Dr William Ha BDSc GCResCommPhD (Endodontic Biomaterials) FPFA

Endodontic Biomaterials

What’s out there

What makes it be0er

What makes it worse

What should I use

MTA perforation repair

MTAs: What’s out there?

ProRoot MTA (DentsplySirona)

Copycat products: MTA Angelus, EndoCem MTA, Neo MTA Plus, MTA PlusBiodentine

“Pre-mixed” puEes (Bioceramics)

BC Putty (TotalFill BC Putty, iRoot BP Plus RRM, Endosequence BC Putty)

BC Fast set putty (TotalFill BC FS Putty, iRoot BP FS RRM, Endosequence BC FS Putty)

What is MTA?

• Great seal and low leakage;• Promotes hard tissue formation;• Hydroxyapatite, dentine and cementum can form against MTA, hence the seal

could improve with time;• Biocompatible; and• Relatively insoluble

80% Portland cement, 20% bismuth oxide (for radiopacity)

Parirokh 2010, Torabinejad 2010, Hwang 2009

Reaction

MTA’s pH over time

Gandolfi 2014

MTA promotes hard tissue barriers

Von Arx 2017, Caicedo 2006

Biocompatible

Wälivaara 2012

Success rates

MTA ≥ CaOH(Mente 2014, Zhu 2015)

MTA ≥ Formocresol ≥ FeSO4(Lin 2014)

MTA is the gold standard(Siew 2015)

MTA > SuperEBA > Amalgam(Von Arx 2007)

MTA ≥ CaOH(Lin 2014)

MTA is the gold standard in pulp regeneration (Kim 2018)

MTAs: What makes it better?

Use MTA with as little water as possible

• Reduces porosity and reduces solubility (Fridland 2003, Cavenago 2013)

• Increases the bond strength (Turker 2016)• Increases radiopacity (Cavenago 2013)• Increases compressive strength (Basturk

2015)

• However, extra water does help flow MTA into hard to reach areas

Dilatant properties (shear thickening)

• MTA (and Portland cement) increase in shear viscosity with applied stress

• If try to push large pieces of MTA down a canal, it’ll s?ck to the walls and refuse to move apically. Ie, use smaller pieces

Problems with CH dressings

~3 monthly dressings of CaOH:

-Increased overheads of revisits and

temporisation

-Increased risk of compromised seal and

hence re-infection

-Poor patient retention

-Porous calcific barrier. (Not a sealed barrier)

-Risk of insufficient calcific barrier leading to

GP extrusion

-No matter how many GP cones are placed,

cones have a taper and in a parallel-walled

tooth, there will be voids towards the apex

Why use apical barrier placement

Darcey 2016

MTA apical barrier placement methods

Castelluci 2003

Buchanan pluggers

PocketDentistry 2016

Cases

One of my own

Clinical steps for MTA apical barrier placement

Largest matching paperpoint Standard GP points (not greater tapered) Buchanan Plugger (KavoKerr) Machtou Plugger (DentsplySirona / VDW)

Keeps the canal dry Best Won’t’ dry Won’t dry Won’t dry

Fits the canal*depends on size and taper of canal

All ISO sizes,

02 taper is ideal

All ISO sizes,

02 taper is ideal

#0 (Yellow):

NiTi size ISO 25, taper 03,

SS ISO 75 taper 02

#1 (Blue)

NiTi size ISO 40, taper 03,

SS ISO 120 taper 02

#2 (Red)

NiTi size ISO 70, taper 03,

SS ISO 120 taper 02

0 (Yellow)

NiTi 0: ISO 40

1-2 (Red)

SS 1: ISO 50

SS 2: ISO 60

3-4 (Grey)

SS 3: ISO 80

SS 4: ISO 100

Risk of deforming instrument during placement

Easy crumbles with smaller sizes Rarely deforms Won’t deform Won’t deform

Ability to compact MTA to minimize voids

Cannot compact MTA Mild compaction Good compaction Good compaction

Can extrude MTA past the apex Will crumble before extruding Rarely extrudes Will easily extrude with excess force Will easily extrude with

excess force

My preference Use to push MTA to create first 1-3mm Use to push MTA create first 1-3mm Compact remaining 4-5 mm Compact remaining 4-5 mm

