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ROOT REPAIR
MATERIALS
Dr.Rakesh Nair
PG Student
KVG Dental College
Sullia
Karnataka
India
 Introduction
 Classification
 MTA
 Biodentine
 GIC based sealers
 Amalgam
 Gutta percha
 ZOE
 Composite resins
...
 Roots needing repair are serious complications in dental
practice and pose a number of diagnostic and
management problem...
Root fracture
Infective
Perforation
Root end
filling
Root
maturogenesis
Internal resorption
Perforation
Iatrogenic
Gouchin...
ROOT END FILLING
MATERIALS
PERFORATION REPAIR
MATERIALS
ROOT
REGENERATION
MATERIALS
ROOT REPAIR MATERIALS
Bioactive
materi...
 Amalgam
 Gutta percha
 ZOE
 GIC related materials
 Composite resin
 Diaket
 MTA
 Biodentine
ROOT END FILLING MATE...
 MTA
 Biodentine
 GIC
 PRF
 Calcium hydroxide
 MTA
 Biodentine
 PRP/PRF
 Traditionally, amalgam was the material of choice for
root-end fillings.
 The biocompatibility of amalgam is cited as a...
 When GP is used as a root-end filling material, it absorbs
moisture from periapical tissues because of its porous nature...
 The material was considered to have good handling properties
and postoperative results.
 However, the original ZOE ceme...
 The partial substitution of eugenol liquid with EBA and the
addition of fused quartz or aluminum oxide to the powder to
...
 Eugenol is the major cytotoxic component in ZOE cements.
 Zinc released from these cements is considered to be partly
r...
 GIC have been suggested as an alternative root-end
filling material.
 Biocompatibility studies exhibited evidence of in...
 Composite resins and resin-ionomer hybrids.
 The biocompatibility of composite resin is influenced by the
amount and na...
 Results of the observational studies examining various
root-end filling materials on gingival fibroblast cells
showed gr...
 (3M ESPE GmbH, Seefeld, Germany)
 A polyvinyl resin, has been advocated for use as a root-end
filling material.
 When ...
 MTA -first described in litrature by Lee , Mahmoud
Torabinejad And Colleagues in 1993 when used as root
end filling mate...
 POWDER
 Tricalcium Silicate
 Dicalcium Silicate
 Tricalcium Aluminate
Tetracalcium Alumino
Ferrite
 Calcium Sulphate...
 Mineral trioxide aggregate (MTA) is a fine hydrophilic
powder available in single use sachets of 1 gram.
 Some companie...
• There are few published reports of experimental
data relating to the comparative setting times of
the different forms of...
• The presence of gypsum is reported to be the reason
for the extended setting time of MTA.
• In order to reduce the setti...
 The regeneration of the new cementum over MTA is a unique
phenomenon that has not been reported to occur with other
root...
 The setting reaction of MTA is a complicated process
depending on the exact proportions of mineral phases,their
purity a...
 CaO + H2O -- Ca(OH)2
 Whereas, C2S and C3S react with water to produce calcium
silicate hydrate (C-S-H) and calcium hyd...
 The C3S is most important mineral phase in MTA and
engages in the formation of C-S-H to provide early
strength.
 On the...
 The C-S-H, the major hydration product of MTA is an
amorphous compound with varying stoichiometric values.
 The Ca:Si r...
 MTA offers a biologically active substrate for bone cells and
stimulates interleukins production.
 Calcium hydroxide in...
 Intra canal repair of accidental perforations after
administering anesthesia, application of rubber dam and
locating the...
 After complete instrumentation and obturation of the canals
with gutta percha and root canal sealer apical to perforatio...
 After repairing the perforation area with MTA, place a wet
cotton pellet over MTA and seal the access cavity with a
temp...
 For apical perforations, mixed MTA should be placed into the
apical portion of the canal with a messing gun (R. chige,
I...
Repair of perforations as a consequence
of an internal resorption
 After administering anesthesia and
preparing the acces...
Root end filling
 Infected root canals harbor numerous species of bacteria which
can progress into periradicular tissues ...
Advantages
 The advantage of using a material to form an immediate apical barrier over
the conventional apexification tre...
 The slow setting time of MTA is an advantage in that it reduces
the amount of setting shrinkage which may help explain M...
 The use of MTA in cases where the material comes in direct
contact with the oral cavity for an extended period of time i...
 When MTA is used as a root canal sealer and is compacted
against dentin a dentin MTA interfacial layer is formed which
r...
 Alkaline environment by hypochlorite irrigation helps in the
efficiency of the material.
 Hence citric acid and EDTA fi...
