Mineral Trioxide Aggregate: A Comprehensive Review

Jasmine Kaur *¹, Kudrat Kang ², Baljit Kaur ³, Kavneet Pannu⁴, Gagandeep singh Waraich⁵

1. BDS, Genesis Institute of Dental Sciences and Research, Ferozepur, Punjab, India.

2. BDS, Dr. Harvansh Singh Judge Institute of Dental Sciences and Hospital, Chandigarh, India.

3. BDS, Genesis Institute of Dental Sciences and Research, Ferozepur, Punjab, India

4. BDS, National Dental college and Hospital, Derabassi, Punjab, India.

5. BDS, National Dental college and Hospital, Derabassi, Punjab, India

*Correspondence to: Jasmine Kaur, BDS, Genesis Institute of Dental Sciences and Research, Ferozepur, Punjab, India.

Copyright

© 2023 Jasmine Kaur. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Received: 17 June 2023

Published: 01 July 2023

Abstract

MTA was created in the 1990s at Loma Linda University by Torabinejad as a root end filling substance. In 1998, the US Federal Drug Administration approved it. Since. The innovative material known as Mineral Trioxide Aggregate (MTA) has a variety of exciting clinical applications. MTA has the potential to rank among the materials used in dentistry today that are most versatile. Its good physical properties, ability to encourage tissue regeneration, and beneficial pulp response are just a few of MTA's noteworthy attributes. In addition to a discussion of MTA's availability, composition, manipulation, setting reaction, and features, this article also discusses some of its clinical applications in dentistry.

Keywords: MTA, Mineral Trioxide Aggregate, Application of MTA, Dentistry

Introduction

As a root end filler substance, MTA was created in the 1990s at Loma Linda University by Torabinejad. In 1998, it was approved by the US Federal Drug Administration. Since its approval, MTA has been commercially accessible under the brand Pro Root MTA. Today, two MTA products with comparable chemical and physical features, the Grey and White MTA, are also offered. [1,2]

Since Lee & colleagues' initial description of MTA in the dental literature, both surgical and nonsurgical uses, such as root end filling, direct pulp capping, pulpotomy, perforation repair, furcation repair, apexification, and obturation, have made use of it. This material shows promise due to its ability to seal, its propensity to set up in the presence of blood, its biocompatibility, and its capacity to trigger the creation of hard tissue.[3]

In addition to a discussion of MTA's availability, composition, manipulation, setting reaction, and features, this article also discusses some of its clinical applications in dentistry.
MTA: Tricalcium silicate, tricalcium aluminate, tricalcium oxide, and silicate oxide are all present in trace amounts in MTA's powder form. Additionally, it has trace amounts of other mineral oxides, which alter its chemical and physical composition. Hydration of the powder creates a colloidal gel with a pH of 12.5, which solidifies to create a strong, impenetrable, hard solid barrier in three to four hours.[4-6]

MTA comprises Portland cement (75%), Bismuth Ox-ide (20%), and gypsum (5%). Portland cement is a mixture of Tricalcium silicate (CaO)₃SiO₂, Dicalcium silicate (CaO)₂SiO₂, Tricalcium aluminate (CaO)₃Al₂O₃, and Tetracalcium  aluminoferrite  (CaO)₄Al₂O₃Fe₂O₃.[7]

Type of MTA:

MTA is offered in two distinct colours: white MTA and grey MTA. Depending on the amount of FeO (black), MgO (white), and Al2O3, the MTA will have a particular colour. Grey MTA turns white when FeO is absent, and vice versa.[8,9]

Grey MTA has more compressive strength than White MTA. For instance, MTA Fillapex (Angelus, Londrina, Brazil) resin is present in some MTA formulations, which are utilised as root canal sealing cements. The addition of the resin has the goal of modifying or improving material flow, dentine bonding, and setting time, which will reduce micro-leakage. [8,9]

NeoMTA (Nusmile, Huston, USA) is a completely unreinforced MTA. It mostly is utilised in pulpotomies and improves the MTA's cost-effectiveness. [10-12]

Manipulation of MTA: Powder water ratio for MTA should be 3:1, according to Sluyk et al. (1998)[13], Torabinejad et al. (1999)[14], and Schmitt et al. (2001)[15]. To achieve a putty-like paste consistency, mixing can be done on a paper pad or on a glass slab using a plastic or metal spatula. To stop the mix from drying out, cover it with moistened cotton pellets. The duration of the mixing process is crucial because if it is too long, the mixture will get dehydrated. After mixing, it is recommended covering the mixture with moistened cotton pellets since, if left exposed, it would suffer dehydration and turn into a sandy mixture [14]. Using an ultrasonic condensation device, a plugger, a paper point, a specially made carrier, or a messing gun, MTA can be placed in the desired spot.

