MTA and Biodentin

CONTENTS
• INTRODUCTION OF MTA
• COMPOSITION OF MTA
• PROPERTIES OF MTA
• TYPES OF MTA
• PORTLAND CEMENT
• MANIPULATION & SETTING REACTION OF MTA
• CLINICAL IMPLICATIONS OF MTA
• ADVANTAGES & DISADVANTAGES
• INTRODUCTION OF BIODENTINE
• COMPOSITION OF BIODENTINE
• PROPERTIES OF BIODENTINE
• MANIPULATION & INDICATION
• CLINICAL IMPLICATIONS OF BIODENTINE
• STORAGE OF MTA & BIODENTINE
• CONCLUSION
• REFERENCES

 Mineral trioxide aggregate, described in 1993, is an aggregate of
mineral oxides added to “trioxides” of tricalcium silicate, tricalcium
aluminate, and tricalcium oxide silicate oxide.
 It was patented by Mahmoud Torabinejad and Dean White, and
described it as the tooth filling material comprising of Portland
cement ( TYPE 1)
 hydraulic type of cement
INTRODUCTION
Mineral trioxide aggregate, properties & clinical applications, Wiley & Torabinejad

75 wt%
Portland
cement,
20 wt%
bismuth
oxide
(Bi2O3),
5 wt%
calcium
sulfate
dihydrate
or
gypsum
(CaSO4 ∙
2H2O).
COMPOSITION
ALITE
tricalcium silicate (3CaO ∙ SiO2 or
Ca3SiO5
BELITE
dicalcium silicate (2CaO ∙SiO2 or
Ca2SiO4
tricalcium aluminate (3CaO ∙
Al2O3 or Ca3Al2O6)
As, Ba, Cd, Cl, Cr, Cu, Ga, In, K,
Li, Mn, Mo, Ni, P2O5, Pb, Sr,
TiO2, Tl, V, and Zn

• Water-powder ratio: 0.33
• pH value : ∼10.2 immediately after mixing, and rises to 12.5 after 3 hrs
( also ph of WMTA > GMTA)
• SOLUBILITY: higher water-powder ratio, increased solubility and porosity
(WMTA > GMTA)
• RADIOPACITY: six times the radiopacity of Portland cement
• COMPRESSIVE STRENGTH : 39.2 Mpa
• FLEXURAL STRENGTH : 11–15 MPa
• MICROHARDNESS : 40 - 60 HV
• COLOR AND AESTHETICS: Dark discolorations
• “SELF-SEALING” property due to secondary formation of hydroxyapatite
PROPERTIES

MTA is a biocompatible material with
good sealing ability
BIOCOMPATIBILITY
generate little or no
inflammatory
response in
periradicular tissues
encourage the
formation of fibrous
connective tissue
formation of
cementum covering
the entire root end
Ca & P are the main
ions present in this
material which are
the components of
dental tissues

When MTA is
placed in
direct contact
with human
tissues
Creates an
antibacterial
environment
by its alkaline
pH
Modulate cytokine
production
Encourages
differentiation
of hard tissue-
producing
cells
Forms hydroxyapatite on
the MTA surface and
provides a biological seal

• Introduced in 1995
• Consists of Tetracalcium
aluminoferrite (4CaO ∙ Al2O3 ∙
Fe2O3) & magnesium oxide
form
• SETTING TIME: 70-170min
• More expansion and better
sealing ability
• Higher dentin bridge
formation
• introduced in 2002
• Consists of tricalcium
aluminate (3CaO.Al2O3)
• Size ranges from <1 µm to
30–50 µm & particles more
homogeneously sized
• SETTING TIME: 40-140min
• Less expansion
• High surface hardness
GRAY MTA WHITE MTA
TYPES OF MTA
Mineral Trioxide Aggregate in Dentistry, Josette Camilleri

• Manufactured by raw materials typically limestone or calcium
carbonate & clay
• crushed to smaller particle size and introduced into a rotary,
cylindrical kiln (1430−1650 ºC).
• Reactions including evaporation of water, dehydration of the clays,
and decarbonation of the calcium carbonate take place
• Referred as clinker.
• Once cooled, grounded to a fine powder size
PORTLAND CEMENT

