A prospective clinical study of periradicular surgery using mineral trioxide aggregate as a root-end filling

Biocompatibility of root-end filling materials: recent update

The purpose of a root-end filling is to establish a seal between the root canal space and the periradicular tissues. As root-end filling materials come into contact with periradicular tissues, knowledge of the tissue response is crucial. Almost every available dental restorative material has been suggested as the root-end material of choice at a certain point in the past. This literature review on root-end filling materials will evaluate and comparatively analyse the biocompatibility and tissue response to these products, with primary focus on newly introduced materials.

Posts--when it all goes wrong! Part 1: case assessment and management options

Posts have been used for many years to retain restorations or cores for extra-coronal restorations in endodontically treated teeth.This article discusses the variety of post systems that are available and the incidence and reasons for failure of teeth that have been restored with posts. The treatment options available for the management of such failures are considered, in addition to the indications for both non-surgical and surgical management of endodontic failures. The attitudes of dentists and the perceived complications of attempting post removal are reviewed, along with the evidence to support the prevalence of complications.

CLINICAL RELEVANCE

Failure of post-retained restorations is a relatively frequent finding due to failure of the restoration itself or the endodontic treatment. It is therefore important to understand and be aware of the various treatment options available, their indications and associated risks.

Influence of hemostatic agents upon the outcome of periapical surgery: dressings with anesthetic and vasoconstrictor or aluminum chloride

OBJECTIVE

To evaluate the effects of different hemostatic agents upon the outcome of periapical surgery.

DESIGN

A retrospective study was made of patients subjected to periapical surgery between 2006-2009 with the ultrasound technique and using MTA as retrograde filler material. We included patients with a minimum follow-up of 12 months, divided into two groups according to the hemostatic agent used: A) dressings impregnated in anesthetic solution with adrenalin; or B) aluminum chloride paste (Expasyl). Radiological controls were made after 6 and 12 months, and on the last visit. The global evolution scale proposed by von Arx and Kurt (1999) was used to establish the outcome of periapical surgery.

RESULTS

A total of 96 patients (42 males and 54 females) with a mean age of 40.7 years were included. There were 50 patients in the aluminum chloride group and 46 patients in the anesthetic solution with vasoconstrictor group. No significant differences were observed between the two groups in terms of outcome after 12 months - the success rate being 58.6% and 61.7% in the anesthetic solution with vasoconstrictor and aluminum chloride groups, respectively (p > 0.05).

CONCLUSION

The outcome after 12 months of follow-up was better in the aluminum chloride group than in the anesthetic solution with vasoconstrictor group, though the difference was not significant.

The effects of humidity and serum on the surface microhardness and morphology of five retrograde filling materials

The purpose of this study was to compare the surface morphology and surface hardness of five materials 24 h after filling, in conditions of 100% humidity, and fetal bovine serum. The five materials were ProRoot Mineral Trioxide Aggregate (MTA), Super-EBA, Intermediate Restorative Materials (IRM), Zinc Oxide Eugenol (ZOE), and Amalgam. The microhardness of these materials was evaluated by Vickers microhardness test, and their morphologies were compared by using scanning electron microscopy (SEM). To evaluate the microhardness, the mixed five materials were measured with Vickers microhardness test. Differences between the experimental groups were analyzed by two-way ANOVA and Duncan's multiple comparison tests. All analyses were performed using the Statistical Package for the Social Sciences (SPSS Inc., Chicago, IL). For the microstructural morphological evaluation, the cross cut and root-end cavity prepared surfaces followed by retrograde filling with five different materials were observed under a Scanning Electron Microscope (Steroscan 440; Leica, Cambridge, England) at ×500. To summarize, Super EBA was less influenced by storage medium than the other materials, especially MTA. However, further long-term studies considering other factors, such as biocompatibility (i.e. cellular toxicity) and retention, are needed to be collaborated with these findings in the clinical context.

Effects of bone graft materials on the microhardness of mineral trioxide aggregate

INTRODUCTION

Large through-and-through lesions have been reported to heal faster and better when filled with bone graft material at the time of an apicoectomy. It is unknown what effect these have on retrograde filling materials such as white mineral trioxide aggregate (WMTA). In this study, the null hypothesis was tested that the presence of bone graft materials does not affect the microhardness of WMTA.