Aminoshariae et al. (2003) compared the hand condensation and ultrasonic methods and discovered that the hand condensation approach had a better MTA adaption to the walls with fewer cavities than the ultrasonic method.[16]

After mixing, MTA has a pH of 10.2, which rises to 12.5 after three hours of setting and is essentially identical to calcium hydroxide.[2] In comparison to other materials, MTA requires more time to set. Torabinejad and colleagues claim that the grey MTA sets in roughly 2 hours and 45 minutes (+5 minutes), while Islam et al claim that the grey MTA sets in 2 hours and 55 minutes and the white MTA sets in 2 hours and 20 minutes. One of the primary issues with MTA is its prolonged setting process. Numerous researchers have proposed that adding accelerators like calcium chloride (CaCl2) and sodium phosphate dibasic (Na2HPO4) may shorten the setting time. [17,18]

Properties of MTA: MTA has a compressive strength of approximately 40 MPa at 24 hours and 67.3 MPa at 21 days. Additionally, according to the research, grey MTA has greater compressive strength than white MTA.[1]

There are no indicators of solubility in the set MTA. However, if more water is added when mixing the MTA, this could lead to more solubility. Set MTA releases calcium hydroxide (CaOH₂) when it is in contact with water. Its ability to promote cementogenesis may be due to CaOH₂. If the mixture is exposed to an acidic environment throughout the setting reaction, this has no effect on the setting.[19]

MTA has been proven to be superior to the other conventional root-end filling materials [20]. MTA has great sealing ability, which may be because MTA expands during the setting reaction [22]. It has been recommended that a moistened cotton pellet be placed in touch with MTA before to placing the permanent restoration because the sealing capacity of MTA is strengthened in the presence of a damp environment due to the setting expansion. According to Valois et al. (2004)[23], a 4-mm thickness of MTA is adequate to ensure a satisfactory seal.

MTA is neither mutagenic and less cytotoxic than Super EBA and IRM.[25] MTA is biocompatible and well tolerated by the tissues.[26] MTA was used by Arens and Torabinejad (1996)[27] to treat osseous repair and furcation holes. Osteoblast-like cell response to MTA was examined by Pelliccioni et al. in 2004[28], and the results revealed that MTA had positive interactions with periapical and periradicular tissues.

MTA may have an impact on the collagen release pathway in cells. According to Koh et al. (2001)[29], MTA has the ability to create interleukin and also provides bone cells with a physiologically active substrate.

Clinical Application of MTA

Pulp capping: Due to its superior tissue compatibility, MTA has been considered as a viable treatment for pulp capping with reversible pulpitis. On the basis of tissue reaction and the quantity of dentine bridge created, it is significantly superior than frequently utilised calcium hydroxide-based cements. With MTA, there isn't any tissue necrosis or inflammation like there is with calcium hydroxide. With MTA, dentin bridge formation following pulp capping was noticed at around one week, and within three months of capping, it rapidly increased in length and thickness. The dentin bridge, in contrast, showed numerous tunnel flaws and less consistent pulp capping with calcium hydroxide.[30]

Root-End Filling of Immature Permanent Teeth: When normal endodontic treatment is not an option, endodontic surgery followed by root-end filling may occasionally be required. In this procedure, the root apex is surgically exposed, the root is cut, and the apical foramen is sealed completely using a substance that is nontoxic, non resorbable, dimensionally stable, and radio opaque.  Teeth treated with MTA showed noticeably decreased inflammation, greater cementum production, and periradicular tissue regeneration.[2]

Obturation of the Canal: When the next permanent tooth is missing, mineral trioxide aggregate might be utilized to seal the root canal of a retained primary tooth. O'Sullivan and Hartwell reported one such application on a main mandibular second molar that was still in place. Since it is predicted that Mineral Trioxide Aggregate would be absorbed slowly, if at all, this procedure is not advised for the obturation of primary teeth that are anticipated to exfoliate.[31]

Perforation Repair: Iatrogenic root perforation or a significant expansion of internal resorption that allows connection between the root canal and the periodontium are both possible causes. With significant hemorrhage, there may be severe inflammation and the production of granulation tissue. Such a communication needs to be repaired using a material that is biocompatible, can endure moisture without dissolving, and has strong sealing capabilities. When compared to amalgam and IRM, Lee and colleagues discovered that MTA had much less leakage and a lower propensity for overfilling or underfilling.