• Mixing the desired amount of MTA is carried out in a glass Dappen
dish, glass slab or mixing pad using a syringe of sterile water or
anesthetic solution.
• Solution should wet the powder particles
• Blot the mixture with sterile gauze to remove excess solution
• Delivered using amalgam carrier or especially designed micro
carriers
MANIPULATION

• Hydrualic type of cement
• exothermic reaction
• working time of 5 minutes
The 2 most imptorant hydration reactions; are those of greatest constituents
TRICALCIUM SILICATE + WATER CALCIUM SILICATE HYDRATE + CALCIUM HYDROXIDE
DICALCIUM SILICATE + WATER CALCIUM SILICATE HYDRATE + CALCIUM HYDROXIDE
 The calcium silicate hydrate may be considered a gel that forms on the
calcium silicate particles and hardens with time to form a solid network
the calcium hydroxide nucleated within the pore and void space
 water is both a reactant and is contained in the reaction products of MTA.
SETTING REACTIONS

 TRICALCIUM ALUMINATE HEXACALCIUM ALUMINATE TRISULPHATE HYDRATE (Ettringite)
+ GYPSUM + WATER ( small needle-like crystals in set MTA)
After all of the gypsum is consumed,
Tricalcium aluminate + Ettringite Monosulfates
Finally, Tetracalcium aluminoferrite hydration in the presence of gypsum
2 Ca2AlFeO5 + CaSO4 +16 H2O → Ca4 (AlO3/ FeO3)2 (SO4). 12H2O +12Al /Fe (OH)3
The hydration reactions of the two minor components of Portland cement
are influenced by gypsum

DEVELOPMENT OF REACTION ZONES
• MTA’s bioactive nature is brought about by dissolution of calcium, which
complexes with phosphate to form hydroxyapatite crystals that grow and fill
the space between MTA and dentin. Over time, this mechanical layer
transforms to a chemically-bonded seal.
• initial nucleus is of an amorphous calcium phosphate acts as a precursor to
the formation of carbonated apatite (after five hours) and a uniform
appearing within seven days
A material is called bioactive if it can interact with cells of the
human body or show a positive biological effect on cells

MTA + H20 CALCIUM HYDROXIDE
(COLLOIDAL GEL)
Calcium Hydroxide calcium and hydroxyl ions
ANTIMICROBIAL ACTIVITY
DUE TO INCREASED PH
ANTIMICROBIAL
EFFECT OF MTA

• Vital pulp therapy is a procedure designed to preserve the vitality of
the pulp
• Objectives of vital pulp therapy include the elimination of bacteria
from the dentin–pulp complex, protection, repair, and promotion of
pulp healing in order to postpone more aggressive endodontic and
restorative care
• The hard tissue formed is amorphous and without dentinal tubules

MTA in Vital Pulp Therapy
MTA stimulates mineralization:
 by up-regulation of bone morphogenic protein
 production of mineralization matrix genes, mRNA, and a protein expression of
cellular markers
 vascular endothelial growth factor transforming growth factor-β (TGF-β),
macrophage colony-stimulating factor (MCSF), and interleukins IL-1α and IL-β
 tenascin and fibronectin

DIRECT PULP
CAPPING
 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.

• Apexification is defined as “a method of inducing a calcified
barrier in a root with an open apex or the continued apical
development of an incompletely formed root in teeth with a
necrotic pulp”
• MTA induces a cemental tissue in the periradicular region of the
tooth
• A thick layer of MTA over the exposure site and the surrounding
dentin increases the probability that remaining microorganisms are
entombed and incapable of challenging the pulp again
APEXIFICATION(necrotic tissue)

 BMP of root canal system complete
 MTA placed (middle to apical third)
 adequate apical plug(3-5mm) of MTA compacted to the working length,
(excess removed by irrigating with sterile water)
 Dried with sterile paper points
 remaining canal restored with a core material (enhance fracture resistance of
the tooth)
 Restored with composite extending coronally to fill the access opening.
TECHNICAL PLACEMENT

APEXOGENESIS(VITAL PULP)
• Maintains the pulp
vitality during the
treatment
• Allows continued
development of root

 LA and placement of rubber dam
 access cavity preparation
 Irrigation using 1.5% NaOCl
 antibiotic paste or calcium hydroxide
 Seal the access cavity with 3–4 mm of Cavit followed by glass ionomer
cement
REGENERATION/REVITALIZATIO
N
FIRST APPOINTMENT

 temporary material removed & canals irrigated using 1.5% NaOCl
followed by 20 ml of 17% EDTA.
 Create bleeding in the canal by over-instrumenting with endodontic files
(#10–15)
 Allow the blood to clot for 10 minutes or place PRF
 After placing 3–4 mm of MTA, apply a wet cotton pellet
temporary filling material
 Permanent restoration & follow up
SECOND APPOINTMENT

