Which material used in one-visit pulpectomy:
a. MTA *** (Mineral Trioxide Aggregate)
b. Ca (OH) 2 + CMCP
C. Formocresol
D. Zn oxide.
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The mineral trioxide aggregate (MTA) has been studied extensively as a material to seal the communication pathways between the root canal system and the periradicular tissues.
MTA and its properties have been evaluated extensively in vitro and in vivo in the literature, but there are still no studies or long-term results. In the short term this material is very promising for certain indications.
MTA is a powder that consists of fine hydrophilic particles that set in the presence of moisture. The hydration of the powder generates a colloidal gel that forms a hard structure. The MTA material is mainly composed of particles of tricalcium silicate, tricalcium aluminate, dicalcium silicate, tetracalcium ferric aluminate, bismuth oxide, and dihydrated calcium sulfate.
The setting time of the material is between three and four hours. MTA is a very alkaline cement, with a pH of 12.5. This pH is very similar to that of Calcium Hydroxide, and may enable antibacterial effects. The material has a low compressive force, which means that it cannot be used in functional areas. Other characteristics of MTA are its low solubility and a radiopacity greater than dentin. In addition, MTA has demonstrated good biocompatibility, excellent sealing to microfiltration, good marginal adaptation and seems to reduce bacterial microfiltration6.
MTA Preparation:
The MTA is marketed by Maillefer-Dentsply (Ballaigues, Switzerland) under the name ProRoot MTA® and is presented in hermetically sealed envelopes containing the MTA powder. The ProRoot attaches some pipettes with sterile water. The MTA must be prepared immediately before use. The powder is mixed with sterile water in a 3: 1 ratio on a glass tile to give a consistency that is manageable. Some authors use anesthetic solution instead of sterile water8. Once the material has taken a suitable consistency, it can be applied using a small conveyor or amalgam holder. The MTA requires for its setting the presence of moisture. It can be condensed by means of a damp cotton ball, a paper tip or a small attacker. After opening an envelope of MTA, the unused powder can be stored in a sealed container, for future use in other treatments. The main drawback of the MTA is its difficult handling, so it requires practice.
----------------------------
The mineral trioxide aggregate (MTA) has been studied extensively as a material to seal the communication pathways between the root canal system and the periradicular tissues.
MTA and its properties have been evaluated extensively in vitro and in vivo in the literature, but there are still no studies or long-term results. In the short term this material is very promising for certain indications.
MTA is a powder that consists of fine hydrophilic particles that set in the presence of moisture. The hydration of the powder generates a colloidal gel that forms a hard structure. The MTA material is mainly composed of particles of tricalcium silicate, tricalcium aluminate, dicalcium silicate, tetracalcium ferric aluminate, bismuth oxide, and dihydrated calcium sulfate.
The setting time of the material is between three and four hours. MTA is a very alkaline cement, with a pH of 12.5. This pH is very similar to that of Calcium Hydroxide, and may enable antibacterial effects. The material has a low compressive force, which means that it cannot be used in functional areas. Other characteristics of MTA are its low solubility and a radiopacity greater than dentin. In addition, MTA has demonstrated good biocompatibility, excellent sealing to microfiltration, good marginal adaptation and seems to reduce bacterial microfiltration6.
MTA Preparation:
The MTA is marketed by Maillefer-Dentsply (Ballaigues, Switzerland) under the name ProRoot MTA® and is presented in hermetically sealed envelopes containing the MTA powder. The ProRoot attaches some pipettes with sterile water. The MTA must be prepared immediately before use. The powder is mixed with sterile water in a 3: 1 ratio on a glass tile to give a consistency that is manageable. Some authors use anesthetic solution instead of sterile water8. Once the material has taken a suitable consistency, it can be applied using a small conveyor or amalgam holder. The MTA requires for its setting the presence of moisture. It can be condensed by means of a damp cotton ball, a paper tip or a small attacker. After opening an envelope of MTA, the unused powder can be stored in a sealed container, for future use in other treatments. The main drawback of the MTA is its difficult handling, so it requires practice.
Clinical indications of MTA:
Pulp coatings and pulpotomies:
The pulp and pulpotomy are only indicated on teeth with immature apices when the pulp is exposed, and its vitality is to be maintained. These treatments are contraindicated if there is irreversible pulpitis symptoms. MTA has been shown to stimulate the formation of dentin bridges adjacent to the dental pulp. This dentin formation may be due to the sealability, alkalinity and biocompatibility or possibly to other properties of the MTA.
Apical barrier with MTA: apicoformations:
The creation of an apical barrier with MTA is indicated in teeth with necrotic pulps and open apices. Several materials (calcium hydroxide, tricalcium phosphate, collagen, calcium phosphate, etc.) have previously been used as an apical barrier, so that gutta percha can condense, and thus prevent a possible extrusion of material during the treatment of teeth with the apex open.
After a first appointment in which we perform the cleaning and conformation of the duct, we place calcium hydroxide for 7 to 14 days to help with disinfection and cleaning.
On the second date, we remove the calcium hydroxide, and dry the duct with paper tips. If we consider it necessary, a matrix can be placed, to avoid an over-sealing of the MTA. For this, biocompatible materials can be used such as: absorbable collagen (CollaCote, Calcitek, Plainsboro, NJ, USA), hydroxyapatite, calcium hydroxide powder, etc.