TotalFill BC Putty

• Calcium silicates in a waterless liquid• Easy to use as no mixing with water is required• It sets by absorbing water from the surrounding tissues

TotalFill BC Putty Fast Set (Flowable)

Nasseh 2015

TotalFill BC Pu-y Fast Set (Flowable)

Nasseh 2015

• Problems: claims that flowable putty and sealer are interchangeable.• BC sealer is more soluble than AH Plus*• The majority of the cavity is filled with BC flowable putty or BC sealer. • No clinical study supporting the use of either BC flowable putty or BC sealer as a root-

end filling

Nasseh 2015, Borges 2012

• Double mix method • Concept taken from prosthodon7c impressions• Line the walls and/or deepest to reach areas with thin amounts of BC

flowable pu=y• Pack the cavity with BC pu=y, pushing out excess flowable pu=y• May reduce hypothe7cal chance of voids• No evidence of advantage

MTAs: What makes it worse?

MTA, acidic environments and EDTA

• Infected and resorbing radicular tissues are acidic and can prevent MTA from setting• Consider dressing with CaOH or substantial NaOCl irrigation

• Etchant, conditioners, local anaesthetic, CHX and chelating irrigants (including EDTA) will retard the setting of MTA• Remove chelators with NaOCl and/or sterile water• Don’t use local anaesthetic or CHX as an irrigant• Cover MTA before etching or conditioning remaining tooth structure.

Ha 2015

Staining and MTA

Belobrov 2011

Colour changes

Mozynska 2017

General Trends with staining

• “White” MTA can stain just like “Grey” MTA

• Blood contamination leads to staining. I.e. ensure haemostasis prior to MTA placement. Or, reconsider treatment and material options.

• NaOCl residue leads to staining. I.e. wash out with saline/water

• Bismuth oxide leads to staining.• Ie. Consider alternative brands (NeoMTA Plus

or Biodentine or TotalFill Putty instead of ProRoot MTA or MTA Angelus)

Lenherr 2012, Camilleri 2015, Marconyak 2016, Felman 2013, Kohli 2015

Nosrat 2012

Blood and MTA

• Compressive strength and hardness reduces

• Less resistance to displacement

• Increased bacterial leakage

Nekoofar 2010, Vanderweele 2006, Montellano 2006

Haemosta(c agents for

apical surgery

Jensen 2006

Jensen 2006

Bleeding reduction

Jensen 2006

Jensen 2006 Jensen 2006

• Little bone formation, slight-severe foreign body and chronic inflammatory reactionBone wax at 12 weeks

• Very little bone formation. Increasing volume of fatty bone marrow. Moderate amount of phagocytes and foreign body giant cells.

Expasyl (and then washed out) at 12 weeks

• Almost complete osseous regeneration with woven bone. Bone marrow was mature and free of inflammatory reactions

Stasis (and then washed out) at 12 weeks

• Moderate amounts of new bone formation with remnants of foreign material, chronic inflammation and multi-nucleated cells.

Expasyl and Stasis (and then washed out) at 12 weeks

• Limited bone formation, foreign body material was reduced compared to 3 weeks. Most of the defects were occupied by chronic inflammatory tissue containing giant cells and phagocytes with Expasyl in the cytoplasm.

Expasyl (implanted) at 12 weeks

Medicament residue

• Medicament residue contains thickening agents which can inhibit the setting of MTA• Remove with EDTA followed by

hypochlorite followed by saline/water

Ha 2015

Storage of MTA

• Don’t keep it in the fridge as it will slow the setting and reduce the hardness of the MTA

• Keep it sealed. • Ie. Use jars or only use one-use-only packages no more

than once.

Saghiri 2012, Saghiri 2010, Ha 2014

MTAs: What should I use? CommercialBrands Manufacturer Cementtype

Radio-opacifier Additive Mixingsolution

Calciumsilicates

Calciumaluminates

Calciumsulphates

Calciumphosphates Phyllo-

silicates CaCl2MixedwithdistilledH2O

orPBS

Mixedwithaqueousgel

Premixedwithnonaqueous

liquid

iRoot®FS,Endosequence®BC

RRMFastSetPuttyTM,

TotalFill®

RRMFastSetPutty

Innovative

BioCeramixInc

(Vancouver,

Canada)

• • • ZrO2 •

MMMTATM Micro-Mega

(Besancon,France)

• • • Bi2O3 •

MTAAngelus®White,Channels

MTA

Angelus(Londrina,

Brazil)

• • Bi2O3 •

MTA*Caps Aceton(Mérignac,

France)

• • Bi2O3&

CaWO4

? ?