 Case 1
Case 2
12 month post
reimplantation
MTA
Internal
resorption
Sagittal section-
CBCT
MTA plug
1 year follow up
Case 3
 Biodentine™ was developed by Septodont’s
Research Group as a new class of dental material
which could conciliate high me...
 Grech et al. investigated the setting time of Biodentine
using an indentation technique while the material was
immersed ...
 Compressive strength is considered as one of the main
physical characteristics of hydraulic cements.
 The product sheet...
 Microhardness. Grech et al. evaluated the microhardness of
the material using a diamond shaped indenter.
 Their results...
7 USES
 Biodentine has a wide range of applications including
endodontic repair (root perforations, apexification, resorptive
le...
 Some authors have indicated that there are few studies on the
properties of newly developed materials such as Biodentine...
 Another area of use of Biodentine, specifically from an
endodontic point of view, is the repair of perforations.
 which...
 Aggarwal et al. studied the push-out bond strengths of
Biodentine, ProRoot MTA, and MTA Plus in furcal
perforation repai...
 In a study by Guneser et al., Biodentine showed
considerable performance as a repair material even after
being exposed t...
 Porosity and Material-Dentine Interface Analysis.
 Tricalcium silicate based materials are especially indicated in
case...
Case 1
Case 2
Palatogingival groove
Biodentine seal
 Radiopacity.
 Radiopacity is an important property expected from a
retrograde or repair material as these materials are...
 Zirconium oxide is used as a radiopacifier in Biodentine
contrary to other materials where bismuth oxide is preferred as...
 A clinical observation stated that the radiopacity of
Biodentine is in the region of dentin and the cement is
not adequa...
Solubility.
 Grech et al. demonstrated negative solubility values for
a prototype cement, Bioaggregate, and Biodentine, i...
Effect on the Flexural Properties of Dentine.
 An important issue related to the usage of calcium
silicate based material...
Discoloration.
 One study evaluated Biodentine from this perspective where
Biodentine, along with 4 different materials, ...
Wash-Out Resistance.
 Washout of a material is defined as the tendency of freshly
prepared cement paste to disintegrate u...
 Biocompatibility of a dental material is a
major factor that should be taken into
consideration specifically when it is ...
 Han and Okiji compared Biodentine and white ProRoot MTA
in terms of Ca and Si uptake by adjacent root canal dentine
and ...
 Recently, ERRM putty and paste (Brasseler USA,
Savannah, GA, USA) have been developed.
 It is available as ready-to-use...
 Biomaterials are native or synthetic polymers that
perform as scaffolds for tissue regeneration and hold
wide importance...
 Various bioactive materials are available in today’s
time like mineral trioxide aggregate (MTA), bioactive
glass, and bi...
 PRF was first developed by Choukroun et al., in 2001 at
France.
 Studies have demonstrated that the PRF has a very sign...
Various clinical applications of PRF include,
 root coverage,
 bone regeneration,
 treatment of endo-perio lesions,
 s...
 PRF represents a new revolutionary step in the platelet gel
therapeutic concept.
 Unlike other platelet concentrates, t...
 No biochemical handling of blood.
 Simplified and cost-effective process.
 Use of bovine thrombin and anticoagulants n...
 The protocol for PRF preparation is very simple and simulates
that of PRP.
 It includes collection of whole venous bloo...
 The middle part is platelets trapped massively in fibrin
meshes.
 The success of this technique entirely depends on tim...
 EndoSequence® BC RRM™ (Root Repair Material) is
available in two specifically formulated consistencies
(syringable paste...
 Calcium silicate
 Calcium phosphate monobasic
 Zirconium oxide
 Tantalum oxide
 Filler and thickening agents.
 pH >...
 The favorable handling properties, increased strength
and shortened set time make BC RRM™ highly resistant
to washout an...
 iRoot BP Plus (Innovative BioCeramix Inc., Vancouver,
Canada) is a fully laboratory-synthesized, water-based
bioceramic ...
 Bioaggregate appears to be a modified or synthetic version of
original MTA.
 According to the manufacturer, this materi...
 Gel-like calcium silicate hydrate.
 Gel-like calcium Aluminate hydrate
 Calcium hydroxide
 Hydroxyapatite
 Calcium s...
 A novel resin based root-end filling material (termed
New resin cement, NRC) has been introduced.
 NRC is a powder and ...
 One study determined the cytotoxicity of NRC and
concluded that the initial biocompatibility results of
NRC are favorabl...
 Newer and better root repair materials are being introduced in
to the market every year.
 The recent trend is towards b...
 Biocompatibility of root-end filling materials: recent update. Payal Saxena1*,
Saurabh Kumar Gupta, Vilas Newaskar. The ...
