MTA: A Versatile Material for Endodontic Applications

 Mineral trioxide aggregate (MTA) is a unique
material with several exciting clinical
applications.
 MTA is one of the most versatile
materials of this century in the field of
dentistry.
 During endodontic treatment of primary and
permanent teeth MTA can be used in many
ways.

History
• was first developed at Loma
Linda university by Mahmoud
Torabinejad & colleagues .
Early
1990
• (MTA) was first
described in the
scientific literature
1993
• given approval for
endodontic use by the U.S.
Food & Drug Administration
and commercially available
as pro Root MTA.
In 1998

Composition
Is mixture of three powder ingredients ;
75 wt%
Portland
cement
20 wt%
bismuth
oxide
(Bi2O3
Trace amount
of SIO2 ,
CAO,MGO,K2S
O4
and 5 wt%
of gypsum

Composition
Portland cement is amixture of tricalcium silicate, dicalcium
silicate, tricalcium aluminate, tetracalcium aluminoferrite
MTA products have been reported to have a smaller mean particle
size, fewer toxic heavy metals, has a longer working time, and
appears to have undergone additional processing / purification
than regular Portland cement
Portland
cement MTA

why bismuth oxide and gypsum
are added?
Bismuth oxide is included in MTA to serve as a radiopaque agent because
Portland cement is not sufficiently radiopaque for dental purposes. and make
the MTA insoluble.
Regardless, it appears that the addition of bismuth oxide to Portland cement
decreases its compressive strength and increases porosity
Gypsum is added to Portland cement/MTA to alter the setting time and does
so primarily by influencing the reactions of the tricalcium aluminate

Properties of MTA
 MTA when hydrated becomes a
colloidal gel then solidify to form
strong impermeable barrier.
 PH
initial pH of 10.2
which rises to 12.5 (similar to calcium
hydroxide) following setting
The high pH is theorized to be responsible
for the antimicrobial action and biological
activity of the material

Properties of MTA
 Working time 5minutes
 Setting time 3-4hours(old one)
20 minutes(new one)
 Solubility
MTA displays low or nearly no solubility,
which is attributable to addition of the
bismuth oxide

 Compressive strength
The compressive strength of set MTA is about
70 MPa, which equals IRM and super EBA,
but is less than that of amalgam (311 mpa).
 Radio-opacity :Slightly greater than dentine
 Biocompatible
 good Sealing Ability (resist Micro leakage)
Usually a thickness of 3 mm to 5 mm is sufficient to provide a good seal.

 Retentive strength : MTA is not suitable as luting
agent
 Marginal adaptation is better than IRM super EBA
,amalgam and GIC

Advantages of MTA
1-versatile application
2-biocompatible
3-excellent sealing ability
4-set in the presence of Moisture
5-MTA has the capacity to induce bone, dentin, and cementum formation
and regeneration of periapical tissues (periodontal ligament)
6. Least cytotoxic compared with other materials .

Disadvantages of MTA
1-technique sensitive
require operator
experience
2-material cost.( old type)

Idications
MTA has been used for both surgical and non surgical application including ;
1-direct pulp capping
2.pulpatomy
3-perforation repairs
in root or furcation.
3-root end filling
4-appexification .etc…

limitations
 MTA is not used in area open to oral environment
(because of solubility in acid environment generated by
bacteria,food and beverages)
 The material is not recommended for obturation
Of primary teeth that are expected to exfoliated since
the material is slowly resorbed if at all
 GMTA is not used with anterior teeth
 Not used as permanent filling because of low compressive
strength

manipulation
The MTA paste is obtained by mixing 3 part of powder with one part of water
(3:1) to obtain putty like consistency mixing can be done on paper or glass slab
using a plastic or metal spatula .
The mixing time should be less than 4 minutes as prolonged mixing can cause
dehydration of the mixture
**excess moisture can result in a soupy mix that is difficult to use

Setting reaction
 The required hydration for setting is provided by a moist cotton pellet
placed temporarily (until the next appointment) in direct contact and/or on
the surrounding tissues
 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
The MTA is being
hydrophilic require
moisture to set
So it is uninhibited by
blood or water, as
moisture is required
for a better setting of
the material