 For open apices & necrotic pulp
 Material of choice as 3-4mm apical plug
 Initiates hard tissue formation
 Prevents extrusion of filling material
during obturation through open apex
APICAL PLUG

• A better understanding of the etiologic factors associated with
successful outcomes and recent, biologically active materials have
greatly improved perforation repair prognosis.
• Wet conditions associated with perforation repair negatively
affected the sealing properties of many of the materials
• MTA has been shown to induce a biologic repair of the perforation
defect.
• When MTA is hydrated in the presence of a balanced salt solution
containing phosphate ions, hydroxyapatite crystals are formed on
the surface of the MTA
PERFORATION REPAIR

1. Access preparation-related perforations
• Exploration for calcified canals
• angulation of the long axis of the root
• inadequate vision and orientation
2. Cleaning and shaping related (“strip”) perforations
• Using instruments too large for a given canal
• failure to recognize the proximity of canals to the
furcation
TYPES OF PERFORATION DEFECTS

3. Resorption-related perforations (internal/external)
• Inflammatory external resorption may perforate into
the pulp canal space
• Replacement resorption (ankylosis) is caused by loss
the cementum barrier.
4. During post space preparation

 Size of perforation
 Location of the perforation
 Time elapsed since
perforation
FACTORS INFLUENCING PROGNOSIS FOR REPAIR

 If the perforation occurred prior endodontic therapy, repair must be
completed before the endodontic procedure maintaining canal patency
 Hemostasis should be achieved
 MTA mixture is delivered at the site & blot the MTA with a sterile cotton
pellet.
 Condensed with an endodontic plugger gently into the perforation.
 A temporary restoration is placed & follow up after week 1, 3, and 6
months
Techniques

• The purpose of the root-end filling is the hermetic sealing of the
apex so that remaining bacteria or bacterial byproducts cannot enter
or leave the canal.
• The root-end filling material is placed to fill the root-end cavity,
which is prepared followed by root end resection
• MTA was introduced into surgical endodontic treatment as a root-
end filling material by Torabinejad and associates in 1993
• MTA exhibits the most favorable periapical tissue response, as
cementum was shown to regenerate in direct contact with the MTA
Root-end fillings MATERIAL

 ADVANTAGES:
• Sustained alkaline pH during slow set
• Forms interfacial layer with dentin similar to hydroxyapatite
• Seals at zero microns
• when examined under SEM Particle size penetrates/occludes dentinal
tubules
• Setting properties not affected by smear layer
• Inhibits growth of E. faecalis and C. albicans
• Promotes cementogenesis and PDL reformation
• Promotes bone coupling factors and osteogenesis
• Antibacterial effect is enhanced in presence of dentin
• Can increase resistance of root to fracture
MTA as a root filling material

 Bogen & Kutler 2008
 After the canals are dried, the mixed MTA is placed in the canal
a carrier gun and pushed apically with an endodontic plugger
 Canal walls are coated & moderate pressure is applied until
resistance is encountered
 Fresh MTA in the canal is compacted from apical to coronal
Standard compaction technique

 Bogen & Kutler 2008
 The canal may be prepared more conservatively as small particle size of
MTA facilitates its travel apically along a glide path with an apical diameter
as small as a #20 K-file
 irrigated with 6.0% sodium hypochlorite & EDTA
 MTA is mixed & transferred from the dappen dish to the chamber
 A series of K-files are used to transfer the prepared MTA to the terminus of
the canal
 The coronal portion of the canal may be obturated with MTA or GP
Lawaty technique

• In teeth with relatively straight roots and closed apices entire canals
can be obturated with the auger technique from apex to pulpal floor
 Conventional .04 and .06 taper NiTi rotary files in the reverse mode
 After delivery of the MTA with a carrier gun, pushed in with a
plugger and the rotary instrument to the apical limit using a
combined circumferential and pecking action.
Auger technique