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Root repair materials

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Root repair materials in Dentistry is evolving like never before with the advent of bioactive materials.lets have quick look at the products that have become history to the recent advances .

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Root repair materials

  1. 1. ROOT REPAIR MATERIALS Dr.Rakesh Nair PG Student KVG Dental College Sullia Karnataka India
  2. 2.  Introduction  Classification  MTA  Biodentine  GIC based sealers  Amalgam  Gutta percha  ZOE  Composite resins  Daiket  Bioceramic sealers  Recent materials  References
  3. 3.  Roots needing repair are serious complications in dental practice and pose a number of diagnostic and management problems.  However, when teeth are of strategic importance root repair is clearly indicated whenever possible.  With advent of 3-D imaging and illumination the scope and success of root repair is very high.
  4. 4. Root fracture Infective Perforation Root end filling Root maturogenesis Internal resorption Perforation Iatrogenic Gouching Strip perforations Apical perforations Furcal perforations Reasons for root repair Trauma
  5. 5. ROOT END FILLING MATERIALS PERFORATION REPAIR MATERIALS ROOT REGENERATION MATERIALS ROOT REPAIR MATERIALS Bioactive materials Biologic materials
  6. 6.  Amalgam  Gutta percha  ZOE  GIC related materials  Composite resin  Diaket  MTA  Biodentine ROOT END FILLING MATERIALS Recent materials • ERRM • Bioaggregate • I root BP Plus bioceramic putty • Novel root-end filling material
  7. 7.  MTA  Biodentine  GIC  PRF
  8. 8.  Calcium hydroxide  MTA  Biodentine  PRP/PRF
  9. 9.  Traditionally, amalgam was the material of choice for root-end fillings.  The biocompatibility of amalgam is cited as a current issue of concern in dentistry.Many in vivo usage studies in animals have reported unfavorable tissue response to amalgam.  The use of amalgam as a root-end filling material can now be confined to history.
  10. 10.  When GP is used as a root-end filling material, it absorbs moisture from periapical tissues because of its porous nature.  It expands initially,then contracts.  Pitt Ford et al. found that the tissue response to GP with zinc oxide root canal sealer was characterized by little or no inflammation.  In a comparative in vivo study on bone defect regeneration, most histological sections using GP as retrograde material showed signs of non-healing with lack of cortical bone and high level of inflammatory infiltration.
  11. 11.  The material was considered to have good handling properties and postoperative results.  However, the original ZOE cements were weak and likely to be absorbed over a period of time.  Therefore, it was unsuitable for longterm use.  Two approaches were adopted to improve the physical properties of ZOE cements.
  12. 12.  The partial substitution of eugenol liquid with EBA and the addition of fused quartz or aluminum oxide to the powder to give an EBA cement, Super EBA cement(Staident International Ltd., Staines, UK).  The addition of polymeric substances to the powder,  (a) polymethymethacrylate to the powder, Intermediate Restorative Material (IRM, DENTSPLY DeTrey GmbH, Konstanz, Germany)  (b) polystyrene to the liquid, Kalzinol (DENTSPLY DeTrey GmbH)
  13. 13.  Eugenol is the major cytotoxic component in ZOE cements.  Zinc released from these cements is considered to be partly responsible for the prolonged cytotoxic effect.  Results of a comparative study showed no cell growth in the originally seeded cells in fresh IRM.  Recent studies have shown IRM to be more toxic than comparative materials.  In a research that investigated cellular attachment to root-end filling materials as a measure of the biocompatibility of the materials, both IRM and Super EBA rendered poor attachment
  14. 14.  GIC have been suggested as an alternative root-end filling material.  Biocompatibility studies exhibited evidence of initial cytotoxicity with freshly prepared samples.  Toxicity decreases as the setting occurs.
  15. 15.  Composite resins and resin-ionomer hybrids.  The biocompatibility of composite resin is influenced by the amount and nature of its leachable components.  The healing response of the periradicular tissues to composite resins in general appears to be very diverse, ranging from poor to good depending on the type of material used.  Two composite resin-based materials, Retroplast (Retroplast Trading, Rorvig, Denmark) and Geristore (Den-Mat, Santa Maria, CA, USA) have been advocated for use as root end filling materials.
  16. 16.  Results of the observational studies examining various root-end filling materials on gingival fibroblast cells showed greater cell attachment to Geristore in comparison to mineral trioxide aggregate (MTA).  Other in vitro interpretations indicate that Geristore is less cytotoxic to gingival fibroblasts in comparison to MTA, GIC and IRM Surgical repair of root and tooth perforations JOHN D. REGAN, DAVID E. WITHERSPOON & DEBORAH M. FOYLE. Endodontic Topics 2005, 11, 152–178
  17. 17.  (3M ESPE GmbH, Seefeld, Germany)  A polyvinyl resin, has been advocated for use as a root-end filling material.  When Diaket was used as a root canal sealer, biocompatibility studies showed that it was cytotoxic in cell culture and generated long-term chronic inflammation in osseous and subcutaneous tissues.  However, when mixed at the thicker consistency advocated for use as a root-end filling material, Diaket has shown good biocompatibility with osseous tissues.