METHODS

Freshly mixed WMTA was condensed into acrylic cylinders and preincubated aerobically at 37°C for 1 hour. Cylinders were immersed in simulated body fluid in close proximity to graft materials: xenograft (Bio-Oss, n = 60), freeze-dried bone allograft (MinerOss, n = 60), demineralized freeze-dried bone allograft (OraGraft, n = 40), and allograft (Puros, n = 60). Knoop microhardness of half the samples in each group was evaluated after 2 weeks of incubation and the remainder at 4 weeks. The values for each group were then compared with 2-way analysis of variance and Bonferroni post hoc tests.

RESULTS

WMTA microhardness values for Bio-Oss, MinerOss, and Puros groups were lower than those for OraGraft and control groups regardless of incubation period (P < .001); values for the OraGraft group were higher than those for the control group at 2 weeks (P < .001), with no difference at 4 weeks. Microhardness values were higher at 4 weeks compared with 2 weeks for MinerOss (P < .05), OraGraft (P < .01), and control (P < .001), with no differences for Bio-Oss and Puros groups. The null hypothesis was rejected.

CONCLUSIONS

Demineralized and mineralized graft materials appear to have a differential effect on the microhardness of WMTA.

The effect of various concentrations of iodine potassium iodide on the antimicrobial properties of mineral trioxide aggregate--a pilot study

BACKGROUND

Mineral trioxide aggregate (MTA) is a multi-purpose dental material with various uses in dentistry. Iodine potassium iodide (IKI) is the most commonly used iodine compound in endodontics. We aimed to assess the antimicrobial activity of tooth-colored ProRoot MTA combined with IKI.

MATERIALS AND METHODS

The antimicrobial activity of IKI was assessed at three concentrations (1%, 2%, and 4%) as the mixing agents combined with MTA against Enterococcus faecalis, Escherichia coli, Staphylococcus aureus, Pseudomonas aeruginosa, and Candida albicans. For each microorganism, three plates were inoculated with 100 μl of a microbial suspension (McFarland 0.5). Four wells were prepared in each plate. MTA (70 mg) was mixed with any of the three concentrations of IKI (25 μl) or sterile distilled water (25 μl) and placed in each well. The plates were incubated for 24 h at 37°C. Zones of inhibition (ZOI) were measured in millimeters by a blinded observer. Data were analyzed using analysis of variance and the Dunnett t-test.

RESULTS

All MTA mixtures with water or IKI solutions showed inhibitory zones. The mean ZOI of each MTA/IKI mixture was not significantly different from MTA/water mixture (P > 0.05). MTA/1% IKI had smaller ZOI than MTA/water against E. coli, E. faecalis, and C. albicans. MTA/2% IKI showed larger ZOI only against P. aeruginosa. MTA/4% IKI showed larger ZOI against P. aeruginosa and E. coli (P < 0.05).

CONCLUSIONS

Substitution of IKI solutions (1%, 2%, and 4%) for water did not significantly increase the antimicrobial activity of MTA.

Effects of calcium silicate-based materials on collagen matrix integrity of mineralized dentin

INTRODUCTION

Calcium silicate-based materials (CSMs) are used in various endodontic procedures. The present study examined whether prolonged contact of mineralized dentin with recently commercialized versions of these materials adversely affects dentin collagen matrix integrity.

METHODS

Dentin slabs prepared from extracted human third molars (7 × 3 × 0.3 mm) were divided into 3 groups on the basis of the material to which dentin was exposed (MTA Plus, Biodentine, untreated control dentin slabs) and the time period of exposure (24 hours, 1, 2, and 3 months; n = 6). Hydroxyproline assay was performed on each group's supernatant to quantify the collagen extraction amounts of each group per time period. Data were analyzed with two-factor repeated-measures analysis of variance and Holm-Sidak pair-wise comparisons (α = 0.05) to determine the effects of material and aging time on collagen extraction. Dentin slabs from the 3 months of aging group were demineralized for transmission electron microscopy examination of collagen matrix ultrastructural changes.

