keuls.
  85. 85. Results  After 28 days MTA was of low solubility(0.78%) compared with CEM I (31.38%) and CEM II (33.33%).  At exposure times >1 min the two PCs were significantly more soluble than MTA (P < 0.05).  The microhardness for MTA was significantly higher (39.99 HV; P < 0.001) compared with the two PC (CEM I: 16.32 HV; CEM II: 13.51 HV).  MTA was significantly more radiopaque (5.34 mm Al) than CEMI (3.32 mm Al) and CEM II (2.52 mm Al) (P < 0.05),whereas CEM I was significantly more radiopaque than CEM II (P < 0.05). Conclusions  Mineral trioxide aggregate displayed superior material properties than both Portland cements.
  86. 86. The effect of mineral trioxide aggregate on the apexification and periapical healing of teeth with incomplete root formation. W. T. Felippe,IEJ 2006 Aim  To evaluate the influence of mineral trioxide aggregate (MTA) on apexification and periapical healing of teeth in dogs with incomplete root formation and previously contaminated canals and to verify the necessity of employing calcium hydroxide paste before using MTA.  Methodology Twenty premolars from two 6- month old dogs were used. After access to the root canals and complete removal of the pulp, the canal systems remained exposed to the oral environment for 2 weeks. Canal preparation was then carried out using Hedstrom files, under irrigation with 1% sodium hypochlorite, 1 mm
  87. 87.  The other eight teeth in each animal were divided into two experimental groups.  The apical thirds of the canals of group 1 were filled with MTA. In the teeth of group 2, the canals were dressed with a calcium hydroxide– propylene glycol paste.  After 1 week, the paste was removed and the apical third was filled with MTA.  All teeth were restored with reinforced zinc oxide cement (IRM) and amalgam.  The animals were killed 5 months later, and blocks of the teeth and surrounding tissues were submitted to histological processing.  The sections were studied to evaluate seven parameters: formation of an apical calcified tissue barrier, level of barrier formation,
  88. 88.  Results  Significant differences (P < 0.05) were found in relation to the position of barrier formation and MTA extrusion.  The barrier was formed in the interior of the canal in 69.2% of roots from MTA group only.  In group 2, it was formed beyond the limits of the canal walls in 75% of the roots. MTA extrusion occurred mainly inroots from group 2. There was similarity between the groups for the other parameters.  Conclusions Mineral trioxide aggregate used after root canal preparation favoured the occurrence of the apexification and periapical healing. The initial use of calcium hydroxide
  89. 89. Effect of mineral trioxide aggregate on proliferation of cultured human dental pulp cells T. Takita IEJ2006  To investigate the effect of mineral trioxide aggregate (MTA) on the proliferation of human dental pulp (HDP) cells ex-vivo.  Methodology  Humandental pulp cells were cultured with MTA or calcium hydroxide-containing cement (Dycal) using culture plate inserts. Control cells were cultured with culture plate inserts only.  Cell proliferation was measured for up to 14 days using a Cell Counting kit, and the concentration of calcium ions released fromthe tested materials was assessed using a Calcium E-test kit.  To confirm that the effect of MTA was
  90. 90. Effect of mineral trioxide aggregate on proliferation of cultured human dental pulp cells. T. Takita IEJ2006  To investigate the effect of mineral trioxide aggregate (MTA) on the proliferation of human dental pulp (HDP) cells ex-vivo. Methodology  Humandental pulp cells were cultured with MTA or calcium hydroxide-containing cement (Dycal) using culture plate inserts. Control cells were cultured with culture plate inserts only.  Cell proliferation was measured for up to 14 days using a Cell Counting kit, and the concentration of calcium ions released fromthe tested materials was assessed using a Calcium E-test kit.  To confirm that the effect of MTA was attributable to released calcium ions, cell
  91. 91. Results  Mineral trioxide aggregate significantly stimulated cell proliferation after 12 days, whereas Dycal had no such effect.  The number of calcium ions released from MTA was significantly higher than that released from Dycal.  Following the addition of calcium chloride, cell proliferation increased in a dose-dependent manner after 12 days.  Moreover, cell proliferation showed a similar pattern whether a given concentration of calcium ions was produced by calcium chloride or by release from MTA. Conclusions
  92. 92. Ex vivo biocompatibility tests of regular and white forms of mineral trioxide aggregate D. A. Ribeiro,IEJ 2006 Aim  To examine the genotoxicity and cytotoxicity of regular and white mineral trioxide aggregate (MTA) ex vivo by the single-cell gel (comet) assay and trypan blue exclusion test, respectively. Methodology  Aliquots of 1 104 Chinese hamster ovary· cells were incubated at 37 C for 3 h with grey and white forms of MTA at final concentrations ranging from 1 to 1000 lg mL)1.  The negative control group was treated with vehicle control phosphate buffer solution for 3 h at 37 C and the positive control group was treated with methyl metasulfonate (at 1 lg mL)1) for 1 h at 37 C.
  93. 93.  and resuspended with fresh medium.  Each individual treatment was repeated three times consecutively to ensure reproducibility. Parameters from single-cell gel (comet) and cytotoxicity assays were assessed by the Kruskal–Wallis nonparametric test.  Results  Neither compounds produced genotoxic effects with respect to the single-cell gel (comet) assay in all concentrations evaluated.  In the same way, the dose–response relationships of all compounds tested at concentrations ranging from 1 to 1000 lg mL)1 on cell viability assessed by the trypan blue assay displayed no statistically significant differences (P > 0.05) for either endodontic material.
  94. 94. Biological response of pulps submitted to different capping materials Andre briso 2006  ABSTRACT:  Pulp capping is a procedure that comprises adequate protection of the pulp tissue exposed to the oral environment, aiming at the preservation of its vitality and functions.  This study evaluated the response of the dental pulps of dog teeth to capping with mineral trioxide aggregate (MTA) or calcium hydroxide .  For that purpose, 37 teeth were divided into two groups, according to the capping material employed.  Two dogs were anesthetized and, after placement of a rubber dam, their pulps were exposed in a standardized manner and protected with the experimental capping materials.  The cavities were then sealed with resin-modified glass ionomer cement and restored with composite resin.
  95. 95. After sixty days, the animals were killed and the specimens were processed in order to be analyzed with optic microscopy. It was observed that MTA presented a higher success rate compared to calcium hydroxide, presenting a lower occurrence of infection and pulp necrosis.
  96. 96. conclusion  Collectively, these studies have shown that MTA is a biocompatible material.  Mineral Trioxide Aggregate is a new material that possesses numerous exciting possibilities for pulpal therapy.  It is a promising material with an expanding foundation of research.  MTA, with an excellent long term prognosis, relative ease at which it can be used and with its numerous exciting clinical applications promises to be one of the most versatile materials of this century in the field of dentistry.
  97. 97. Thank you

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