  18. 18.  MTA -first described in litrature by Lee , Mahmoud Torabinejad And Colleagues in 1993 when used as root end filling material..  Mineral trioxide aggregate, or MTA, is a biocompatible material with numerous exciting clinical applications in endodontics.  The material appears to be an improvement over other materials for endodontic procedures that involve root repair and bone healing.
  19. 19.  POWDER  Tricalcium Silicate  Dicalcium Silicate  Tricalcium Aluminate Tetracalcium Alumino Ferrite  Calcium Sulphate  Bismuth Oxide WATER Distilled water
  20. 20.  Mineral trioxide aggregate (MTA) is a fine hydrophilic powder available in single use sachets of 1 gram.  Some companies also provide premeasured water sachets for ease of use.  The important barriers to the widespread use of MTA are its cost and difficulty in storage.
  21. 21. • There are few published reports of experimental data relating to the comparative setting times of the different forms of MTA. • Although the manufacturers of MTA-Angelus claim that this material has a setting time of 10 min, there appears to be no independent evidence to confirm this Grey Proroot MTA - 2 h 45 mins ± 5 mins (Torabinejad) - 2 h 55 min (Islam et `al) White MTA - 2 h 20 mins (Islam et `al) SETTING TIME
  22. 22. • The presence of gypsum is reported to be the reason for the extended setting time of MTA. • In order to reduce the setting time, the effect of accelerators such as sodium phosphate dibasic (Na2HPO4) and calcium chloride (CaCl2) are being investigated currently. • MTA Bio is one commercially available product which incorporates an accelerator of this sort, and is promoted as a rapid-setting material. Mineral trioxide aggregate in paediatric dentistry VIDYA SRINIVASAN1 , PAULA WATERHOUSE2 & JOHN WHITWORTH3 mineral trioxide aggregate in paediatric dentistry VIDYA SRINIVASAN1 , PAULA WATERHOUSE2 & JOHN WHITWORTH3
  23. 23.  The regeneration of the new cementum over MTA is a unique phenomenon that has not been reported to occur with other root end fillings.  The deposition of cementum hard tissue with MTA was also seen in root end fillings , dental pulps and apical tissue after root canal filling.  Torabinejad et al believed that the deposition of cementum against MTA may be due to a number of factors such as sealing ability, biocompatibility or alkaline pH on setting.
  24. 24.  The setting reaction of MTA is a complicated process depending on the exact proportions of mineral phases,their purity and temperature of the mix.  On hydration calcium silicates present in MTA undergoes hydrolysis and produce calcium silicate hydrate and calcium hydroxide.  About one third of hydration products is constituted by calcium hydroxide which makes MTA highly alkaline.
  25. 25.  CaO + H2O -- Ca(OH)2  Whereas, C2S and C3S react with water to produce calcium silicate hydrate (C-S-H) and calcium hydroxide  as:  2(3CaO.SiO2) + 6H2O -- 3CaO2.SiO2.3H2O+ 3Ca(OH)2  2(2CaO.SiO2) + 4H2O --3CaO2.SiO2.3H2O+ Ca(OH)2
  26. 26.  The C3S is most important mineral phase in MTA and engages in the formation of C-S-H to provide early strength.  On the other hand, C2S reacts relatively slow and give later strength to the set material.  C3A present in MTA reacts with water to form calcium aluminates and (in presence of calcium sulphate) sulfate aluminates.
  27. 27.  The C-S-H, the major hydration product of MTA is an amorphous compound with varying stoichiometric values.  The Ca:Si ratio in C-S-H generally varies between 0.8 and 2.1 with highly variable content of water therefore, set MTA can be described as calcium hydroxide contained within a silicate matrix.
  28. 28.  MTA offers a biologically active substrate for bone cells and stimulates interleukins production.  Calcium hydroxide in contact with pulp tissue or culture medium produces deposition of calcite crystals. Also observed was rich extra cellular network of fibronectin in close contact with these crystals.  MTA is superior to amalgam, IRM, and super-EBA in preventing leakage of methylene blue, fusobacterium nucleatum, and endotoxin . It is biocompatible and induces osteogenesis and cementogenesis.  Which makes it an ideal choice for root repair.