RESULTS

Material (P = .002), aging time (P < .001), and their interactions (P = .007) significantly affected the amount of hydroxyproline (pg/mg of mineralized dentin) extracted from mineralized dentin and were significantly correlated by power regression models. Collagen degradation was identified from the surface of dentin slabs that were in direct contact with CSMs.

CONCLUSIONS

Prolonged contact of mineralized dentin with CSMs has an adverse effect on the integrity of the dentin collagen matrix. However, the amount of collagen extracted was limited to the contact surface. Clinicians can continue to apply CSMs in endodontic procedures; however, caution is advised when these materials are applied to thin dentinal walls.

Outcome of endodontic surgery: a meta-analysis of the literature--Part 2: Comparison of endodontic microsurgical techniques with and without the use of higher magnification

INTRODUCTION

The aim of this study was to investigate the outcome of root-end surgery. It identifies the effect of the surgical operating microscope or the endoscope on the prognosis of endodontic surgery. The specific outcomes of contemporary root-end surgery techniques with microinstruments but only loupes or no visualization aids (contemporary root-end surgery [CRS]) were compared with endodontic microsurgery using the same instruments and materials but with high-power magnification as provided by the surgical operating microscope or the endoscope (endodontic microsurgery [EMS]). The probabilities of success for a comparison of the 2 techniques were determined by means of a meta-analysis and systematic review of the literature. The influence of the tooth type on the outcome was investigated.

METHODS

A comprehensive literature search for longitudinal studies on the outcome of root-end surgery was conducted. Three electronic databases (ie, Medline, Embase, and PubMed) were searched to identify human studies from 1966 up to October 2009 in 5 different languages (ie, English, French, German, Italian, and Spanish). Review articles and relevant articles were searched for cross-references. In addition, 5 dental and medical journals (ie, Journal of Endodontics, International Endodontic Journal, Oral Surgery Oral Medicine Oral Pathology Oral Radiology and Endodontics, Journal of Oral and Maxillofacial Surgery, and International Journal of Oral and Maxillofacial Surgery) dating back to 1975 were hand searched. Following predefined inclusion and exclusion criteria, all articles were screened by 3 independent reviewers (S.B.S., M.R.K., and F.C.S.). Relevant articles were obtained in full-text form, and raw data were extracted independently by each reviewer. After agreement among the reviewers, articles that qualified were assigned to group CRS. Articles belonging to group EMS had already been obtained for part 1 of this meta-analysis. Weighted pooled success rates and a relative risk assessment between CRS and EMS overall as well as for molars, premolars, and anteriors were calculated. A random-effects model was used for a comparison between the groups.

RESULTS

One hundred one articles were identified and obtained for final analysis. In total, 14 studies qualified according to the inclusion and exclusion criteria, 2 being represented in both groups (7 for CRS [n = 610] and 9 for EMS [n = 699]). Weighted pooled success rates calculated from extracted raw data showed an 88% positive outcome for CRS (95% confidence interval, 0.8455-0.9164) and 94% for EMS (95% confidence interval, 0.8889-0.9816). This difference was statistically significant (P < .0005). Relative risk ratio analysis showed that the probability of success for EMS was 1.07 times the probability of success for CRS. Seven studies provided information on the individual tooth type (4 for CRS [n = 457] and 3 for EMS [n = 222]). The difference in probability of success between the groups was statistically significant for molars (n = 193, P = .011). No significant difference was found for the premolar or anterior group (premolar [n = 169], P = .404; anterior [n = 277], P = .715).

CONCLUSIONS

The probability for success for EMS proved to be significantly greater than the probability for success for CRS, providing best available evidence on the influence of high-power magnification rendered by the dental operating microscope or the endoscope. Large-scale randomized clinical trials for statistically valid conclusions for current endodontic questions are needed to make informed decisions for clinical practice.

