SEMINAR ON

CONTENTS
Introduction
Composition
Types Gray & White
Mixing time
Setting time
Solubility
Biocompatibility
Radiopacity
p

!hysical !roperties
"d#antages $ %isad#antages
Indications $ Contra&Indication
Clinical "pplications
%irect pulp capping
"pical plug
Root end 'illing
Root per'orations
(urcation in#ol#ement
)
Resorpti#e de'ect
Comparison o' Ca*+,
)
& MT"
-eurotoxic .#aluation
Cytotoxic .#aluation
istologic .#aluation
Cellular Response to MT"
Conclusion
Re'erences
/
INTRODUCTION
Independent analysis suggests that the material o' Mineral Trioxide
"ggregate *MT", is identical to !ortland cement0 It is a ne1 remar2able
biocompatible material 1ith exciting clinical applications pioneered by
Dr. Mahmoud Torabinejad3 4oma 4inda 5ni#ersity3 in 677/0 Its 'irst
description in the dental literature in 677/3 by Lee & colleagues3 that
MT" has been used in both surgical and non surgical applications3
including root end 'illings3 direct pulp capping3 per'oration repairs in
roots or 'urcations and "pexi'ication0 In 67783 MT"9s appro#al by 50S
(ood and %rug "dministration led to 1idespread use0 MT" cement
pro#ides a better sealing ability o#er "malgam3 GIC3 IRM3 :+.3 and
Super .B"0 It9s an ideal material 'or use against bone 'or the o#ergro1th
o' cementum3 'ormation o' bone and 'acilitates the regeneration o' the
periodontal ligament 'ibers0
Chemical Composition
*Sar2ar et al ;+. )<<=,
MT" is a mechanical mixture o' / po1der ingredients>
!ortland cement *?=@,
Bismuth oxide *)<@,
A
Gypsum *=@,
Composition includes
Tricalcium silicate
%icalcium silicate
Tricalcium aluminate
Tetracalcium alumino'errite
Calcium sul'ate
Bismuth oxide
MT" po1der consists o' 'ine hydrophilic particles0 Tricalcium silicate3
Tricalcium aluminate3 Silica oxide and Tricalcium oxide are the maBor
components and 'e1 other mineral oxides are responsible 'or chemical
and physical properties o' MT"0 Bismuth oxide added 'or radio opacity0
Types of MTA:
There are t1o types o' MT"
Gray and White *Saeed "sgary et al ;+. )<<=,
Gray MTA White MTA
=
(e+ & !resent (e+ replaced 1ith Mg+
(e+ *Blac2, Mg+ *White,
hue matched the color o' teeth
Many o' the transitional element *Cr3 Mn3 (e3 Cu,3 1hich ha#e 'ree
d& electrons *electrons not in#ol#ed in bonding, exhibit strong colors
1hen in their oxide 'orms *because these d& electrons can be readily
excited by light in the #isible spectrum& that is the solid has a small band
gap,0 By contrast3
+xides o' the elements that do not ha#e excited electrons *Mg3 "l3 Si3!3 S3
C3 Ca3 Ti, tend to be colorless or 1hite *large band gap,3 1here as hea#ier
element Bismuth oxide has a yello1 oxide0
Miin! MTA
!repared immediately be'ore use0
Cept al1ays in closed containers or 'ree 'rom moisture0
!o1der> Water D /> 6
Glass or paper slab used 'or mixing 1ith plastic $ metal spatula0 It
reEuires moisture to set0 +nce the mix is dry sandy 'orm its ready 'or
application0
F
Settin! Time
MT" po1der consists o' 'ine hydrophilic particles0 ydration o'
MT" po1der results in a colloidal gel that solidi'ies to a hard structure in
G A hrs 1hich has a long setting time0 It is generally considered that a
potential root end 'illing material should set as soon as placed in root end
ca#ity 1ithout signi'icant shrin2age0 This condition 1ould allo1 the
dimensional stability o' the material a'ter placement and less time 'or an
unset material to be in contact 1ith #ital tissues0 In general3 Euic2er a
material sets more it shrin2s0 But MT" has long setting time 1ith less
shrin2age0
Sol"#ility
4ac2 o' solubility is an ideal characteristic o' MT" as a root end
'illing material0 %espite o' some ad#antages o' controlled long term
clinical studies3 because o' its long setting time3 the recommended
methods o' IS+ *F, or "%"S H /< *?,3 the test solubility o' MT" had to
be modi'ied0
$iocompati#ility
?
Clinically MT" is a biocompatible material 1ith good sealing
ability should generate little or no in'lammatory response in periradicular
tissues3 and encourage the 'ormation o' 'ibrous connecti#e tissue and $ or
cementum co#ering the entire root end0
Calcium & !hosphorus are the main ions present in this material3
1hich are the principle components o' dental tissues3 hence MT" pro#ed
to be biocompatible 1hen used in contact 1ith cells and tissues0
Ra%io Opacity
Bismuth oxide added 'or radio opacity and it is more radio opaEue
than its surrounding structures0
Shah et al in 677= sho1ed that the MT" is less radio opaEue than
CalIinol& *?07?, and more radio opaEue than G! *F06A,3 IRM *=0/<,3
Super .B" *=06F,3 %entin& *<0?<,0 More radio opaEue than G! & dentin
are #ery much distinguishable on radiographs0
8
p
&
MT" has a high p o' 6)0= similar to calcium hydroxide cement3
1hich pre#ents the bacterial gro1th and maintains the long lasting
bactericidal potential0 Induction o' hard tissue 'ormation $ barrier in
"pexi'ication procedures and root end 'illing 1ould minimiIe the
interaction bet1een material and host tissues
'hysical 'roperty
Compressi#e Strength is an important 'actor to be considered 1hen
a 'illing material is placed in a ca#ity that bears occlusal pressure0 "s a
root end 'illing material do not bear direct pressure3 the Compressi#e
strength o' this material is not as signi'icant as materials used to repair
de'ects in occlusal sur'aces0 Compressi#e strength in )6days ?< Mpa0
Mechanical 1ear3 an important 'actor in coronal restoration3 MT" is not
used as coronal restoration or not placed in 'unctional areas0 .rosion o'
restorati#e 'illing materials can occur either by acids generated by
bacteria3 acids present in 'ood or be#erages or by mechanical 1ear0
7
A%(anta!es
"ntimicrobial "cti#ity
Micro4ea2age
Cementoconducti#e
-on toxic
-on&mutagenic
Cell adherence & gro1th
"l2aline phosphotase$ osteocalcin
Interleu2in production
!eriodontal ligament attachment to cementum gro1th
%entinal bridge 'ormation
Disa%(anta!es
More di''icult to manipulate
4onger setting time