  29. 29.  Intra canal repair of accidental perforations after administering anesthesia, application of rubber dam and locating the perforation site, the area should be rinsed thoroughly with sodium hypochlorite.  In cases of long – standing perforations or in the presence of contamination, sodium hypochlorite should be left in the root canal system for a few minutes to disinfect the site of the perforation. Perforation repair
  30. 30.  After complete instrumentation and obturation of the canals with gutta percha and root canal sealer apical to perforation sites (furcation and stripping), mix MTA with sterile water and place it at the perforation site with an amalgam carrier and pack it against the site with a plugger or a cotton pellet.
  31. 31.  After repairing the perforation area with MTA, place a wet cotton pellet over MTA and seal the access cavity with a temporary filling material.  Remove the temporary and the wet cotton pellet at least 3 to 4 hours later and place a permanent filling material in the root and / or in the access cavity preparation.  When MTA is placed in perforations with a high degree of inflammation, the material remains soft when checked at the second appointment. This is due to the presence of low pH, which prevents proper setting of MTA.  Assess the healing in 3 to 6 months as indicated.
  32. 32.  For apical perforations, mixed MTA should be placed into the apical portion of the canal with a messing gun (R. chige, Inc.,Boca Raton, FL ) or a small amalgam carrier and packed with small pluggers or paper points.  A 3 to 5 mm apical plug is needed to prevent coronal leakage and extrusion of obturation material into the periapical tissues. After inducing an apical plug, place a wet cotton pellet against it and close the access cavity with a temporary filling material.  Remove the cotton pellet at least 3 to 4 hours later and obturate the rest of the canal with gutta – percha and root canal sealer. In case of a large apical perforation, and ample moisture, placement of apical plug and obturation of the root canal system can be accomplished in one visit.
  33. 33. Repair of perforations as a consequence of an internal resorption  After administering anesthesia and preparing the access cavity, the root canal should be completely cleaned and shaped.  Because of the presence of granulation tissue and the presence of communication between the root canal and the periodontium,heavy hemorrhage is usually encountered.
  34. 34. Root end filling  Infected root canals harbor numerous species of bacteria which can progress into periradicular tissues and cause development of periradicular lesions.  Because of the complexity of the root canal system and our inability to completely clean it using present techniques and instruments, root canals cannot always be adequately treated.
  35. 35. Advantages  The advantage of using a material to form an immediate apical barrier over the conventional apexification treatment is that endodontic treatment can be achieved in a single appointment .  (MTA can be used as a one step obturation material in an open apex)  70% of the failures in study of perforation repair were associated with extrusion of repair material. But MTA does not have to be compacted as firmly as amalgam to adapt adequately to the tooth surface .  The setting ability of MTA is uninhibited by blood or water. This is an important request of a material which has to be used normally in presence of blood & water and also in teeth with necrotic pulps and inflamed periapical lesions because one of problems in these cases is presence of exudates at the root apex
  36. 36.  The slow setting time of MTA is an advantage in that it reduces the amount of setting shrinkage which may help explain MTA’s low micro leakage .  A major problem in performing endodontics in immature teeth with necrotic pulp and wide open apices is obtaining an adequate seal of the root canal system. MTA has been proposed as a potential material to create an apical plug at the end of the root – canal system, thus preventing the extrusion of filling materials  MTA has an antibacterial effect on few of the facultative bacteria, when comparatively none other test materials had all of antibacterial effects desired .  MTA has low solubility and a radioopacity slightly more than that of dentin
  37. 37.  The use of MTA in cases where the material comes in direct contact with the oral cavity for an extended period of time is unpredictable. This is due to the fact that MTA dissolves in an acidic pH  MTA powder has to be mixed with sterile water and cannot be mixed with anesthetic / sterile liquid. This is because the effects other liquids may have on MTA’s physical, chemical and biological properties are unknown  Excess moisture has to be removed from the preparation / resorptive defect site, because MTA becomes soupy and difficult to condense.  It has low compressive strength, and so can not be placed in functional areas
  38. 38.  When MTA is used as a root canal sealer and is compacted against dentin a dentin MTA interfacial layer is formed which resembles hydroxyapatite in composition and structure when examined under x-ray diffraction and SEM analysis.  Morover the hydration of MTA forms a gluey matrix that will adhere to the guttapercha providing a better seal.  Also the relatively long setting time and maturation add to the sealability of the material. MTA based root canal sealers.Manjusha et`al.Journal of orofacial research.2013
  39. 39.  Alkaline environment by hypochlorite irrigation helps in the efficiency of the material.  Hence citric acid and EDTA final rinses are not advocated with MTA sealer.  Eg:-Pro root endo sealer,cpm sealer,mta obtura,mtas,F-doped MTA.
