Mineral Trioxide Aggregate

Mahmoud Torabinejad, DMD, MSD, PhD, is Professor of Endodontics and Director of the Advanced Specialty Education Program in Endodontics at Loma Linda University School of Dentistry in Loma Linda, California. As a researcher and international lecturer on dental and endodontic issues and procedures, Dr. Torabinejad has made over 200 national and international presentations in more than 40 countries. In addition to co-authoring three textbooks in nonsurgical and surgical endodontics, he has authored more than 300 publications on various endodontic and dental topics. As a researcher, he is the top -cited author in endodontic journals, with authorship in 16 articles of the top 100 list. Dr. Torabinejad was the principle investigator in the applications of MTA in dental procedures.

Contributors xv

Preface xvii

1 Pulp and Periradicular Pathways, Pathosis, and Closure 1
Mahmoud Torabinejad

Pulp and Periradicular Pathways 2

Natural Pathways 2

Apical foramen 2

Lateral canals 4

Dentinal tubules 4

Pathological and Iatrogenic Pathways 5

Dental caries 5

Role of microorganisms 6

Root perforations 7

Root perforations during access preparation 7

Root perforations during cleaning and shaping 8

Root perforations during post space preparations 10

Vertical fracture 10

Periradicular Pathosis 11

Inflammatory process of periradicular lesions 11

Materials to Seal the Pathways to the Root Canal System and the Periodontium 13

References 15

2 Chemical Properties of MTA 17
David W. Berzins

Introduction 17

MTA Composition 19

Portland cement 19

Role of bismuth oxide and gypsum 20

MTA powder morphology 21

Trace elements and compounds 23

Setting Reactions 23

Setting time 26

Maturation 26

Factors that affect setting: additives and accelerants 26

Effect of water and moisture 27

Interaction with environment 27

Development of Reaction Zones 28

References 31

3 Physical Properties of MTA 37
Ricardo Caicedo and Lawrence Gettleman

Introduction 38

pH 38

Solubility 40

Setting Expansion 45

Radiopacity 46

Various Types of Strength 49

Compressive strength 49

Flexural strength 54

Shear strength 55

Push-out strength 56

Shear bond strength 56

Overview 57

Microhardness 59

Color and Aesthetics 61

Physicochemical Properties 62

Acknowledgment 66

References 66

4 MTA in Vital Pulp Therapy 71
Till Dammaschke, Joe H. Camp, and George Bogen

Introduction 72

Advantages 74

Pulp Responses to Capping Materials 74

Direct Pulp Capping with Calcium Hydroxide 75

Mineral Trioxide Aggregate 77

Physiochemical properties 77

Mode of action in pulp capping and pulpotomy 80

Comparison with calcium hydroxide 83

Pulpotomy in Primary Teeth 85

MTA Pulpotomy 86

Primary teeth 86

Immature permanent teeth 88

Symptomatic permanent teeth 90

Pulp Capping in Teeth Diagnosed with Reversible Pulpitis 94

Treatment Considerations 96

Disadvantages 98

Summary 99

Acknowledgment 99

References 100

5 Management of Teeth with Necrotic Pulps and Open Apices 111
Shahrokh Shabahang and David E. Witherspoon

Diagnosis in Immature Teeth 111

History of Treating Immature Teeth 114

Infection Control in Immature Teeth 116

Apexification 118

Calcium Hydroxide Apexification Therapy: Outcomes 119

Non-Vital Pulp Therapy 121

Root-end closure via the use of apical barriers 121

Mineral trioxide aggregate apical plug 122

Technical placement 124

Outcomes 124

References 131

6 Regenerative Endodontics (Revitalization/Revascularization) 141
Mahmoud Torabinejad, Robert P. Corr, and George T.-J. Huang

Introduction 142

Revascularization after Replantation and Autotransplantation 143

Revitalization of Nonvital-Infected Teeth in Animals 145

Clinical Evidence for Revitalization in Nonvital-Infected Teeth in Humans 152

Potential Role of Stem Cells in Canal Tissue Generation and Regeneration 160

Role of DPSCs and SCAP in revitalization and regenerative endodontic treatments 161