Microsatellites behaving badly: empirical evaluation of genotyping errors and subsequent impacts on population studies

Microsatellites are useful tools for ecological studies because they can be used to discern population structure, dispersal patterns and genetic relationships among individuals. However, they can also yield inaccurate genotypes that, in turn, bias results, promote biological misinterpretations, and create repercussions for population management and conservation programs. We used empirical data from a large-scale microsatellite DNA study of white-tailed deer (Odocoileus virginianus) to identify sources of genotyping error, evaluate corrective measures, and provide recommendations to prevent bias in population studies. We detected unreported mutations that led to erroneous genotypes in five of 13 previously evaluated microsatellites. Of the five problematic markers, two contained mutations that resulted in null alleles, and three contained mutations that resulted in imperfect repeats. These five microsatellites had error rates that were four times greater on average than those observed in the remaining eight. Methodological corrections, such as primer redesign, reduced errors up to 5-fold in two problematic loci, although analytical corrections (computational adjustment for errors) were unable to fully prevent bias and, consequently, measures of genetic differentiation and kinship were negatively impacted. Our results demonstrate the importance of error evaluation during all stages of population studies, and emphasize the need to standardize procedures for microsatellite analyses. This study facilitates the application of microsatellite technology in population studies by examining common sources of genotyping error, identifying unreported problems with microsatellites, and offering solutions to prevent error and bias in population studies.

Uptake of calcium and silicon released from calcium silicate-based endodontic materials into root canal dentine

AIM

To compare Biodentine and White ProRoot mineral trioxide aggregate (MTA) with regard to Ca and Si uptake by adjacent root canal dentine in the presence of phosphate-buffered saline (PBS).

METHODOLOGY

Root canals of bovine incisor root segments were instrumented, filled with either Biodentine or MTA (n = 20 each) and then immersed in Ca-and Mg-free PBS for 1, 7, 30 or 90 days (n = 5 each). Unfilled, unimmersed dentine specimens (n = 5) served as controls. The specimens were sectioned longitudinally, and the ultrastructure of the dentine-material interface and the elemental composition/distribution in the material-adjacent dentine were analysed using a wavelength-dispersive X-ray spectroscopy electron probe microanalyser with image observation function. Data were statistically analyzed using one-way anova and Tukey's honestly significant difference test or the Mann-Whitney U-test.

RESULTS

Along the material-dentine interface, both materials formed a tag-like structure that was composed of either Ca- and P-rich crystalline deposits or the material itself. The width of a Ca- and Si-rich layer detected along the dentine layer of the material-dentine interface showed increases over time. The Ca- and Si-rich layer width was significantly larger (P < 0.05) in Biodentine than MTA at 30 and 90 days.

CONCLUSIONS

Both Biodentine and MTA caused the uptake of Ca and Si in the adjacent root canal dentine in the presence of PBS. The dentine element uptake was more prominent for Biodentine than MTA.

The chemical composition of mineral trioxide aggregate

Mineral trioxide aggregate (MTA) is composed of Portland cement, with 4:1 addition of bismuth oxide added so that the material can be detected on a radiograph. The cement is made up of calcium, silicon and aluminium. The main constituent phases are tricalcium and dicalcium silicate and tricalcium aluminate. There are two commercial forms of MTA, namely the grey and the white. The difference between the grey and the white materials is the presence of iron in the grey material, which makes up the phase tetracalcium alumino-ferrite. This phase is absent in white MTA. Hydration of MTA occurs in two stages. The initial reaction between tricalcium aluminate and water in the presence of calcium sulphate results in the production of ettringite. Tricalcium and dicalcium silicate react with water to produce calcium silicate hydrate and calcium hydroxide, which is leached out of the cement with time.

Scanning electron microscopic evaluation of the material interface of adjacent layers of dental materials

OBJECTIVE

Many dental materials are used in contact with each other in sandwich techniques. Liners, bases and permanent restorative materials are placed adjacent to each other and allowed to set under the same conditions. The same applies for endodontic materials where irrigating solutions and root canal dressings come in contact with root canal obturating materials and root-end fillers. The aim of this research was to investigate the material interface of mineral trioxide aggregate (MTA) in contact with non-setting calcium hydroxide paste (CH), glass ionomer cement (GIC) and intermediate restorative material (IRM).