Mechanism of action
From the time that MTA is placed in direct
contact with human tissues, its mechanism of
action is as follows-
(1) Forms calcium hydroxide that releases
calcium ions for cell attachment and proliferation.
(2) Creates an antibacterial environment by its
alkaline PH.
(3) Modulates cytokine production.(IL1 , IL6 and
osteocalcin)
(4) Encourages differentiation and migration of
hard tissue-producing cells.
(5) Forms hydroxyapatite (or carbonated apatite)
on the MTA surface and provides a biologic seal

Types of MTA
Grey
MTA
White
MTA

MTA was introduced as grey but because of the discoloration
problem ,white MTA was developed in 2002 , achieved by
eliminating iron oxide (FeO) from the formulation

WMTAGMTA
Tooth colored due to lower
amount of Fe2O2
And high amount of MGO
Contains aluminoferrite
(iron) which is responsible
for the grey color
composition
Smaller particle size8 times larger than WMTACrystal sizes
Greater than GMTALess than WMTACompressive strength
Produces 43% surface
hydroxyapatite than WMTA
in an environment with PBS
(phosphate buffered saline)

MTA-Angelus
Absence of dehydrated calcium sulfate makes the
material setting time 10 to 15 minutes

Available in grey (AGMTA) and white (AWMTA).
is silicate cement mainly consisting of 80% PC and 20% bismuth
oxide .
It has greater amount of calcium carbonate, calcium silicate, and
barium zinc phosphate than GMTA.

MM-MTA (MICRO MEGA MTA)
Is a modified Portland Cement with added calcium carbonate
(CaCO3), which allows the reduction of the setting time to 20
minutes .
available as capsules containing MM-MTA powder and liquid,
automatic mixing is achieved quickly with a vibrating mixer to
produce homogenous mixing.

(mixing time 30 seconds) is
achieved by a high frequency
mixer
MM-MTA gun
for the extrusion of the
material from the capsule

DEFERANT MTA BASE ROOT
CANAL SEALER
1-Pro root Endo sealer
2- Fill apex
3- CPM sealer
4- MTA obtura
5- MTAS experimental sealer

MTA Fillapex
Is a mineral trioxide aggregate-based, salicylate resin root canal
sealer. It is designed to provide a high flow rate and a low film
thickness for easy penetration of lateral and accessory canals.
.developed by Angelus (Londrina/Parana/Brazil) and launched
commercially in 2010

 It contains 13% MTA and salicylate resin for their
antimicrobial and biocompatibility properties
 working time is 23 minutes with a complete set time is
approximately 2 hours
 Biocompatible ,Excellent Flow ,Setting expansion , Calcium ion
release (induces rapid tissue regeneration in sites) and Easy
removal .

Placement of MTA
MTA carrier
Reusable dental tools for
handling and application of
prepared MTA material.
Instruments made of stainless
steel resistant to corrosion.

BLOCK MATRIX MTA
Block Matrix MTA is designed to form a portion of prepared MTA to place it in
the fraction of the tooth or the root canal.
All walls of the MTA matrix have mould with the description of diameter from
0.7 to 1.0mm.
Place prepared material in the chosen wall mould to form the required
diameter.
Use proper sterile instrument for handling formed material from the mould.

MAP system
The MAP (Micro-Apical
Placement) System, provides an
efficient method for placing
repair materials for the
treatment of perforations, root-
end fillings and pulp cappings
using curved needles
or by retrograde obturation after
apical resection of anterior teeth,
using the hooked needles.
NiTi 'memory' needle (PEEK
Plunger). Will return to original
shape when autoclaved

Perforation repair with MTA
Recently, the prognosis of teeth with a perforation has
improved with the use of the operating microscope & and
the introduction of MTA.

Why MTA is ideal for
perforation repair ?
Good sealing ability :A barrier is created to achieve a
dry field and prevent the extrusion of the restorative
material.
It is hydrophilic (not affected by moisture)
Opposite to other restorative materials currently used
(amalgam, Super EBA, IRM, composite resins)which
require a dry field

Biocompatible
supporting new tissue formation (tissue
regeneration)
In addition cementum has been shown to grow
over MTA, allowing for normal attachment of the
periodontal ligament.

Operative sequence for
treatment of a perforation
First visit :
1) isolation
of the
operative
field with a
rubber dam.
2) cleansing
of the
perforation
site
3)
application
of 2-3mm of
MTA
4)
radiograph
to check the
correct
positioning
of the
material
5)
application
of a small
wet cotton
pellet in
contact with
MTA.
6)Temporary
cement

after 24 hours, removal of temporary cement to check if MTA is set
completion of therapy .