 Cavity preparation for MTA root-end filling to a depth of 3 mm
along the long axis of the root.
 MTA is mixed & delivered using a syringe-type carrier or MTA pellet
 Cover the plastic MTA with moistened gauze will prevent its
desiccation as a dry mixture becomes crumbly and unmanageable
TECHNIQUE

 Root canal therapy performed
 Putty mixture of MTA inserted in the canal till the level of defect
 Gutta percha & root canal sealer is placed over the defect to
complete the root canal therapy
INTERNAL ROOT RESORPTION

• easy to manipulate,
• radiopaque,
• dimensionally stable,
• bactericidal or bacteriostatic,
• nonresorbable, and
• unaffected by the presence of moisture
• should adhere to the prepared cavity walls,
• seal the root canal system,
• promote healing,
• nontoxic and
• well-tolerated by periapical tissues
REQUIREMENTS OF IDEAL material

• lower solubility,
• improved mechanical strength
• superior marginal adaptation to dentin
• Hydrophilic cement
• Reduced microleakage
• excellent biocompatibility
Advantages of mta

• Delayed setting time
• Can’t be used in long term use as its strength is lower than
dentin
• Its handling, and application can be difficult
• tooth discoloration
• relatively expensive material
• May not set in presence of high pH
• Hygroscopic expansion
DISADVANTAGES

MTA OVER
CALCIUM
HYDROXIDE
 Rapid cell growth promotion
 Better ability to maintain the integrity
of pulp tissue
 Thicker dentin bridge & lesser
inflammation at a faster rate
 Better resistance to penetration of
micro organisms

• Biodentine, a tricalcium silicate based dental material was
introduced by Septodont in the year 2010
• known as “dentine in a capsule”
• The product was synthesized de novo and was free from the
impurities present in the derivatives of portland cement like MTA
• It helps in achieving biomimetic mineralisation within the depths of
a carious cavity
INTRODUCTION
Priyalakshmi S & Ranjan M , Review on Biodentine-A Bioactive Dentin
Substitute ,IOSR-JDMS 2014; 13(1):13-17

COMPOSITION
POWDER
LIQUID
A Review on Biodentine, a Contemporary Dentine Replacement and Repair Material, Özlem Malkondu, BioMed Research
International, Volume 2014, 1-10
Tricalcium silicate, dicalcium silicate, calcium carbonate and
oxide filler,
iron oxide shade, and zirconium oxide
Calcium chloride as an accelerator and a hydrosoluble
polymer that serves as a water reducing agent

• Tissue Regeneration & Early
Mineralisation
• Short setting time
• high alkaline pH.
• higher porosity
• good marginal adaptation
• Radiopaque
• increased sealing ability
• color stability
• Low washout resistance
• Elastic modulus: 22.0 Gpa
• Compressive strength: 220 MPa
• Microhardness: 60 HVN
• Acid resistance
PROPERTIES

 TISSUE REGENERATION & EARLY MINERALIZATION
Early mineralization by increased secretion of TGF beta 1 from pulpal
cells after application
Acts by odontobalstic cells stimulation & cell differentiating that
facilitates reactionary & tertiary dentin formation

• alkaline environment at the
boundary area of contact
between biodentine & hard
tooth surface opens a path via
which dentin substitute mass
can enter the exposed opening
of the dentinal canaliculi
• Hydrosoluble polymer reduce
the amount of water that has a
positive influence of density
• Due its lower porosity it offers
better & enhanced mechanical
properties
• DENSITY : 2.26g/cm3
• POROSITY : 6.8%
MARGINAL ADAPTATION &
SEALING ABILITY
DENSITY & POROSITY

• Surface hardness ranges
similar to dentin
• & even more when compared
with other materials like glass
ionomer cement
• Approx. 3mm of aluminium
• Suitable material for canal
repair
• Interaction between the
phosphate ions of saliva &
calcium silicate based cements
may lead to the formation of
apatite crystals, that increase
the sealing potential of
material
MICRO HARDNESS & BOND
STRENGTH
RADIOPACITY &
MICROLEAKAGE

• The powder is mixed with the liquid in a capsule in the triturator for
30 sec
• Setting Time- approximately 12 minutes.
Manipulation
Priyalakshmi S & Ranjan M , Review on Biodentine-A Bioactive Dentin Substitute ,IOSR-JDMS 2014; 13(1):13-17

 C-S-H gel formation is due to permanent hydration of tricalcium
silicate, which gradually fills the spaces between the tricalcium
silicate grains.
 The hardening process results from the formation of crystals that
are present in super saturated crystals.