METHODS

All materials were mixed according to manufacturer's instructions. Freshly mixed MTA (Dentsply) was placed in a plastic container and another dental material was compacted on it while still unset. These materials included GIC (Fuji IX), non-setting calcium hydroxide (Calasept) and IRM (Dentsply). The materials were allowed to set for 28 days at 37°C and 100% humidity. The layered materials were sectioned longitudinally embedded in resin and polished to expose the interface between the two materials. Scanning electron microscopy (SEM) was performed of the interface and X-ray energy dispersive analysis (EDX) was conducted at 50 μm intervals to establish elements present at specific distances from the material interface.

RESULTS

The calcium hydroxide paste did not affect the hydration of MTA. Migration of silicon, aluminum and bismuth from the MTA to the CH occurred. The GIC exhibited a high degree of micro-cracking and some porosity in the interfacial region. Strontium from the GIC was detected at 200 μm within the MTA. The zinc from the IRM cement was detected at 100 μm within the MTA. The zinc affected the hydration of the MTA leading to retardation of setting and increased porosity.

CONCLUSIONS

MTA interacts with other dental materials with resultant elemental migration in adjacent materials. Zinc oxide eugenol based cements should be avoided in the presence of MTA as zinc causes retardation of cement hydration with increased porosity. Glass ionomer cements absorb the water of hydration from the MTA also resulting in increased porosity and incomplete hydration of MTA.

A comparative evaluation of the sealing ability of 2 root-end filling materials: an in vitro leakage study using Enterococcus faecalis

OBJECTIVE

The purpose of this study was to evaluate the sealing ability of EndoSequence Bioceramic Root-end Repair (BCRR) material when compared with white mineral trioxide aggregate (WMTA).

STUDY DESIGN

Forty single-rooted teeth were instrumented, obturated with gutta-percha, root-end resected, and retrofilled with 2 different materials: white ProRoot MTA (WMTA) (n = 15) and BCRR (n = 15). Unfilled specimens (n = 10) received no retrofill and were used as controls. All groups received E. faecalis in a created reservoir coronal to the root filling and the presence of microleakage was evaluated by counting the colony-forming units from each specimen. The results were analyzed with 1-way analysis of variance.

RESULTS

There was no significant difference in leakage between the 2 experimental groups, but there was a significant difference with the control (P ≤ .05).

CONCLUSIONS

This study suggests that BCRR is equivalent in sealing ability to WMTA when used as root-end filling material in vitro.

Dynamic sealing ability of MTA root canal sealer

AIMS

To evaluate (i) the sealing ability of two sealers, mineral trioxide aggregate sealer (MTAS) and Pulp Canal Sealer (PCS), used with gutta-percha utilizing the fluid filtration method, (ii) leaching and surface characteristics in Hank's balanced salt solution (HBSS) over a period of time.

METHODOLOGY

Surface characteristics in HBSS were evaluated under the scanning electron microscope after 1 and 28 days, and the leaching of both sealers were assessed by inductively coupled plasma atomic absorption spectrometry (ICP-AAS). In addition, 24 single rooted extracted teeth were root filled using warm vertical compaction with either MTAS or PCS used as sealers with gutta-percha. Four teeth were used as positive and negative controls. Sealing ability was evaluated after 1 or 28 days using the fluid filtration method.

RESULTS

Mineral trioxide aggregate sealer exhibited crystalline deposits rich in calcium and phosphorus on its surface when in contact with a physiological solution. These crystalline deposits were absent in PCS and on MTAS stored at 100% humidity. The sealing ability of MTAS was similar to that of PCS.

CONCLUSIONS

The novel sealer based on mineral trioxide aggregate had comparable sealing ability to a proprietary brand sealer cement. In contact with a simulated body fluid, the MTA sealer released calcium ions in solution that encouraged the deposition of calcium phosphate crystals.

"MTA"-an Hydraulic Silicate Cement: review update and setting reaction

OBJECTIVES

To review the current status and understanding of Portland cement-like endodontic materials commonly referred to by the trade designation "MTA" (alias "Mineral Trioxide Aggregate"), and to present an outline setting reaction scheme, hitherto unattempted.