MTAPlusTM PrevestDenPro

(Jammu,India)

• • Bi2O3 •

MTARepairHP Angelus(Londrina,

Brazil)

• • CaWO4 •

NeoMTAPlusTM,NuSmile®

NeoMTA®

AvalonBiomed

(Bradenton,USA)

• • Ta2O5 •

OrthoMTA BioMTA(Seoul,

SouthKorea)

• • Bi2O3 •

ProRoot®MTA DentsplySirona

(York,USA)

• • • Bi2O3 •

RetroMTA BioMTA(Seoul,

SouthKorea)

• • Bi2O3 •

SavDen®MTA ChenselectCoLtd

(Taipei,Taiwan)

• • • Bi2O3&

ZnO

•

TechBioSealerApex Isasan(Rovello

Porro,Italy)

• • • - • • •

TechBioSealerRootEnd Isasan(Rovello

Porro,Italy)

• • • Bi2O3 • • •

TechBioSealerCapping Isasan(Rovello

Porro,Italy)

• • • - •

Trioxident VladMiVa

(Belgorod,Russia)

• • • (BiO)2CO3 •

Table 3: Commercial packable hygroscopic dental cement permanent restoratives (Part 2, I-T) ?Informationwaswithheldfrommanufacturerforcommerciallyconfidentialreasons.

Otheradditivesmaybepresentbutmaynotbeincludedhereifinformationwaswithheldbythemanufactureroriftherewasnootherproductfeatured

thesameadditive.

CommercialBrands Manufacturer CementtypeRadio-opacifier Additives Mixingsolution

Calciumsilicates

Calciumaluminates

Calciumsulphates

Calciumphosphates Phyllo-

silicates CaCl2MixedwithdistilledH2O

orPBS

Mixedwithaqueousgel

Premixedwithnonaqueous

liquid

BioAggregate®RCRFM,DiaRoot®BioAggregateRCRFM

InnovativeBioCeramixInc(Vancouver,Canada)

• • Ta2O5 •

Biodentine® Septodont(Saint-Maur-des-Fossés,France)

• ZrO2 • •

CEMCement® BioniqueDent(Tehran,Iran)

• • • • •

EndocemMTA Maruchi(Wonju-si,SouthKorea)

• • • Bi2O3 • •

EndocemZr Maruchi(Wonju-si,SouthKorea)

• • • ZrO2 • •

GreyMTAPlus® AvalonBiomed(Bradenton,USA)

• • Bi2O3 •

HarvardMTAUniversalHandMixHarvardMTAUniversalOptiCaps®,ZendoMTAUniversalHarvardMTAXRFastOptiCaps,ZendoMTAFirmFastHarvardMTAXRFlowEWTOptiCaps®HarvardMTAXRFlowFastOptiCaps®,ZendoFlowFastHarvardMTAXROptiCaps®,ZendoFirmFast

HarvardDentalInternational(Hoppegarten,Germany)

• • ? ? ?

iRoot®BP,EndoSequence®BCRRMTM(Putty&InjectableRCFRM),TotalFill®BCRRMTMPutty

InnovativeBioCeramixInc(Vancouver,Canada)

• • • ZrO2 •

Table2:Commercialpackablehygroscopicdentalcementpermanentrestoratives(Part1,A-I)?Informationwaswithheldfrommanufacturerforcommerciallyconfidentialreasons.Otheradditivesmaybepresentbutmaynotbeincludedhereifinformationwaswithheldbythemanufactureroriftherewasnootherproductfeaturedthesameadditive.