  40. 40.  Case 1
  41. 41. Case 2 12 month post reimplantation MTA
  42. 42. Internal resorption Sagittal section- CBCT MTA plug 1 year follow up Case 3
  43. 43.  Biodentine™ was developed by Septodont’s Research Group as a new class of dental material which could conciliate high mechanical properties with excellent biocompatibility, as well as a bioactive behavior  The material is actually formulated using the MTA-based cement technology and the improvement of some properties of these types of cements, such as physical qualities and handling.
  44. 44.  Grech et al. investigated the setting time of Biodentine using an indentation technique while the material was immersed in Hank’s solution  The setting time of Biodentine was determined as 45 minutes.  This short setting time was attributed to the addition of calcium chloride to the mixing liquid
  45. 45.  Compressive strength is considered as one of the main physical characteristics of hydraulic cements.  The product sheet of Biodentine states that a specific feature of Biodentine is its capacity to continue improving in terms of compressive strength with time until reaching a similar range with natural dentine.  In the study by Grech et al., Biodentine showed the highest compressive strength compared to the other tested materials.  The authors attributed this result to the enhanced strength due to the low water/cement ratio used in Biodentine.
  46. 46.  Microhardness. Grech et al. evaluated the microhardness of the material using a diamond shaped indenter.  Their results showed that Biodentine displayed superior values compared to Bioaggregate and IRM.
  47. 47. 7 USES
  48. 48.  Biodentine has a wide range of applications including endodontic repair (root perforations, apexification, resorptive lesions, and retrograde filling material in endodontic surgery) and pulp capping and can be used as a dentine replacement material in restorative dentistry.
  49. 49.  Some authors have indicated that there are few studies on the properties of newly developed materials such as Biodentine.  The material is characterized by the release of calcium when in solution.  Tricalcium silicate based materials are also defined as a source of hydroxyapatite when they are in contact with synthetic tissue fluid.
  50. 50.  Another area of use of Biodentine, specifically from an endodontic point of view, is the repair of perforations.  which is likely to be encountered in clinical practice. It is essential that a perforation repair material should have sufficient amount of push-out bond strength with dentinal walls for the prevention of dislodgement from the repair site.
  51. 51.  Aggarwal et al. studied the push-out bond strengths of Biodentine, ProRoot MTA, and MTA Plus in furcal perforation repairs.  Push-out bond strength increased with time. Their results showed that the 24 h push-out strength of MTA was less than that of Biodentine .  Blood contamination affected the push-out bond strength of MTA Plus irrespective of the setting time. A Review on Biodentine, a Contemporary Dentine Replacement and Repair Material.Ozlem Malokondu et`al.J.Bio Med Res.2014.
  52. 52.  In a study by Guneser et al., Biodentine showed considerable performance as a repair material even after being exposed to various endodontic irrigation solutions, such as NaOCl, chlorhexidine, and saline, whereas MTA had the lowest push-out bond strength to root dentin. Effect of various endodontic irrigants on the push-out bond strength of biodentine and conventional root perforation repair materials.Guneser,Akbuluz,Eldinez.J.Endod.March.2013
  53. 53.  Porosity and Material-Dentine Interface Analysis.  Tricalcium silicate based materials are especially indicated in cases such as perforation repair, vital pulp treatments, and retrograde fillings where a hermetic sealing is mandatory.  Therefore, the degree of porosity plays a very important role in the overall success of treatments performed using these materials, because it is critical factor that determines the amount of leakage.
  54. 54. Case 1
  55. 55. Case 2 Palatogingival groove Biodentine seal
  56. 56.  Radiopacity.  Radiopacity is an important property expected from a retrograde or repair material as these materials are generally applied in low thicknesses and they need to be easily discerned from surrounding tissues.  The ISO 6876:2001 has established 3mmAl as the minimum radiopacity value for endodontic cements.
  57. 57.  Zirconium oxide is used as a radiopacifier in Biodentine contrary to other materials where bismuth oxide is preferred as a radiopacifier.  The reason for such a preference might be due to some study results which show that zirconium oxide possesses biocompatible characteristics and is indicated as a bioinert material with favorable mechanical properties and resistance to corrosion.
  58. 58.  A clinical observation stated that the radiopacity of Biodentine is in the region of dentin and the cement is not adequately visible in the radiograph.  This posed difficulty in terms of practical applications T. Dammaschke, “Biodentine-an overview,” Septodont CaseStudies Collection, no. 3, 2012.