The MTA is transported to the duct by means of an amalgam holder, and gently condenses to create about 3-4 mm of apical barrier. The barrier is checked radiographically. If we do not achieve the expected result, it is advisable to wash with sterile water to remove the MTA, and try the procedure again. If the apical barrier of MTA seems appropriate, we place a damp cotton ball in the duct next to the MTA, and seal the opening with a provisional seal.
In a third appointment, the temporary one is removed (at least three or four hours later), the rest of the duct is sealed with gutta-percha or composite and the permanent filling material is placed.
MTA can, therefore, be used as an apical barrier in teeth with immature apices and necrotic pulp. This material stimulates the formation of hard tissue without causing inflammation in the area adjacent to the apex of the immature roots.
Root Perforations:
Root perforations can occur during the preparation and conformation of root canals, in the placement of posts, in retreatments, and also as a result of a perforating internal reabsorption to the periradicular tissues.
Perforation repair can be attempted surgically or non-surgically. The factors that affect the prognosis are the size of the perforation, the damage to the bone and ligament, the time between perforation and repair, the ability to get a tight seal, and if the perforation is supraosseous or infraosseous. Many materials have been used for the repair of perforations such as gutta-percha, silver amalgam, glass ionomer, composite, Super EBA® (Harry J. Bosworth, USA), Cavit® (ESPE, Seefeld, Germany) or calcium hydroxide.
When sealing a perforation, the extrusion of material to the periradicular tissues must be avoided. An internal matrix provides us with biocompatibility and control of the restorative material, avoiding the over-or sub-ablation of the MTA in the perforation. Biocompatible materials such as absorbable collagen (CollaCote, Calcitek, Plainsboro, NJ, USA), hydroxyapatite, calcium hydroxide powder, etc. can be used for this purpose. The matrix will be used in perforations larger than one millimeter. The clinical procedure depends on the location of the perforation:
- In the case of a perforation in the furca:
First, we clean the area with NaOCl or saline. The ducts and drilling are located. First, the instrumentation and sealing are carried out, and then the perforation is repaired; Or you can repair the perforation first and then instrument and seal the ducts.
If necessary, an internal matrix is placed before the MTA. Mix the MTA with sterile water and place it in the hole with a small amalgam holder. After the repair, a damp cotton ball is placed next to the MTA, and the opening is sealed with a temporary seal. Then, the provisional is removed (at least three or four hours later) at the next appointment to put the permanent filling material.
- In the case of a lateral perforation (stripping) in the middle third of the root:
The instrumentation and filling of the ducts is always carried out first, and then the perforation is repaired in the manner described above.
- In the case of a perforation in the apical third of the root:
The MTA should be placed to form an apical plug of three to five millimeters. It is placed with a very small amalgam holder. Then a damp cotton ball is placed, and the opening is sealed with a temporary. At the next appointment (at least three or four hours later) the rest of the duct is sealed with gutta-percha and sealing cement. At the end, a permanent sealing material is placed.
- In the repair of a perforating internal reabsorption:
First we proceed to the cleaning and conformation of the duct. NaOCl is used during the preparation, and calcium hydroxide between appointments, to help us clean the defect while reducing bleeding. In the following appointment, we remove the calcium hydroxide, and fill the duct with gutta-percha and cement, except for the defect, in which we place the MTA. To set the MTA, we put a damp cotton ball on top. At the next appointment, we remove the cotton ball, and proceed to permanent sealing.
To achieve a good seal, it is always important to check the hardness of the MTA before the permanent sealing material is placed.
Several in vitro and in vivo studies have shown that MTA is a suitable material for the repair of lateral or furcal root perforations.
Retro seals in endodontic surgery:
The performance of an apicectomy and a retro cavity, and the subsequent sealing thereof with an apical filling material is indicated to achieve a good apical seal, and thus prevent the penetration of irritants from the duct to the periradicular tissues, and vice versa. Several materials (amalgam, IRM, Super EBA ...) have been used as retro sealing materials. Through in vivo studies, MTA has been shown to be associated with less inflammation of adjacent tissues, cement formation adjacent to MTA, and good regeneration of periradicular tissues.
Other indications:
MTA can also be used as a coronary barrier material, after duct filling, and before internal bleaching. Avoid using the MTA on the tooth above the gingival margin, because it can cause discoloration of the tooth. A white MTA formula is currently being studied to avoid this type of situation.
Another indication may be the repair of vertical fractures. Vertical fracture repair usually has an unfavorable evolution. The prognosis of a treatment with MTA in a case with vertical fracture, in which there is direct communication with the oral cavity for a prolonged period of time, is unpredictable. This is because the MTA dissolves in an acidic pH. Despite this, clinical cases have been described in the vertical fracture repair literature.
Conclusions:
MTA and its properties have been widely valued in numerous studies in the literature, but there are still no long-term studies or results.
In the short term, this material is very promising. It has been shown to be a biocompatible material, with adequate sealing capacity and low solubility, with antimicrobial effects, and that induces the formation of hard tissue and at the same time facilitates the regeneration of the periodontal ligament.
All these treatments should be evaluated with periodic controls of at least six months to a year, or longer.
To perform many of the treatments with this material it is advisable to use magnification, either by means of a dental microscope, endoscope, or magnifying glasses to help in the visualization of the field.
In recent research it has been seen that the composition of MTA and Portland cement is similar. Some in vivo studies have found very similar biological results and reactions between the two materials. Portland cement can become a very promising material for Endodontics in the near future.
It is also important to assess the prognosis of the tooth and its importance for the patient before starting a procedure that will not have a predictable result. Another aspect to evaluate is the possibility of referring to an endodontist the most difficult patients or cases that escape our possibilities, time, or specialty.
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