Ha 2017

ProRoot MTA vs MTA AngelusProRoot MTA MTA Angelus

Packaging One use only satchels (single use) Re-sealable jar (multi use)

Cost per use $391 for 4 satchels = $98 per use $123 for roughly 7 uses = $18 per use

Setting time Similar (171-175 min) Similar (140-284 min) (Ha 2017)

Clinical evidence Very extensive studies Less studies

Popularity in Australia 81.5% of endodontists 17.3% of endodontists (Ha 2016)

Seal Equal Equal (Lolayekar 2009)

Cytotoxicity Equal Equal (Koulaouzidou 2008)

Radiopacity Similar Similar (Ha 2017)

Solubility Similar Similar (Ha 2017)

Compressive strength Similar MPa Similar MPa (Ha 2017)

ProRoot MTA vs BiodentineProRoot MTA Biodentine

Packaging One use only satchels (single use) Single use, auto-mixed capsules (multi use)

Cost per use $391 for 4 satchels = $98 per use $92 for roughly 5 capsules = $19 per use

Setting time Longer (171-175 min) Shorter (45-85.7 min) (Ha 2017)

Clinical evidence Very extensive studies Less studies

Popularity in Australia 81.5% of endodontists 0% of endodontists (Ha 2016)

Radiopacity Higher Lower and fails standards (Ha 2017)

Solubility Less More (Kaup 2015)

Compressive strength Less More (Ha 2017)

ProRoot MTA vs BiodentineProRoot MTA Biodentine

Packaging One use only satchels (single use) Single use, auto-mixed capsules (multi use)

Cost per use $391 for 4 satchels = $98 per use $92 for roughly 5 capsules = $19 per use

Setting time Longer (171-175 min) Shorter (45-85.7 min) (Ha 2017)

Clinical evidence Very extensive studies Less studies

Popularity in Australia 81.5% of endodontists 0% of endodontists (Ha 2016)

Radiopacity Higher Lower and fails standards (Ha 2017)

Solubility Less More (Kaup 2015)

Compressive strength Less More (Ha 2017)

MTAs in Australia

Commercial Brands Cement type Radio-

opacifier H2O

Calcium silicates

Calcium aluminates

Calcium sulfates

Mixed with distilled H2O

or PBS

Mixed with aqueous gel

Biodentine® ✔ ZrO2 ✔

Endocem MTA ✔ ✔ ✔ Bi2O3 ✔

Endocem Zr ✔ ✔ ✔ ZrO2 ✔

MTA Angelus® ✔ ✔ Bi2O3 ✔

NeoMTA® ✔ ✔ Ta2O5 ✔

ProRoot® MTA ✔ ✔ ✔ Bi2O3 ✔

Ha 2017

MTAs in Australia

Ha 2017

Commercial Brands Cement type Radio-

opacifierRadiopacity

(mm Al)

Calcium silicates

Calcium aluminates

Calcium sulfates

Mixed with distilled H2O or

PBS

Mixed with aqueous gel

Biodentine® ✔ ZrO2 2.8

Endocem MTA ✔ ✔ ✔ Bi2O3 4.5

Endocem Zr ✔ ✔ ✔ ZrO2 4.2

MTA Angelus® ✔ ✔ Bi2O3 4.7

NeoMTA® ✔ ✔ Ta2O5 3.8

ProRoot® MTA ✔ ✔ ✔ Bi2O3 6.4

Total Fill BC RRM (Putty in a Jar) and Total Fill BC Fast Set RRM (Putty in a syringe)

Bioceramics in Australia

Commercial Brands Cement type Radio-opacifier H2O

Calcium silicates

Calcium aluminates

Calcium sulfates

Calcium phosphates

Mixed with distilled H2O

Premixed with non-aqueous

liquidTotalFill® BC RRMTM

Putty ✔ ✔ ✔ZrO2 & Ta2O5 ✔

TotalFill® RRM Fast Set Putty ✔ ✔ ✔ ZrO2 & Ta2O5 ✔

ProRoot® MTA✔ ✔ ✔

Bi2O3

✔

Ha 2017

ProRoot MTA vs TotalFill BC RRM and FS BC RRMProperty ProRoot MTA iRoot BP (Pu1y) iRoot FS (Syringe) Relevant papers