6<
In%ications
To preser#e pulp #itality
!re#ent pathological changes in the peri & radicular tissues
Mechanical pulp exposures
Carious pulp exposures 1ith immature apices
Contra)in%ications
Irre#ersible pulpitis
Clinical Applications
%irect !ulp Capping
"pical plug
Root .nd (illing
!er'oration Repair
(urcation in#ol#ment
Resorpti#e %e'ects
Immature apices *apexogenesis$ "pexi'ication,
Pulpotomy
66
(Beir !arabuca et al" dental traumatology #$$%&
(or !artial !ulpotomy or C#e2 !ulpotomy3 (ormocresol or
Calcium hydroxide based materials has been recommended as a choice o'
material to conser#e the healthy pulp0 %ue to its toxic $mutagenic
$carcinogenic e''ect3 MT" 1as tried 'or !ulpotomy or C#e2 !ulpotomy0
-e1 matrix 'ormation 1ith cellular inclusions and dentin&li2e barrier at
/
rd
12 that 'ound to be success'ul in preser#ing the pulpal #itality and
continued de#elopment o' tooth0
Direct '"lp Cappin!
In .xposed pulps3 to preser#e the pulpal #itality3 MT" is used as a
pulp capping material0 It pre#ents Bacterial lea2age 1ith a high le#el o'
biocompatibility0 MT" stimulates dentin bridge 'ormation adBacent to
dental pulp0 %entinogenesis o' MT" due to its sealing ability3
biocompatibility3 al2alinity and other properties associated 1ith this
material0
%entin bridge 'ormation that promotes healing0 It 'ormed a
complete barrier at exposure site 1ith 'ree o' in'lammations0
6)
Reparati#e dentin 'ormed by MT" does not originate 'rom se#erely
damaged odontoblasts3 but 'rom undi''erentiated cells that migrated 'rom
deep regions o' pulp3 1hich replaced the degenerated odontoblasts0
Reparati#e dentin 'ormed is regular and odontoblasts remain intact0
6/
Root En% *illin! (Torabinejad et al ( )**% & )**+&
MT" has the ability to pre#ent the irritants in the root canal to
extrude into periradicular tissues0 There is a less in'lammation3 1ith
cementum 'ormation and the regeneration o' periradicular tissues0
Apical 'l"!
MT" indicated 'or -ecrotic pulps and With open apices0