METHOD

The literature was searched using on-line tools, overlapping an earlier substantial review to pick up any omissions, including that in respect of ordinary Portland cement (OPC), with which MTA shares much. The search was conducted for the period January 2005 to December 2009 using 'MTA', 'GMTA', 'WMTA', and 'mineral AND trioxide AND aggregate' as keywords, with various on-line search engines including ScienceDirect (http://www.sciencedirect.com), SAGE Journals Online (http://online.sagepub.com), Wiley Online Library (http://onlinelibrary.wiley.com), SciELO Scientific electronic library online (http://www.scielo.br/scielo.php), JSTOR (http://www.jstor.org), and Scopus (http://www.scopus.com). References of articles found were cross-checked where appropriate for missed publications. Manufacturers' and related websites were searched with Google Search (http://www.google.com.hk).

RESULTS

A generic name for this class of materials, Hydraulic Silicate Cement (HSC), is proposed, and an outline reaction scheme has been deduced. HSC has distinct advantages apparent, including sealing, sterilizing, mineralizing, dentinogenic and osteogenic capacities, which research continues to demonstrate. However, ad hoc modifications have little supporting justification.

SIGNIFICANCE

While HSC has a definite place in dentistry, with few of the drawbacks associated with other materials, some improvements in handling and other properties are highly desirable, as are studies of the mechanisms of the several beneficial physiological effects. Reference to the extensive, but complex, literature on OPC may provide the necessary insight.

Apical surgery: A review of current techniques and outcome

Apical surgery is considered a standard oral surgical procedure. It is often a last resort to surgically maintain a tooth with a periapical lesion that cannot be managed with conventional endodontic (re-)treatment. The main goal of apical surgery is to prevent bacterial leakage from the root-canal system into the periradicular tissues by placing a tight root-end filling following root-end resection. Clinicians are advised to utilize a surgical microscope to perform apical surgery to benefit from magnification and illumination. In addition, the application of microsurgical techniques in apical surgery, i.e., gentle incision and flap elevation, production of a small osteotomy, and the use of sonic- or ultrasonic driven microtips, will result in less trauma to the patient and faster postsurgical healing. A major step in apical surgery is to identify possible leakage areas at the cut root face and subsequently to ensure adequate root-end filling. Only a tight and persistent apical obturation will allow periapical healing with good long-term prognosis. The present paper describes current indications, techniques and outcome of apical surgery.

Morphological assessment of dentine and cementum following apicectomy with Zekrya burs and Er:YAG laser associated with direct and indirect Nd:YAG laser irradiation

OBJECTIVES

This study aimed to assess the apical surface morphology of maxillary central incisors resected 3.0 mm from the tooth apex using Zekrya burs or Er:YAG laser, with or without subsequent direct Nd:YAG laser irradiation (apical and buccal surfaces) and indirect irradiation (palatal surface).

STUDY DESIGN

Forty maxillary central incisors were instrumented and obturated. The roots were divided into 4 groups according to the root resection method (Zekrya bur or Er:YAG laser - 1.8 W, 450 mJ, 4 Hz, 113 J/cm(2)) and further surface treatment (none or Nd:YAG laser - 2.0 W, 100 mJ, 20 Hz, 124 J/cm(2)). The teeth were prepared for SEM analysis. Scores ranging from 1 to 4 were attributed to cut quality and morphological changes. The data were analyzed by the Kruskal-Wallis test and by Dunn's test.

RESULTS

SEM images showed irregular surfaces on the apical portions resected with Zekrya burs, with smear layer and grooves in the resected dentine and slight gutta-percha displacement and plasticization. On the other hand, apicectomies carried out with Er:YAG laser showed morphological changes compatible with ablated dentine, with rough surfaces and craters. In spite of the presence of plasticized gutta-percha, with the presence of bubbles, an irregular adaptation of the filling material to the root walls was also observed. Direct Nd:YAG laser irradiation of the apical and buccal surfaces of the resected roots resulted in areas of resolidification and fusion in the dentine and cementum, with a vitrified aspect; indirect Nd:YAG laser irradiation of the palatal surfaces yielded a lower number of changes in the cementum, with irregular resolidification areas.

CONCLUSIONS

There were no differences in terms of cut quality between the use of burs and Er:YAG laser or between the 2 surfaces (apical and buccal) treated with Nd:YAG laser with direct irradiation. However, morphological changes were significantly less frequent on surfaces submitted to indirect irradiation (palatal) when compared with those directly irradiated.