Regenerative Endodontic therapy: Regenerative endodontic therapy is a process aimed to replace diseased pulp tissue with healthy tissue, hence restoring the pulp-dentin structure's natural function. Ideal conditions can result in ongoing root development and hard tissue deposition on the dentinal wall following regenerative endodontic therapy.[31]

Pulpotomy: For deciduous teeth, formocresol has traditionally been employed as a pulpotomy agent. However, this substance has come under fire for its mutagenic, cytotoxic, and tissue-irritating effects. MTA was examined and shown to be an excellent substance with minimal toxic effects, enhanced tissue-regenerating abilities, and positive clinical outcomes.[33-35] When compared to hydroxyapatite and formocresol, MTA was determined to be a better option as pulpotomy material in a histology investigation by Jabbarifar et al [36].

Advantage and Disadvantage of MTA:

MTA is a great biocompatible material, according to the current literature evaluation. MTA has many fascinating clinical uses since it possesses several essential characteristics of the ideal dental material. Clinicians need to research MTA more to take advantage of its beneficial qualities. The long setting time, high cost, and risk for discoloration of MTA are some of its known downsides. When MTA comes into touch with tissue synthetic fluid, hydroxyapatite crystals start to grow on top of it.[32]

Conclusion

MTA is a superb material that possesses a plethora of desirable traits. The tooth becomes less resistant to breakage and more unpredictable after apexification with calcium hydroxide. MTA apical plug implantation performed in a single visit has proven to be an effective substitute in these circumstances. Additionally, MTA is successful in creating thicker bridge dents with fewer flaws and adverse effects. Clinicians must research MTA in order to uncover its therapeutic benefits.

References

1. Torabinejad M, Hong CU, McDonald F, Pitt Ford TR. Physical and chemical properties of a new rootend filling material. J Endod 1995 Jul;21(7):349-53.

2. Torabinejad M, Hong CU, Pitt Ford TR, Kettering JD. Antibacterial effects of some root end filling materials. J Endod 1995 Aug; 21(8):403-6.

3. Sarita Singh,*, Jyoti Mandlik, Kalpana kanyal, Rajendra Danle, Abhijit Jadhav. Mineral Trioxide Aggregate-A Review. Indian Journal of Conservative and Endodontics, January-March,2017;2(1):16-21

4. Lee SJ, Monsef M, Torabinejad M. Sealing ability of a mineral trioxide aggregate for repair of lateral root perforations. J Endod 1993;19:541-4.

5.Schwartz RS, Mauger M, Clement DJ, Walker WA 3rd. Mineral trioxide aggregate: A new material for endodontics. J Am Dent Assoc 1999;130:967-75.

6. Srinivasan V, Waterhouse P, Whitworth J. Mineral trioxide aggregate in paediatric dentistry. Int J Pediatr Dent 2009;19:34-47.

7. Kadali N, Alla RK, Vineeth G, Ramaraju AV, Suresh Sajjan MC, Raju RV. Mineral Trioxide Aggregate: An overview of composition, properties and clinical applications. Int J Dent Mater 2020;2(1): 11-18.DOI:http://dx.doi.org/10.37983/IJDM.2020.21031.

8. Parirokh M, Torabinejad M.Mineral trioxide ag-gregate: a comprehensive literature review-Part I: chemical, physical, and antibacterial properties. J Endod. 2010; 36: 16-27.

9. Kratchman  SI.Perforation  repair  and  one-step apexification  procedures.  Dent  Clin  North  Am. 2004; 48: 291-307

10. Camilleri J. Staining potential of Neo MTA Plus, MTA Plus, and biodentine used for pulpotomy pro-cedures. J Endod. 2015; 41: 1139-1145.

11. Camilleri J. Hydration characteristics of Biodentine and Theracal used as pulp capping materials. Dent Mater. 2014; 30: 709-715.

12. Khan J, El-Housseiny A, Alamoudi N. Mineral Triox-ide Aggregate Use in Pediatric Dentistry: A Litera-ture Review. J Oral Hyg Health. 2016; 4: 209.