Mechanism
Of Action
 Induces mineralization in the form of osteodentine
 By expressing markers of odontoblasts & increases
TGF-Beta1 secretion from pulpal cells enabling early
mineralization.
 During the setting of the cement Calcium hydroxide is
formed. Due to its high pH, Calcium hydroxide causes
irritation at the area of exposure.
 Coagulation necrosis causes division and migration
of precursor cells to substrate surface
 Induces apposition of reactionary dentine
by odontoblast stimulation and reparative dentin by
cell differentiation
• High alkalinity has inhibitory effects on microorganism.

• cells secreting the structure well exhibited
DSP expression as well as osteopontin
expression, which are critical regulators of
reparative dentine formation by release of
TGF – ϐ from pulpal cells to encourage pulp
healing
• and by odontoblast stimulation for dentine
bridge formation to protect the pulp
encourages hard tissue regeneration, and
provoke no signs of pulp inflammation
response
• formation of hydroxyapatite crystals at the
surface which enhances the sealing ability
PULP CAPPING

• ease of handling, faster setting kinetics, biocompatibility, early mineralisation.
• dentine bridge formation induced by Biodentine showed a pattern well-
localized at the injury site
• complete healing of necrotic immature teeth with open apex after 12
months, with superior root growth and dentin thickness
• Due to its biocompatibility and bioactivity, favorable tissue response when
used as blood clot protecting Material & placing Biodentine over blood clot
for revascularization
Apexification

• Biodentine stimulates dentine regeneration by
inducing reparative dentine synthesis
• Biodentine has better consistency, better
handling, safety and faster setting time
• well tolerated by periradicular tissues with no
inflammatory reactions, stimulate the
regeneration of Periodontium
• non toxic both systemically and locally
Root-End Filling

 Biodentine contains more anti-bacterial and antifungal inhibitors
 It is effective against against Streptococcus mutans,
 Enterococcus faecalis, Escherichia coli, and Candida albicans
ANTIMICROBIAL ACTIVITY
Bioactive materials in dentistry, remineralizarion & biomineralization, Francine Benetti

STORAGE
 Powder form of MTA pouches must
be kept tightly closed & stored in dry
area to avoid degradation by
moisture
 Biodentine is available in the form of
capsules

MTA BIODENTINE
MTA VS BIODENTINE
MTA versus Biodentine: Review of Literature with a Comparative Analysis KAUR et al, Journal of Clinical and Diagnostic Research. 2017
mixture of three powder ingredients
Reaction occurs between tricalcium silicate and dicalcium silicate to
form a calcium hydroxide and calcium silicate hydrate gel
delayed setting time
low compressive strength, flexural strength, hardness, push out
bond strength
Higher radiopacity, solubility, marginal adaptation
Produces discoloration
available in the form of a capsule containing the ideal
ratio of its powder and liquid
calcium silicate particles react with water to from
solution containing Ca2+, OH- and silicate ions
Faster setting time
high compressive strength, flexural strength, hardness,
push out bond strength
Lower radiopacity, solubility, marginal adaptation
Color stable

CONCLUSION
 The clinical uses of bioceramics have
increased exponentially over the years
because of their wide range of
applicability in restorative dentistry and
endodontics
 MTA & biodentine are the innovations
that have led dentistry to another level
by their ability to biomineralize the
tissues to simulate their original
structure as they possess biomimmetic
property.
 They have increased the efficacy of the
various treatment modalities &
therefore proved to be beneficial for
the dentist as well as the patient.

• Mineral trioxide aggregate, properties & clinical applications, Wiley
& Torabinejad
• Priyalakshmi S & Ranjan M , Review on Biodentine-A Bioactive
Dentin Substitute ,IOSR-JDMS 2014; 13(1):13-17
• A Review on Biodentine, a Contemporary Dentine Replacement and
Repair Material, Özlem Malkondu, BioMed Research International,
Volume 2014, 1-10
• MTA versus Biodentine: Review of Literature with a Comparative
Analysis KAUR et al, Journal of Clinical and Diagnostic Research.
2017 Aug, Vol-11(8)
• Bioactive materials in dentistry, remineralizarion & biomineralization,
Francine Benetti
• Mineral Trioxide Aggregate in Dentistry, Josette Camilleri
References

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