Cost per use $98 per use $91 $131

Radiopacity Good Good* Good* According to manufacturers

Setting time in blood Good Bad No studies Charland 2013

Cytotoxicity Good Good Not as good Ma 2011

1-3-week Skin implantation Good Best Worst Taha 2016

6-week skin implantation Good Good Worst Kahlil 2015

Bone implantation Good No studies No studies Rahimi 2012

Antimicrobial effects Some Some Some Damlar 2014

Marginal adaptation Good Good Worst Shokouhinejad 2014

Bacterial leakage Good Bad No studies Hirschberg 2013

Solubility Good No studies No studies Camilleri 2011

Dimensional change Good No studies No studies Camilleri 2011

2-year clinical performance (apical surgery) Good Good No studies Safi 2015

5-year clinical performance (apical surgery) Good No studies No studies Von Arx 2014

ProRoot MTA vs TotalFill BC RRM and FS BC RRMProperty ProRoot MTA iRoot BP (Putty) iRoot FS (Syringe) Relevant papers

Cost per use $98 per use $91 $131

Radiopacity Good Good* Good* According to manufacturers

Setting time in blood Good Bad No studies Charland 2013

Cytotoxicity Good Good Not as good Ma 2011

1-3-week Skin implantation Good Best Worst Taha 2016

6-week skin implantation Good Good Worst Kahlil 2015

Bone implantation Good No studies No studies Rahimi 2012

Antimicrobial effects Some Some Some Damlar 2014

Marginal adaptation Good Good Worst Shokouhinejad 2014

Bacterial leakage Good Bad No studies Hirschberg 2013

Solubility Good No studies No studies Camilleri 2011

Dimensional change Good No studies No studies Camilleri 2011

2-year clinical performance (apical surgery) Good Good No studies Safi 2015

5-year clinical performance (apical surgery) Good No studies No studies Von Arx 2014

My recommendations

MTA with bismuth oxide for anything outside the aesthetic zone

MTA without bismuth oxide for anything in the aesthetic zone

If Chuck Norris was an Endodontist• All teeth are tender

when Chuck taps them.

MTA for perforation repair

Classification and Prognosis

• Time• Fresh perforation: treated immediately, good prognosis• Old perforation: likely bacterial infection, questionable prognosis

• Size• Smaller than #20 instrument: easier to create seal, good prognosis• Larger than #20: significant damage, questionable prognosis

• Location• Coronal perforation: above biologic width, easy for the patient to

keep clean, good prognosis• Crestal perforation: within biologic width, hence a pocket can

form and is difficult to clean, questionable prognosis• Apical perforation: apical to the crestal bone, unreachable to

bacteria, good prognosisTsesis 2006

Classification and Prognosis

• Time• Fresh perforation: treated immediately, good prognosis• Old perforation: likely bacterial infection, questionable prognosis

• Size• Smaller than #20 instrument: easier to create seal, good prognosis• Larger than #20: significant damage, questionable prognosis

• Location• Coronal perforation: above biologic width, easy for the patient to

keep clean, good prognosis• Crestal perforation: within biologic width, hence a pocket can

form and is difficult to clean, questionable prognosis• Apical perforation: apical to the crestal bone, unreachable to

bacteria, good prognosisTsesis 2006

Perforation prevention

• Know your canal anatomy• Inspect the radiograph for depth and angulations• Know the axial inclination – tilted teeth, heavily restored

and crowns will throw you offPerforation recognition

• Radiographically mal-positioned file• “Apex” on apex locator far from working

length

More reliable signs

• Sudden pain during during WL determination

• Sudden haemorrhage• Burning pain or bad taste during NaOCl

irrigation

Less reliable, but signs are signs!

Torabinejad 2014

Initial treatment

• But if there is excessive bleeding or too much pus,

dress with CaOH or wait it out until the bleeding

stops

• Do not irrigate NaOCl into the perforation

Perforations should be

sealed immediately

before bacterial

invade the perforation

• Otherwise, dress with CaOH and

• try again another day

• refer on

But, you MUST have

found all the canals

first

• 73% after 3.4 years

• 86% after 2.75 yearsPrognosis studies:

Torabinejad 2014, Krupp 2013, Mente 2010

Initial treatment

Perforations should be sealed immediately before

bacterial invade the perforation

• But if there is excessive bleeding or too much pus, dress with CaOH or wait it out until the bleeding stops

• Do not irrigate NaOCl into the perforation

But, you MUST have found all the canals first

• Otherwise, dress with CaOH and • try again another day• refer on

Prognosis studies:

