Mineral trioxide aggregate and other bioactive endodontic cements: an updated overview - part II: other clinical applications and complications

Mineral trioxide aggregate (MTA) is a dental material used extensively for vital pulp therapies (VPT), protecting scaffolds during regenerative endodontic procedures, apical barriers in teeth with necrotic pulps and open apices, perforation repairs as well as root canal filling and root-end filling during surgical endodontics. A number of bioactive endodontic cements (BECs) have recently been introduced to the market. Most of these materials have calcium and silicate in their compositions; however, bioactivity is a common property of these cements. These materials include the following: BioAggregate, Biodentine, BioRoot RCS, calcium-enriched mixture cement, Endo-CPM, Endocem, EndoSequence, EndoBinder, EndoSeal MTA, iRoot, MicroMega MTA, MTA Bio, MTA Fillapex, MTA Plus, Neo MTA Plus, Ortho MTA, Quick-Set, Retro MTA, Tech Biosealer, and TheraCal LC. It has been claimed that these materials have properties similar to those of MTA but without the drawbacks. In Part I of this review, the available information on the chemical composition of the materials listed above was reviewed and their applications for VPT was discussed. In this article, the clinical applications of MTA and other BECs will be reviewed for apexification, regenerative endodontics, perforation repair, root canal filling, root-end filling, restorative procedures, periodontal defects and treatment of vertical and horizontal root fractures. In addition, the literature regarding the possible drawbacks of these materials following their clinical applications is reviewed. These drawbacks include their discolouration potential, systemic effects and retreatability following use as a root filling material. Based on selected keywords, all publications were searched regarding the use of MTA as well as BECs for the relevant clinical applications. Numerous publications were found regarding the use of BECs for various endodontic applications. The majority of these investigations compared BECs with MTA. Despite promising results for some materials, the number of publications using BECs for various clinical applications was limited. Furthermore, most studies had several methodological shortcomings and low levels of evidence.

Calcium-enriched mixture cement as artificial apical barrier: A case series

In comparison to the conventional apexification using calcium hydroxide, artificial apical barrier technique is more valuable and less time consuming. This article describes successful use of calcium-enriched mixture (CEM) cement as an artificial apical barrier in open apices. In this study, 13 single-rooted teeth with necrotic pulps and open apices were treated non-surgically. After copious irrigation of the root canals with NaOCl 5.25% and gentle filing, based on need for interappointment dressing, treatments were followed by CEM cement (BioniqueDent, Tehran, Iran) apical plug insertion in the first or second appointment. All cases were then permanently restored. All subjects were followed until radiographic evidence of periradicular healing was seen (mean 14.5 months). Clinically, all cases were functional and asymptomatic and complete osseous healing was observed in all the teeth. Considering the biological properties of CEM cement, this new endodontic biomaterial might be appropriate to be used as artificial apical barrier in the open apex teeth.

Porosity Distribution in Apically Perforated Curved Root Canals Filled with Two Different Calcium Silicate Based Materials and Techniques: A Micro-Computed Tomography Study

The present study evaluated the porosity distribution of BioRoot RCS/single gutta-percha point (BR/SC) and MTA flow (MF) fillings, which were used as plugs for the apical perforation repair in curved canals of extracted mandibular molars using micro-computed tomography (μCT). Forty mesial root canals of mandibular first molars were shaped with ProTaper NEXT X1-X5 files 2 mm beyond the apex to simulate apical perforations that were randomly divided into two groups (n = 20) according to the material and technique used for the apical plug: BR/SC or MF. The specimens were scanned before and after canal filling at an isotropic resolution of 9.9 μm. The volumetric analysis of voids in the apical 5 mm of the fillings was performed. Data were analyzed using one-way ANOVA with Bonferroni correction (p < 0.05). Micro-computed tomography (µCT) evaluation revealed significant differences between the groups in terms of porosity: the total volume and percentage volume of voids was lower in the BR/SC group in comparison with the MF group (p < 0.05), with the predominance of open pores in both groups. Neither of the materials and/or application techniques were able to produce void-free root fillings in the apical region of artificially perforated curved roots of mandibular molars.

Effect of accelerants on the immediate and the delayed sealing ability of mineral trioxide aggregate when used as an apical plug: An in vitro study

Aim:

To evaluate and compare the influence of various accelerators, 15% disodium hydrogen phosphate (Na₂HPO₄), 10% calcium chloride (CaCl₂) and 23.1 wt% calcium lactate gluconate (CLG), on the immediate (after 72 h) and delayed (after 2 months) sealing ability of white ProRoot mineral trioxide aggregate (WMTA) when it is used as an apical plug.

Materials and Methods:

Eighty, single-rooted mandibular premolars were instrumented and standardized artificial open apices were created. The samples were then randomly assigned into four experimental groups and two control groups. WMTA was mixed with the respective accelerators and an apical plug of 4-mm thickness was fabricated. The remaining canal spaces were then backfilled. The samples were stored for the stipulated time periods and then immersed in 0.2% Rhodamine B solution for 72 h. Dye leakage was analyzed using a stereomicroscope.

Results:

Mean microleakage values of all experimental groups revealed that MTA + 23.1 wt% CLG showed the least leakage, followed by MTA + 15% Na₂HPO₄ and MTA + 10% CaCl₂ with MTA + deionized water showing the maximum leakage at both the time intervals (P < 0.001). All the samples stored for a period of 2 months showed less leakage as compared with the samples stored for 72 h (P < 0.05).