MT" can be used as a material o' choice 'ir apical plug and placed /&
Amm in the apical plug0
It creates a hard tissue 'ormation or as an apical plug to pre#ent the
extrusion o' 'illing material during obturation o' the canal 1ith open
apices0
Retro!ra%e *illin!
;ordan in 6778 MT" 1as tried as retro grade 'illing material0 It 1as
'ound that it
Inhibits dye penetration 1ith a
Good sealing ability0
(,icholson et al" BD- #$$$ )..(%&/ #00(#0..&
Root 'erforations
6A
Root per'orations can occur during root canal treatment3 post space
preparation or as a conseEuence o' internal resorption0 MT" can be
placed in the repair area as a reparati#e material0 Repair can be achie#ed
by Intracoronal $ .xtracoronal placement0
Lee etal3 677/3 'ound to ha#e less lea2age 1ith least o#er'illing
,ataa3 677?3 'ound that there 1as least bacterial lea2age than amalgam
Pitt'ord3 677=3 'ound that per'orated area had non&in'lamed surroundings
1ith cementum 'ormation o#er MT"0
*"rcation In(ol(ement
-o in'lammation 1ith no loss o' periodontal attachment
surrounding MT"0 MT" 'orms cementum and is continuous 1ith
cementum and also 'orms a hard tissue bridges0 MT" extruded into bony
de'ect cementum 'ormed around excess material and the periodontal
ligament has a separated cementum 'rom bone0
Resorpti(e Defects
MT" used 'or repairing the resorpti#e de'ects0 There 1ill not be
in'lammation surrounding it 1ith continuous cementum 'ormation0 It
'orms a hard tissue bridges also 1ith reduced ostoeclastic acti#ity0
6=
Comparison of Calci"m &y%roi%e + MTA
The hard tissue 'ormed3 as a calci'ic bridge 1ith MT" 1as less
period o' time compared 1ith Calcium ydroxide0 MT" 'orms a thic2
dentinal bridge in the pulps capped and the dentinal bridge 1ere
continuous 1ith dentin or dentinal tubules3 that are close to pulp 1ith no
tunnel de'ects0 The degree o' in'lammation is also less 1ith MT"
compared 1ith Calcium ydroxide0 MT" sets hard and pre#ents
recontamination and seals the path1ays o' communication bet1een root
canal system and the external sur'aces o' the teeth0
1alcium hydroxide2s high p

inhibits essential enIyme acti#ities>

JMetabolism3 gro1th and cellular di#ision0 " high p alters integrity o'
cytoplasmic membrane by disrupting organic components *proteins and
phospholipids, and inter'eres 1ith nutrient support0 o1e#er3 intestitial
'luid #ia cro1n $ apex3 necrotic tissue and normal cellular respiration can
partially dissol#e Ca *+,
)0
Resorption rate o' Calcium ydroxide paste
1ill #ary 1ith density and a rapid barrier 'ormation 1as related to both
Calcium ydroxide change rate and a narro1 initial apical 1idth0 Though
it has many ad#antages3 its disad3antages includes3
!ermeable to 'luids
Soluble in periapical tissues
6F
!oor #iscosity
-ot easy to apply in RC
Multiple step "pexi'ication 1ith
5npredictability o' apical closure
!atients 'ollo1 up
%elay in the completion o' treatment
MT4 is an
Insoluble matrix o' silica that maintains the integrity e#en in contact 1ith
1ater0 MT" is itsel' apical barrier material 1ith good sealing ability
properties and a high degree o' biocompatibility0 MT" has root&end
induction capacity by producing an apical hard tissue 'ormation 1ith
signi'icant greater consistency0 MT" is capable o' maintaining high p
during a long time and 'orms an apical barrier that creates a 'a#orable
en#ironment 'or cell di#ision and matrix 'ormation0 Its ad3antages o#er
calcium hydroxide are
+ne& #isit "pexi'ication0
Shortens the treatment time0
!t9s recall #isit is less0
6?
Ca,O&-
.
MTA
&ar% tiss"e formation -ot much Root&end induction
Calcific #ri%!e -ot Continuous Continuous 1ith
dentin
'erio% of time More
Tunnel de'ects
4ess
-o tunnel de'ects
$iocompati#ility 4o1 igh
De!ree of
inflammation
igh 4ess
Sets -ot hard ard
Seals the path/ays of
comm"nication
Better Good
p& igh igh
Sol"#ility !artially dissol#e 4ess soluble