• 73% after 3.4 years• 86% after 2.75 years

Torabinejad 2014, Krupp 2013, Mente 2010

Initial treatment

Perforations should be sealed immediately before

bacterial invade the perforation

• But if there is excessive bleeding or too much pus, dress with CaOH or wait it out until the bleeding stops

• Do not irrigate NaOCl into the perforation

But, you MUST have found all the canals first

• Otherwise, dress with CaOH and • try again another day• refer on

Prognosis studies:

• 73% after 3.4 years• 86% after 2.75 years

Torabinejad 2014, Krupp 2013, Mente 2010

General Dentists Endodontists

Do you restore perforations? 39.8% 98.8%

What do you use to restore perforations?MTA 87.8% 97.5%

Biodentine 6.1% 0.0%

If radiolucency is present how do you manage the radiolucency?Will use a calcium hydroxide dressing first 58.7% 51.9%

Will restore the tooth immediately 32.6% 40.5%

Ha 2016

General Dentist Endodontist

Final irrigant for perforation repairSodium hypochlorite 35.8% 64.2%

EDTA 20.8% 19.8%

Chlorhexidine 11.3% 3.7%

What is your order of restoring perforations?Perforation first, obturate rest of tooth in subsequent

appointment 54.3% 44.3%

Perforation first, obturate rest of canals in the same appointment 32.6% 13.9%

Obturate canals first and then perforation in the same appointment 4.3% 27.8%

Ha 2016

General Dentist Endodontist

Final irrigant for perforation repairSodium hypochlorite 35.8% 64.2%

EDTA 20.8% 19.8%

Chlorhexidine 11.3% 3.7%

What is your order of restoring perforations?Perforation first, obturate rest of tooth in subsequent

appointment 54.3% 44.3%

Perforation first, obturate rest of canals in the same appointment 32.6% 13.9%

Obturate canals first and then perforation in the same appointment 4.3% 27.8%

Ha 2016

Repair perforation first

Mente 2014

Repair perforation first

• Advantages:• Once repaired, there will not be

any blood contamination affecting obturation of the canals

• Disadvantages• MTA can fall into the canals

making obturation difficult

Mente 2014

Repair perforation first• Tricks

• Magnification and illumination

• If bleeding is coming from the perforation, focus on preparing the canals. The bleeding will be reduced by the time you’ve finished preparing and dressing the canals.

• Place Cavit or small teflon tape or cotton pellets into the canal orifices then restore the perforation with MTA. MTA must not cover the orifice barriers.

• OR, place GP into each canal to stop MTA entering canals. These can easily be removed at the next visit as there is no sealer sticking the GP to the dentine

Mente 2014

Obturate canals first

da Silva 2012

Obturate canals first

• Advantages:• If the canals are already obturated, there’s

no risk of MTA entering the canals.

• Disadvantages• Blood from the perforation can enter the

canals resulting in leakage.• Sealer from canals may enter perforation

Obturate canals first

• Tricks• Magnification and illumination• Cover the perforation with a small

cotton pellet or Endofrost pellet to prevent contamination with sealer and the flow of blood out of the perforation

• The pellet may need to be soaked in NaOCl or a haemostatic agent.

Clinical steps for perforation repair

Revisit Revisit tooth and restore remaining canals and chamber

Temporize Temporize remainder of pulp chamber

Confirm Confirm placement with a radiograph. If an adequate barrier has not been created, rinse material out and repeat procedure

Apply Apply MTA into perforation site. Condense using small plugger, damp cotton pellets or paper points

Mix Mix MTA

Dry Dry the canal system with paper points and isolate the perforation

Rubber dam Using a rubber dam, debride the canals

Modified from ProRoot MTA’s Instructions for Use

My preferred steps for perforation repair

Focus on preparing other canals first – at least perform initial orifice opening and place medicament.

Cover the orifices

Dispense MTA into a dappens dish

Add a single droplet of water to a dappens dish

Pick up small ‘wet crumbs’ and compact it with endodontic pluggers into the perforation. As you compact pieces, you will notice it will become solid-like

Dry cotton pellets are good for cleaning excess amounts

Once it’s compacted, you can gently wash out the debris with saline

Questions?

• Any further questions,please feel welcome to email me at • w.ha@uq.edu.au

• Or add me on Facebook or LinkedIn• https://www.facebook.com/liamha• https://www.linkedin.com/in/drwilliamha/