Conclusions:

It was found that all three accelerators significantly accelerated the set of WMTA, of which 23.1 wt% CLG showed the best results, followed by 15% Na₂HPO₄ and 10% CaCl₂. The sealing ability of all the experimental groups was significantly superior after 2 months as compared with that after 72 h.

Evaluation of a Novel Tool for Apical Plug Formation during Apexification of Immature Teeth

The purpose of this study was to compare the sealing ability and time required for the formation of Biodentine and mineral trioxide aggregation (MTA) apical plugs, using three different delivery methods: an amalgam carrier (AC), the Micro Apical Placement (MAP) System or a novel tool using a modified cannula (MC). Materials and Methods: A total of 60 uniformed molar roots were divided into three main groups, according to the technique of apical plug formation: AC, MAP, and MC. Each group was divided into two subgroups, according to the filling material used: MTA and Biodentine. A timer was used to calculate the required time for apical plug formation. After setting the filling materials, the apical microleakage of the formed plugs was quantified using the dye extraction method and spectrophotometry. The differences between the groups were analyzed using the one-way ANOVA and LSD post hoc tests. The significance level was set at 0.05. Results: No significant differences were reported in the time required to form the apical plugs in all groups (p > 0.05). However, the apical plugs formed by the AC method had significantly higher microleakage than those formed using the MAP and MC methods (p < 0.05). Conclusion: Within the limitations of this study, the sealing ability of the apical plugs formed by the MC method is comparable to the MAP method and better than the AC method.

Nonsurgical management of an extensive endodontic lesion in an orthodontic patient by calcium-enriched mixture apical plug

Periapical lesion is a general term used to describe the periapical inflammatory process that occurs in response to the invasion of micro-organisms in the root canal system as well as inflamed vital pulp. This phenomenon necessitates endodontic intervention and if the necrosis has occurred prior to tooth maturation, wide patency of the apical foramen requires some treatment modalities such as apexification or apical plug. Orthodontic treatment, on the other hand, is cautiously done for previously traumatized teeth due to increased risk for necrosis of the compromised tooth. This article tends to review the successful treatment process with calcium-enriched mixture (CEM) cement apical plug for an immature previously traumatized incisor tooth with an extensive periapical lesion, which was under orthodontic treatment as well.

The Effect of Ultrasonic Agitation on the Porosity Distribution in Apically Perforated Root Canals Filled with Different Bioceramic Materials and Techniques: A Micro-CT Assessment

The present study evaluated the effect of ultrasonic agitation on the porosity distribution of BioRoot RCS/single gutta-percha cone (BR/SC) and MTA Flow (MF) root canals fillings used as apical plugs in moderately curved and apically perforated roots. Eighty mesial root canals of mandibular first molars were enlarged up to ProTaper NEXT X5 rotary instrument 2 mm beyond the apical foramen, simulating apical perforations. Specimens were randomly divided into four experimental groups (20 canals per group) according to the material and technique used for root canal obturation: BR/SC, BR/SC with ultrasonic agitation (BR/SC-UA), MF and MF with ultrasonic agitation (MF-UA). The ultrasonic tip was passively inserted into the root canal after the injection of flowable cement and activated for 10 s. The specimens were scanned before and after obturation with a high-resolution micro-computed tomography scanner, and the porosity of the apical plugs was assessed. The differences between groups were analyzed using the Kruskal-Wallis and Mann-Whitney tests, with the significance level set at 5%. None of the obturation materials and techniques used in this study was able to provide a pore-free root canal filling in the apical 5 mm. Considerably higher percentages of open and closed pores were observed in the MF and MF-UA groups, with the highest porosity being in the MF-UA group (p < 0.05). No significant differences were observed between the BR/SC and BR/SC-UA groups, where the quantity of open and closed pores remained similar (p > 0.05).

Comparative evaluation of calcium release of the apical plugs formed by mineral trioxide aggregate, Biodentine, and EndoSequence root repair material with and without 2% triple antibiotic powder: An in vitro study

BACKGROUND

Apical plug formation by mineral trioxide aggregate (MTA), Biodentine, and EndoSequence root repair material (RRM) is an excellent alternative technique to the conventional apexification procedure. Several antimicrobial agents have been incorporated in MTA and Biodentine to boost their antimicrobial efficacy. Considering the polymicrobial nature of root canal infection, a combination of potent antimicrobials like triple antibiotic powder (TAP) would be needed to address the diverse flora encountered. Calcium release is the consequential factor in the clinical excellence of these cements.

AIM

The aim of the study was to evaluate and compare the calcium released from the apical plugs formed by MTA, Biodentine, and EndoSequence RRM with and without incorporation of 2% TAP.

METHODS

Ninety single-rooted teeth were divided into (n = 15) Group A: MTA + 2% TAP, Group B: MTA, Group C: Biodentine + 2% TAP, Group D: Biodentine, Group E: EndoSequence RRM + 2% TAP, and Group F: EndoSequence RRM to form the 4 mm apical plugs. Each sample tooth was then immersed in 10 ml of deionized water. Evaluation of calcium release was done on days 7, 15, and 30 using an atomic absorption spectrophotometer. Data were analyzed using one-way analysis of variance, post hoc test, and unpaired t-test.

RESULTS

Calcium released was maximum for Group E compared to Group F (P < 0.05), maximum for Group C compared to Group D, and was maximum for Group A compared to Group B (P < 0.05) at days 7, 15 and 30.

CONCLUSION

Incorporation of 2% TAP resulted in increased calcium ions released from MTA, Biodentine, and EndoSequence RRM.