!ermeable to 'luids impermeable
Soluble in periapical
tissues
insoluble
(iscosity !oor #iscosity good
68
Application -ot easy to apply in
RC
easy
Resorption Rate #ary 1ith density -o resorption
Apical #arrier formn0 Change rate $ initial
narro1 apical 1idth
4ess $ 1ide
Apeification step Multiple One
Apical clos"re 5npredictability Good
'atients follo/ "p More 4ess
Treatment %elay Shortens
Sealin! A#ility E(al"ation
Ste#e %aIey et al> 677<
4u2e Moloney et al> 677/
Seung ;ong 4ee et al> 677/
Mahmoud TorabineBad et al> 677/
Christopher Bates> 677F
;ohn % Welch et al> 677F
Roberto olland> 6777
Roberto olland> )<<6
BargholI> )<<=
Sar2ar et al> )<<=
1ea2a!e E(al"ation
M TorabineBad et al> 677=
!itt (ord et al> 677=
67
!itt (ord et al> 677F
-a2ata et al> 6778
M TorabineBad et al> 6777
Toh et al> )<</
BargholI> )<<=
Colceriu> )<<=
Ne"rotoic E(al"ation
(5ahshid 4srari" -67 #*())&/ ,o3 #$$8.&
.''ects o' root end 'illing materials on neurons in primary cortical
cell cultures0 -eurons are highly sensiti#e system to study toxicity0
-eurons are highly susceptible to 'ree&radical&mediated inBury3 metabolic
inBury and en#ironmental toxins0 They are much more sensiti#e than
'ibroblasts0 Root end materials may absorb by the body3 causing systemic
toxicity0 There is also possibility that these materials may cause local
neurotoxicity 1hen they are placed near the local ner#es and ner#e
endings0
Cytotoic E(al"ation
(arl !eiser et al " -67 #0 (%&/ May #$$$&
)<
MT" is less toxic compared to other root end 'illing materials0
In )A hrs3 at lo1 concentrations the seEuence o' toxicity 1as
Super .B" K MT" $ "malgam
4'ter #9( hrs: at high concentrations: the se;uence o' toxicity <as
Super .B" K "malgam K MT"
&istolo!ic E(al"ation
(Torabinejad et al -67: #)()#&: Dec )**%.&
MT" as a root end 'illing material does not pre#ent regeneration o'
dental and osseous tissues and induced cementoblasts to produce matrix
'or cementum 'ormation o#er the MT"0 The presence o' cementum
'ormation o#er the MT" in canals obturated 1ith gutta percha either 1ith
or 1ith out a root canal sealer indicated the superior sealing ability o'
MT" and its biocompatibility 1ith periradicular tissues0 There 1as an
enhanced cementogenesis3 due to its sealing ability or by acti#ation o'
cementoblasts to produce cementum 'ormation or by the release o'
substances that acti#ate the cementoblasts to laid do1n a matrix 'or
cementogenesis0 %ue to its al2aline p3 the 'ormation o' 'ibrous
connecti#e tissue that 1as as calci'ied as the post surgical time inter#al
)6
increased 1ith no in'lammatory cells in periradicular tissues and reduced
bacterial lea2age0
(Torabinejad et al -67: #8(9&: 4pr )**+&
MT" has the ability to stimulate the cyto2ine release 'rom bone
cells and promotes hard tissue 'ormation rather than being inert or being
irritant as a root end 'illing material0 "
Thic2 layer cementum o#er MT" 1as continuous 1ith dentin incremental
lines & cell inclusions0 Some o' the cementum sur'ace 1as characteriIed
by 'iber insertion3 mimic2ing sharpeys 'ibers0 The -e1 cementum 1as
attached to the original cementum0 T1o possibilities 'or the source o' the
ne1 cementum either deri#ed 'rom the remaining periodontal ligament or
'rom ingro1n connecti#e tissue 'rom bone0 I' the cementum had gro1n
lateral aspects3 incremental lines run diagonally 'rom the cementum
rather than parallel0
Cell"lar response to MTA
=7ng Tiong !oh et al" -67 #9(.&/ 4ug: )**.>
1ytoines3 are soluble substances that are capable o' acti#ating
other cells are released by #ariety o' cells0 They are lo1 molecular 1t
glycoproteins secreted as a result o' cellular stimulation and are
extremely potent0 They interact 1ith cell receptors3 leading to a change in
))
synthesis o' cellular R-" and !rotein and there'ore they are coordinating
in bone metabolism0
MT" compared 1ith IRM3 the tissue response 1as characteriIed by
mar2ed rounding o' cells and depletion o' cell numbers indicating IRM is
toxic0
MT" at 6 & / days3 the cells obser#ed 1ere normal morphology3
gro1ing in intimate contact 1ith cement and a ne1 hard tissue 'ormation
by measuring the release o' cyto2ines 'rom the bone cells0 Small amounts
o' I4&6a3 I4&6b3 I4&F produced by cells in contact 1ith MT"0 The maBor
Cyto2ines include I4s and colony stimulating 'actor0 Most I4s cause T
and$or B cell proli'eration3 and can stimulate by mature +steoblast0
Cyto2ines in#ol#ed in bone 'ormation di#ided in t1o groups> 'irst
includes stimulate bone cell proli'eration and inhibit mature osteoblasts
and second includes stimulate precursor proli'eration and mature
osteoblasts acti#ity0
Concl"sion
Than2s to %r TorabineBad 'or remar2able material 'or use in
endodontics0 MT" 1ith high biocompatibility3 al2alinity3 sealing ability
pro#ided hermetic seal0 MT" is !anacea 'or pulpal $ periodontal diseases0
)/
)A