  59. 59. Solubility.  Grech et al. demonstrated negative solubility values for a prototype cement, Bioaggregate, and Biodentine, in a study assessing the physical properties of the materials.  They attributed this result to the deposition of substances such as hydroxyapatite on the material surface when in contact with synthetic tissue fluids.  This property is rather favorable as they indicate that the material does not lose particulate matter to result in dimensional instability. A Review on Biodentine, a Contemporary Dentine Replacement and Repair Material. Özlem Malkondu, Meriç Karapinar KazandaL and Ender KazazoLlu.Bio Med Res.June.2014
  60. 60. Effect on the Flexural Properties of Dentine.  An important issue related to the usage of calcium silicate based materials is their release of calcium hydroxide on surface hydrolysis of their calcium silicate components.  On the other hand, it has also been indicated that prolonged contact of root dentine with calcium hydroxide as well as MTA has detrimental and weakening effects on the resistance of root dentine.
  61. 61. Discoloration.  One study evaluated Biodentine from this perspective where Biodentine, along with 4 different materials, was exposed to different oxygen and light conditions and spectrophotometric analysis was performed at different periods until 5 days.  Favorable results were obtained for Portland Cement (PC) and Biodentine and these 2 materials demonstrated color stability over a period of 5 days.  Based on their results, the authors suggested that Biodentine could serve as an alternative for use under light-cured restorative materials in areas that are esthetically sensitive.
  62. 62. Wash-Out Resistance.  Washout of a material is defined as the tendency of freshly prepared cement paste to disintegrate upon early contact with fluids such as blood or other fluids.  The results of the available study on these characteristics of Biodentine did not reveal favorable results as the material demonstrated a high washout with every drop used in the methodology.  The authors attributed this result to the surfactant effect by the water soluble polymer added to the material to reduce the water/cement ratio.
  63. 63.  Biocompatibility of a dental material is a major factor that should be taken into consideration specifically when it is used in pulp capping, perforation repair or as retrograde Filling  Though the information accumulated so far regarding the biocompatibility of Biodentine is rather limited, the available data generally is in favor of the material in terms of its lack of cytotoxicity and tissue acceptability.
  64. 64.  Han and Okiji compared Biodentine and white ProRoot MTA in terms of Ca and Si uptake by adjacent root canal dentine and observed that both materials formed tag-like structures.  They observed that dentine element uptake was more prominent for Biodentine than MTA. The same authors in another study also showed the formation of tag-like structures composed of Ca and P-rich and Si-poor materials.  They also determined a high Ca release for Biodentine.
  65. 65.  Recently, ERRM putty and paste (Brasseler USA, Savannah, GA, USA) have been developed.  It is available as ready-to-use, premixed bioceramic materials recommended for perforation repair, apical surgery, apical plug, and pulp capping.
  66. 66.  Biomaterials are native or synthetic polymers that perform as scaffolds for tissue regeneration and hold wide importance in the field of dentistry, drug delivery, cancer treatment, thrombotic diseases, and cosmetic surgery.
  67. 67.  Various bioactive materials are available in today’s time like mineral trioxide aggregate (MTA), bioactive glass, and bioaggregate materials.  In regenerative endodontic therapy, an ideal autologous biomaterial for pulp-dentin complex regeneration is platelet-rich fibrin (PRF).
  68. 68.  PRF was first developed by Choukroun et al., in 2001 at France.  Studies have demonstrated that the PRF has a very significant slow sustained release of many key growth factors like platelet-derived growth factor and transforming growth factor- β for at least 1 week and up to 28 days.
  69. 69. Various clinical applications of PRF include,  root coverage,  bone regeneration,  treatment of endo-perio lesions,  sinus floor elevation,  stabilize graft material in ridge augmentation,  socket preservation,  filling cystic cavities,  and in various medical fields.
  70. 70.  PRF represents a new revolutionary step in the platelet gel therapeutic concept.  Unlike other platelet concentrates, this technique does not require any gelifying agent, but not more than centrifugation of the natural blood without additives.
  71. 71.  No biochemical handling of blood.  Simplified and cost-effective process.  Use of bovine thrombin and anticoagulants not required.  Favorable healing due to slow polymerization.  More efficient cell migration and proliferation.  PRF has supportive effect on immune system.  PRF helps in hemostasis.
  72. 72.  The protocol for PRF preparation is very simple and simulates that of PRP.  It includes collection of whole venous blood (around 5 ml) in each of the two sterile vacutainer tubes (6 ml) without anticoagulant and the vacutainer tubes are then placed in a centrifugal machine at 3,000 revolutions per minute (rpm) for 10 min  After which it settles into the following three layers: Upper straw-colored acellular plasma, red-colored lower fraction containing red blood cells (RBCs), and the middle fraction containing the fibrin clot.