The effect of blood contamination on the compressive strength and surface microstructure of mineral trioxide aggregate

AIM

To investigate the effects of whole, fresh human blood contamination on compressive strength and surface microstructure of grey and tooth-coloured mineral trioxide aggregate (MTA).

METHODOLOGY

The materials investigated were grey ProRoot MTA Original (Dentsply Tulsa Dental, Johnson City, TN, USA) and tooth-coloured ProRoot MTA (Dentsply Tulsa Dental). Three groups of 10 custom-made cylindrical moulds (internal dimensions 6 +/- 0.1 mm length and 4 +/- 0.1 mm diameter) were filled with tooth-coloured MTA. In the control group, MTA was mixed with water and exposed to water. In the second group, MTA was mixed with water and exposed to whole, fresh human blood. In the third group, MTA was mixed with and exposed to whole, fresh human blood. These three groups were then duplicated using grey MTA, creating a total of 60 samples. A predetermined amount of MTA and appropriate liquid were triturated in a plastic mixing capsule then subjected to ultrasonic energy after placement in the moulds. After 4 days of incubation, specimens were subjected to compressive strength testing. The surface microstructure of one extra specimen in each group was examined using scanning electron microscopy. Data were subjected to a two-way anova.

RESULTS

Regardless of MTA type, the mean compressive strength values of both experimental groups, which were in contact with blood, were significantly less than that of the control groups (P < 0.0001). In experimental groups in which MTA was mixed with water and exposed to blood, there was a significant difference (P < 0.0001) in compressive strength between tooth-coloured MTA (30.37 +/- 10.16 MPa) and grey MTA (13.92 +/- 3.80 MPa).

CONCLUSION

When blood becomes incorporated into MTA, its compressive strength is reduced. In clinical situations in which blood becomes mixed with MTA, its physical properties are likely to be compromised.

Essentials of endodontic microsurgery

While endodontic microsurgery has been making tremendous strides in the past 20 years, there are still basic concepts that are confusing or frustrating for the novice and experienced surgeon alike. These issues, such as microscope positioning and the relationship with the surgeon's ergonomics and line of sight to the surgical field, making use of natural hand movements and positions, are addressed in this article. Other topics include major flap designs and guidelines for their implementation, effective hemostasis using materials with less tissue toxicity, root end preparation techniques and guidelines, site-determined choice of root end filling material, and placement and finishing tips for Mineral Trioxide Aggregate.

Environmental scanning electron microscopy connected with energy dispersive x-ray analysis and Raman techniques to study ProRoot mineral trioxide aggregate and calcium silicate cements in wet conditions and in real time

INTRODUCTION

ProRoot mineral trioxide aggregate (MTA) and calcium silicate cements are able to set in a moist environment. The aim of the study was to examine the surface structure and composition of a cement paste under wet conditions and in real time during setting by environmental scanning electron microscopy connected with energy dispersive x-ray analysis (ESEM-EDX) and micro-Raman techniques.

METHODS

White ProRoot MTA and experimental white tetrasilicate cement (wTC) and wTC containing bismuth oxide (wTC-Bi) were studied. Cement disks were analyzed 10 minutes after powder-liquid mixing (freshly prepared samples) and after immersion in Dulbecco phosphate-buffered saline at 37 degrees C for 24 hours (24-hour-aged samples).

RESULTS

Freshly prepared wet cements at ESEM-EDX exposed an irregular surface (displaying calcium, silicon, aluminum, chlorine reflexes, and bismuth traces in MTA and wTC-Bi) with needle-like and cubic-hexagonal shaped crystals. Aggregates of spheroidal Ca-P-rich crystals (spherulites) appeared on the surface of 24-hour-aged samples. The starting unhydrated powders displayed the typical Raman bands of Portland cement components: alite, belite, and calcium sulfate (only as anhydrite in MTA and as both anhydrite and gypsum in wTC and wTC-Bi). MTA powder showed higher amount of calcium carbonate and lower quantities of anhydrite and higher crystallinity of the silicate component, leading to a slower hydration reaction. Products/markers of hydration reactions were present on fresh samples; ettringite formed on the surface of all the cements; calcium hydroxide (portlandite) was detected only on the surface of wTC, but no conclusion can be drawn on wTC-Bi and MTA because of the interference of bismuth oxide. Calcium phosphate and calcite/aragonite bands were detected on all 24-hour-aged cements; portlandite was no longer detected on wTC.