Scaffolds and growth factors for regenerative endodontics (Revitalization) 164

Clinical Procedures for Pulp Revitalization 168

First appointment 168

Second appointment 168

Clinical and radiographic follow-up 170

References 170

7 Use of MTA as Root Perforation Repair 177
Mahmoud Torabinejad and Ron Lemon

Introduction 178

Types of Perforation Defects 182

Access preparation-related perforations 182

Cleaning and shaping related (“strip”) perforations 184

Resorption-related perforations (internal/external) 184

Factors Influencing Prognosis for Repair 187

Size of perforation 187

Location of the perforation 187

Pulp Chamber Perforations 189

Etiologies 189

Prevention 189

Recognition and treatment of pulp chamber perforations 189

Lateral surface repairs 190

Furcation repairs 190

Root Perforations During Cleaning and Shaping 191

Coronal root perforations 191

Causes, indicators and prevention 191

Treatment 193

Prognosis 193

Lateral perforations 194

Causes and indicators 194

Treatment of mid-root perforation 194

Prognosis 195

Apical perforations 195

Causes and indicators 196

Treatment 197

Prognosis 197

Root Perforation during Post Space preparation 197

Causes, indicators and prevention 197

Treatment 197

Prognosis 199

Time elapsed since perforation 199

Techniques for Internal Repair Using MTA 199

Method 199

Summary 202

References 203

8 MTA Root Canal Obturation 207
George Bogen, Ingrid Lawaty, and Nicholas Chandler

Introduction 208

Charactertics/Properties 210

Mechanisms of action in obturation 210

Particle size 211

Hydration products and pH 211

Formation of interstitial layer 212

Fracture resistance 212

Sealing ability and setting expansion 213

Applications/Uses 214

Conventional obturation 214

Retreatment 216

Obturation prior to surgery 219

Obturation with perforation repair 219

Apexification using MTA obturation 222

Obturation for dental anomalies 225

Obturation Techniques 225

Standard compaction technique 226

Lawaty technique 229

Auger technique 231

Restorative Considerations 234

Drawbacks 234

Sealers 235

Zinc oxide–eugenol sealers 236

Calcium hydroxide sealers 236

Epoxy resin-based sealers 236

Glass ionomer sealers 237

Silicone-based sealers 237

Monoblock sealer systems 237

Calcium silicate-based sealers 237

Summary 238

References 239

9 Root-End Fillings Using MTA 251
Seung-Ho Baek and Su-Jung Shin

Introduction of Root-End Filling Materials 252

Purpose of root-end fillings 252

History of Root-End Filling Materials 253

Amalgam 254

ZOE-based materials: IRM and SuperEBA 254

Resin-based materials: Retroplast and Geristore 256

Mineral trioxide aggregate (MTA) 256

Gray vs. White MTA 257

New types of MTA-like cements 257

Requirements of Ideal Root-End Filling Materials 258

Advantages and disadvantages of MTA as a root-end filling material 258

Advantages of MTA 258

Disadvantages of MTA 259

MTA as a Root-End Filling Material 260

Cytotoxicity and biocompatibility 260

Bioactivity 263

Sealability 264

Antibacterial effect 265

Clinical Applications of MTA 265

Retropreparation and root-end filling 265

Cavity preparation for MTA root-end filling 265

Mixing procedure 266

Methods for placement of MTA 266

Clinical outcomes 268

Conclusion 272

References 275

10 Calcium Silicate–Based Cements 281
Masoud Parirokh and Mahmoud Torabinejad

Introduction 284

Portland Cement (PC) 285

Chemical composition 285

Physical properties 286

Antibacterial activity 287

Sealing ability 288

Biocompatibility 288

Cell culture studies 288

Subcutaneous implantation 288

In vivo investigations 289

Clinical applications 289

Limitations 289

Angelus MTA 291

Chemical composition 291

Physical properties 292

Antibacterial activity 293

Sealing ability 293

Biocompatibility properties 293

Cell structure studies 293

Subcutaneous implantation 294

Intraosseous implantation 294

In vivo investigations 294

Clinical applications 295

Bioaggregate (BA) 295

Chemical composition 295

Physical properties 296

Antibacterial activity 296

Sealing ability 296

Biocompatibility 296

Cell culture studies 296

Biodentine (BD) 297

Chemical composition 297

Physical properties 297

Biocompatibility and clinical applications 297

iRoot 298

Chemical composition 298

Physical properties 298

Biocompatibility 299

Calcium Enriched Mixture (CEM) Cement 299

Chemical composition 299

Physical properties 300

Antibacterial activities 301

Sealing ability 301

Biocompatibility 301

Cell culture studies 301

Skin test and subcutaneous implantation 302

Intraosseous implantation 302

In vivo investigations 302

Clinical investigations 303

MTA Fillapex 304

Chemical composition 304

Physical properties 304

Antibacterial activities 305

Biocompatibility 306

Cell culture studies 306

Subcutaneous implantation 306

Endo-CPM 306

Chemical composition 307

Physical properties 307

Antibacterial activity 307

Sealing ability 307

Biocompatibility 307

Cell culture studies 307

Subcutaneous implantation 307

In vivo investigations 308

Cimento Endodontico Rapido (CER) 308

Chemical composition 308

Physical properties 308

Biocompatibility 308

Subcutaneous implantation 308

Endosequence 309

Chemical composition 309

Physical properties 309

Antibacterial activities 310

Sealing ability 310

Biocompatibility 310

Cell culture studies 310

EndoSequence BC Sealer 310

Chemical composition 311

Physical properties 311

Biocompatibility 311

ProRoot Endo Sealer 311

Chemical composition 311

Physical properties 312

MTA Plus 312

Chemical composition 312

Physical properties 312

Ortho MTA 313

Chemical composition 313

Biocompatibility 313

Cell culture studies 313

MTA Bio 313

Chemical composition 313

Physical properties 314

Biocompatibility 314

Cell culture studies 314

Subcutaneous implantation 315

MTA Sealer (MTAS) 315

Chemical compositions and physical properties 315

Fluoride-Doped MTA Cement 315

Chemical composition 315

Physical properties 316

Sealing ability 316

Capasio 316

Chemical composition and physical properties 316

Generex A 317

Chemical composition and physical properties 317

Biocompatibility 317

Cell culture study 317

Ceramicrete-D 317

Chemical composition and physical properties 317

Nano-Modified MTA (NMTA) 318

Chemical composition and physical properties 318

Light-Cured MTA 318

Chemical composition and physical properties 318

Biocompatibility 319

Subcutaneous implantation 319

Calcium Silicate (CS) 319

Chemical composition and physical properties 319

Endocem 320

Chemical composition and physical properties 320

Biocompatibility 320

Cell culture study 320

Other Experimental MTA Lookalike Mixtures 320

Conclusion 320

References 321

Index 333