13. Sluyk SR, Moon PC, Hartwell GR. Evaluation of setting properties and retention characteristics of Mineral Trioxide Aggregate when used as a furcation perforation repair material. J Endod 1998;24:768-71. 

14. Torabinejad M, Chivian N. Clinical applications of mineral trioxide aggregate. J Endod 1999;25:197-205. 

15. Schmitt D, Lee J, Bogen G. Multifaceted use of ProRoot MTA root canal repair material. Pediatr Dent 2001;23:326-30.

16. Aminoshariae A, Hartwell GR, Moon PC. Placement of mineral trioxide aggregate using two different techniques. J Endod 2003;29:679-82.

17. Islam I, Chang HK, YapAUJ. X-Ray diffraction analysis of mineral trioxide aggregate and Portland cement. Int Endod J, 2006; 39: 220–225.

18. Kogan P, He J, Glickman GN, Watanabe I. The effects of various additives on setting properties of MTA. J Endod, 2006; 32: 569–572.

19. Budig CG, Eleazer PD. In vitro comparison of the setting of dry ProRoot MTA by moisture absorbed through the root. J Endod 2008;34:712-4.

20. Bates CF, Carnes DL, del Rio CE. Longitudinal sealing ability of mineral trioxide aggregate as a root-end filling material. J Endod 1996;22:575-8. 

21. Shipper G, Grossman ES, Botha AJ, Cleaton-Jones PE. Marginal adaptation of mineral trioxide aggregate (MTA) compared with amalgam as a root-end filling material: A low vacuum (LV) versus high vacuum (HV) SEM study. Int Endod J 2004;37:325-36. 

22. Torabinejad M, Smith PW, Kettering JD, Pitt Ford TR. Comparative investigation of marginal adaptation of Mineral Trioxide aggregate and other commonly used root-end filling materials. J Endod 1995;21:295-9. 

23. Valois CR, Costa ED Jr. Influence of the thickness of mineral trioxide aggregate on sealing ability of root-end filling in vitro. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2004;97:108-11.

24. Kettering JD, Torabinejad M. Investigation of mutagenicity of mineral trioxide aggregate and other commonly used root-end filling materials. J Endod 1995;21:537-42. 

25. Sumer M, Muglali M, Bodrumlu E, Guvenic T. Reactions of connective tissue to amalgam, intermediate restorative material, mineral trioxide aggregate mixed with chlorhexidine. J Endod 2006;32:1094-6. 

26. Arens DE, Torabinejad M. Repair of furcal perforations with mineral trioxide aggregate: Two case reports. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1996;82:84-8. 

27. Pelliccioni GA, Ciapetti G, Cenni E, Granchi D, Nanni M, Pagani S, et al. Evaluation of osteoblast-like cell response to Proroot MTA (mineral trioxide aggregate) cement. J. Mater Sci Mater Med 2004;15:167-73. 

28. Koh ET, Ford TR, Kariyawasam SP, Chen NN, Torabinejad M. Prophylactic treatment of dens evaginatus using mineral trioxide aggregate. J Endod 2001;27:540-2.

29. Hedge R, Battepati.Clinical applications of MTA: report of four cases. Int J ClinPediat Dent. 2010; 3(1):43-50.

30. O’Sullivan S.M. and G.R. Hartwell. Obturation of a retained primary mandibular second molar using mineral trioxide aggregate: a case report. J Endod, 2001;27: 703–705.

31. Benny Budhwar, “Mineral Trioxide Aggregate: A Literature Review” MAR Dental Sciences Volume 6 Issue 3

32. Macwan C, Deshpande A. Mineral trioxide aggregate (MTA) in dentistry: A review of literature. J Oral Res Rev 2014;6:71-4

33. Eidelman E, Holan G, Fuks AB. Mineral trioxide aggregate vsformacresol in pulpotomized primary molars: a preliminary report. Pediatr Dent, 23: 15–18, 2001.

34. Farsi N, Alamoudi N, Balso K, Mushayt A. Success of mineral trioxide aggregate in pulpotomized primary molars. J ClinPediatr Dent, 29: 307–311, 2005.

35. Ebrahim J, Mohammad RS, Neda A. Histopathologic Responses of Dog’s Dental Pulp to Mineral Trioxide Aggregate, Bio Active Glass, Formocresol, Hydroxyapatite. Dental Research Journal, 4: 83–87, 2007

36. Arora A, Pareek A, Danish Prabhakar, Liners, Bases and Varnishes: A Review, International Journal of Health Sciences (2021)5 (S1)1-9