CONCLUSIONS

ESEM and micro-Raman are powerful and suitable techniques to investigate endodontic calcium silicate hydrated cements in real time and in their humid state without inducing artifacts by sample preparation. The formation of apatite spherulites on calcium silicate cements might have clinical relevance.

Evaluation of the physical properties of an endodontic Portland cement incorporating alternative radiopacifiers used as root-end filling material

AIM

To investigate the physical and chemical properties of Portland cement (PC) loaded with alternative radiopacifying materials for use as root-end filling materials in a mineral trioxide aggregate (MTA)-like system.

METHODOLOGY

Portland cement loaded with barium sulphate, gold and silver/tin alloy was mixed with water, and the physical and chemical properties of the hydrated cements were evaluated. MTA and intermediate restorative material (IRM) were used as controls. The radiopacity was compared to the equivalent thickness of aluminium, and the setting time of the cements was assessed using an indentation technique. The compressive strength and the stress-strain relationship were determined at 28 days. The stress-strain relationship was determined by monitoring the strain generated when the cement was subjected to compressive load. In addition, the pH was determined in water and simulated body fluid for a period of 28 days.

RESULTS

The radiopacity of the cements using alternative radiopacifiers was comparable to MTA (P > 0.05). IRM demonstrated a higher radiopacity than all the materials tested (P < 0.05). All the cements with the exception of IRM exhibited an alkaline pH and had an extended setting time when compared to IRM. MTA had a longer setting time than the PC (P < 0.001), and its setting time was similar to the gold-loaded cement (P = 0.159). The addition of a radiopacifier retarded the setting time (P < 0.001) but did not have any effect on the compressive strength as all loaded cements had comparable strength to PC (P > 0.05). IRM was the weakest cement tested (P < 0.001). The cement loaded with gold radiopacifier had comparable strength to MTA (P = 1). The stress-strain relationship was linear for all the cements with IRM generating more strain on loading.

CONCLUSIONS

Within the parameters set in this study, bismuth oxide in MTA can be replaced by gold or silver/tin alloy. The physical, mechanical and chemical properties of the cement replaced with alternative radiopacifiers were similar and comparable to ProRoot MTA.

Surgical endodontic treatment under magnification has high success rates

DATA SOURCES

Medline, Embase and reference lists of identified articles were used to find relevant publications; searches were limited to English language.

STUDY SELECTION

Randomised control trials (RCT) or prospective case series of surgical endodontic treatments performed by a modern technique using magnification, root-end resection with minimal or no bevel, retrograde cavity preparation with ultrasonic tips, and retrograde root canal filling where the lesion was located at the periapical area, with a minimum of 1-year followup and outcomes assessed according to the Rud¹ or Molven² criteria, were included. Studies that did not use a modern surgical approach, involved teeth with apico-marginal defects, periodontal disease, root fractures and root perforations or undergoing repeat surgery were excluded, as were those with less than 1-year followup and with outcomes not evaluated using the Rud¹ or Molven² criteria.

DATA EXTRACTION AND SYNTHESIS

Studies were reviewed and data extracted independently by three observers, with disagreements resolved by discussion. Studies included were combined to estimate the pooled successes and 95% confidence intervals (CI), where success was considered to be complete healing or incomplete healing, by using generalised linear models, assuming a binomial (proportion) distribution.

RESULTS

Eleven studies (six RCT and five prospective case series) met the criteria. The pooled proportion of treatments deemed to be a success (complete healing and incomplete healing) was found to be 91.6% (95% CI, 85.9-95.1%). The pooled proportion deemed to be failures was found to be 4.7% (95% CI, 2.24-9.50%). The remainder were categorised as of uncertain healing (3.7%).

CONCLUSIONS

Surgical endodontic treatment carried out using a modern technique carries predictable outcomes. Additional large-scale prospective clinical studies are needed to evaluate further predictors of success and failure.