Root end filling material
Endodontic surgery followed by root end filling may at time be
necessary for certain tooth where routine endodontic treatment is
not possible

Why MTA is better than other
materials as root end filling?
 many material have been used as root end filling
agent but the main disadvantage in their failure
to prevent leakage and lack of biocompatibility.
 MTA treated teeth exhibited significant less
inflammation ,more cementum formation ,
regeneration per radicular tissue.
 MTA provide double seal consisting of
1-physical barrier provided by root end filling material.
2-Biological seal by regeneration of periodontal
apparatus over the resected root.

Operative sequence
1-flap is raised followed by
osteotomy , root end
resection and hemorrhage
control
2- MTA
placement into
the prepared
root end cavity
with small carrier
and patted with
plugger
3-Flap
is then
suture
back in
place

**Since placement of wet cotton over setting MTA is not possible
,moist environment can be created by induce mild bleeding from
adjacent tissue and bringing the blood over the MTA

Direct pulp capping
After achieving anesthesia
and isolation with a
rubber dam, the exposed
pulp is irrigated with
NaClO to control bleeding.
The prepared MTA is
placed in contact with the
exposure 1-1.5 thick layer

MTA produces thicker dentin bridge formation,
with less inflammation, hyperemia, and pulpal
necrosis compared to calcium hydroxide.
MTA also appears to induce dentin bridge at a
faster rate than calcium hydroxide at amputation
sites.

pulpatomy
MTA can be used for vital
pulp therapy in patient with
traumatic crown fractures
exposing vital pulp tissue
a shallow {partial
pulpotomy }is performed
in which MTA is placed
directly against the pulp
wound
and in children with
carious exposure of pulp
in teeth with incompletely
formed root
the coronal pulp tissue is
removed allowing
placement of MTA against
the pulp tissue at floor of
the pulp chamber f

Procedure of pulpotomy
with MTA
Control the
bleeding
MTA placement
over exposure pulp
tissue by using
MTA carries.
Moist cotton
pellet placement
on MTA material
allow setting

the rest of cavity filled with
temporary filling
Next visit the temporary
filling removed along
cotton pellet tooth rest
orated with permanent
restoration.

Why use MTA for pulpotomy
instead of formacresol?

**Formacresol has been criticized for its tissue irritant , cytotoxic
and mutagenic effect. While MTA found to be ideal material with
low toxic effect increased tissue regeneration properties and good
clinical result .
**An important clinical advantage of MTA over FC is less time is
required for the procedure. While FC requires 3–5 minutes
application before the cotton pellet is removed.
**During the removal of FC-soaked cotton pellet, there is a
possibility of the cotton fibers adhering to clot, resulting in
reoccurrence of bleeding. This does not occur with MTA as it is
applied directly without cotton pellet

Apexification
MTA has been suggested as an ideal material to promote the
formation of an apical barrier in a root with open apex in a one-
visit procedure

 when compared MTA with calcium hydroxide MTA induced
the same amount of apical hard tissue formation, and
without an inflammatory response.
 newly formed bone, periodontal ligament, and cementum in
direct contact with MTA.
 a good apical seal
 its antimicrobial properties.
 biocompatibility and hydrophilic properties.
MTA Ca(oh)2

 While therapy with CH requires multiple appointments for
either reapplication of calcium hydroxide or to check its
presence inside the root canal.
and the time interval between visits is at least three months. This
may lead to loss of the coronal seal with consequent
recontamination and exposure of the healing tissues to bacteria.
In these cases an acute exacerbation and delayed healing
response may occur

Clinical steps
1.Clean and shape the root canal (minimum shaping)
2. rinse with sodium hypochlorite then insert a prepared paste of calcium
hydroxide and leave it there for 1-2 weeks (as intracanal medicament)
3. next visit remove calcium-hydroxide and rinse with sodium
hypochlorite2%
4. Prepare MTA and place in the apical area in contact with periapical tissue
.MTA should create the barrier 3 to 5 mm.
.

5. An X-ray is required to confirm the position of MTA
6. A damp paper poit inserted into the root canal ,close the procedure with a
temporary filling .
7. the next visit check the MTA bonding, the structure should be hard, and
complete the root canal filling with gutta bercha

MTA: A Versatile Material for Endodontic Applications

MTA: A Versatile Material for Endodontic Applications

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