  73. 73.  The middle part is platelets trapped massively in fibrin meshes.  The success of this technique entirely depends on time gap between the blood collection and its transfer to the centrifuge and it should be done in less time.  The blood sample without anticoagulant, starts to coagulate almost immediately upon contact with the glass, and it decreases the time of centrifugation to concentrate fibrinogen. Platelet-rich-fibrin: A novel root coverage approach K Anilkumar,Geetha,Pameela. J Indian Soc Periodontol. 2009 Jan;13(1):50-4
  74. 74.  EndoSequence® BC RRM™ (Root Repair Material) is available in two specifically formulated consistencies (syringable paste or condensable putty) and contains many of the same characteristics as BC Sealer.
  75. 75.  Calcium silicate  Calcium phosphate monobasic  Zirconium oxide  Tantalum oxide  Filler and thickening agents.  pH > 12
  76. 76.  The favorable handling properties, increased strength and shortened set time make BC RRM™ highly resistant to washout and ideal for all root repair and pulp capping procedures.  Research and countless cases confirm that BC RRM™ is highly biocompatible and osteogenic. Cytotoxicity evaluation of endosequence root repair materialAmer Z. AlAnezi, Jin Jiang, Kamran E. Safavi. Oral Surg Oral Med Oral Pathol Oral Radiol Endod.2013
  77. 77.  iRoot BP Plus (Innovative BioCeramix Inc., Vancouver, Canada) is a fully laboratory-synthesized, water-based bioceramic cement.  It claims to be a more convenient reparative material, because it is a ready to-use white hydraulic premixed formula.  A current study to verify in vitro cytocompatibility of iRoot BP Plus bioceramic putty concluded that iRoot and MTA were biocompatible and did not induce critical cytotoxic effects. De-Deus G, Canabarro A, Alves GG, Marins JR, Linhares AB, Granjeiro JM. Cytocompatibility of the ready-to-use bioceramic putty repair cement iRoot BP Plus with primary Saxena P et al.. Int Endod J 2012;45:508-513.
  78. 78.  Bioaggregate appears to be a modified or synthetic version of original MTA.  According to the manufacturer, this material contains biocompatible pure white powder composed of ceramic nano- particles and deionized water.  Bioaggregate appeared to be biocompatible compared with WMTA on human pulp cells, PDL cells and MG63 cells.
  79. 79.  Gel-like calcium silicate hydrate.  Gel-like calcium Aluminate hydrate  Calcium hydroxide  Hydroxyapatite  Calcium sulfate  Bismuth oxide.  Tantalum oxide  Amorphous silicon oxide
  80. 80.  A novel resin based root-end filling material (termed New resin cement, NRC) has been introduced.  NRC is a powder and liquid system. The liquid is composed of hydroxyethylmethacrylate, benzoyl peroxide, toluidine, and toluenesulfinate.  And the powder is made of calcium oxide,calcium silicate, and triphenyl bismuth carbonate. Novel root-end filling material
  81. 81.  One study determined the cytotoxicity of NRC and concluded that the initial biocompatibility results of NRC are favorable for a root-end filling material.  A recent in vivo study concluded that NRC shows moderately higher inflammatory reaction than MTA however, the calcium reservoir capability of NRC may contribute to mineralization of the tissues.
  82. 82.  Newer and better root repair materials are being introduced in to the market every year.  The recent trend is towards bioactive materials which have osteo inductive and conductive properties.  The clinician should have a thorough knowledge about these products to compare and contrast before using the best material for each case.
  83. 83.  Biocompatibility of root-end filling materials: recent update. Payal Saxena1*, Saurabh Kumar Gupta, Vilas Newaskar. The Korean Academy of Conservative Dentistry.  BioDentine: A dentin substitute for the repair of root perforations, apexification and retrograde root filling.J Conserv dent.Francois bronne.  Repair of Furcal Perforation with Mineral Trioxide Aggregate: Long-Term Follow-Up of 2 Cases. Camila M.M. Silveira et `al. JCDA • October 2008, Vol. 74, No. 8.  Mineral Trioxide Aggregate—A Review. Arathi Rao, Ashwini Rao, Ramya Shenoy. The Journal of Clinical Pediatric Dentistry Volume 34, Number 1/2009.  Evaluation of Radiopacity, pH, Release of Calcium Ions,and Flow of a Bioceramic Root Canal Sealer. George Taccio de Miranda Candeiro. JOE — Volume 38, Number 6, June 2012.  Role of Platelet rich fibrin in wound healing:A critical review. Balaram Naik, P Karunakar1, M Jayadev1, V Rahul Marsha. Journal of Conservative Dentistry .Jul-Aug 2013 .Vol 16 .Issue 4  Dental materials-Mahalakshmi.Edition 1.

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