MTA and Biodentine: the active biosilicaates.pptx

MTA & Biodentine : the active biosilicate materials

1. GOOD MORNING

2. THE ACTIVE BIOSILICATE MATERIALS INDUCING APEXIFICATION: TWO DIFFERENT CASE REPORTS Presented By: Akash Kr. Baranwal (PGT, 2 nd yr) Guide : Prof. (Dr .) Mohan Paul MDS (Cal) Post Graduate Teacher Dept. Of Conservative Dentistry & Endodontics Dr. R. Ahmed Dental College & Hosp., Kolkata MTA AND BIODENTINE –

3. INTRODUCTION

4. INTRODUCTION The maxillary central incisor is the most frequently affected tooth in both dentitions. 2 Injuries to young permanent teeth are a frequent finding following orofacial trauma in children and adolescents. (12) Luxation injuries appear to be associated with the greatest risk of incomplete root development with between 15 and 59% of teeth losing their vitality. (2)

5. Thin root canal walls susceptible to fracture The majority of these incidents occurs before root formation is complete and may result in pulpal inflammation or necrosis. 12 Such endodontic complications may lead to - cessation of root development compromised apical closure. 12

6. INTRODUCTION In the past, treatment of these teeth aimed at creating a barrier with hard tissue at the end of the root, a procedure known as apexification . 8 It is defined by the American Association of Endodontics (AAE) as ‘a method of inducing a calcified apical barrier or the continued apical development of an incompletely formed root in which the pulp is necrotic‘. 8 Traditionally, apexification procedures have consisted of multiple and long-term applications of calcium hydroxide [Ca(OH)2] in order to create an apical barrier before obturation of the root canals. 7

7. INTRODUCTION Because these procedures might alter the mechanical properties of dentin and make these teeth more susceptible to root fracture, developing artificial apical barriers using bioactive mineral trioxide aggregate (MTA) has been suggested before obturation of the rest of the root canal. 7 More recently, a new bioactive cement, Biodentine ™ ( Septodont , St. Maur -des- Fossés , France), was launched on the dental market as a dentin substitute. It shares both its indications and mode of action with calcium hydroxide, but does not have its drawbacks. 14

8. Currently, these bioactive silicate cements have gradually become the material of choice for the repair of all types of dentinal defects creating communication pathways between the root-canal system and the periodontal ligament ( Bogen and Kuttler 2009, Parirokh and Torabinejad 2010).

9. HISTORY Before 1966, immature teeth with necrotic pulps were often extracted and the clinical management of a “blunderbuss” canal usually required a surgical approach for the placement of an apical seal into the often fragile and flaring apex. 7 Granath (1959) – 1 st to describe the use of Ca(OH)2 for apical closure. Frank (1966) – popularized a technique in which a paste of Ca(OH)2 and CMCP was placed inside canal and it required the replacement with this paste every 3 months until the barrier was formed. Cvek (1992) – noted that immature teeth weakened by filling the root canals by Ca(OH)2 dressing and subsequent gutta percha obturation.

10. HISTORY Torabinejad M (1993) - first described MTA in the dental scientific literature U.S. Food and Drug Administration (1998) - given approval to MTA for endodontic use. Torabinejad M & Chiviari (1999) – indicated the use of MTA for apical filling of teeth with open apices & apexification therapy. Machtou (2009) – added Biodentine’s ability to be used as dentin substitute and it’s safely used for each indication where dentine is damaged. Bronnec (2009), Laurent et al (2008), Valyi (2008) – have validated experimentally the efficacy of BioDentine as a dentin substitute

11. This paper illustrate about two different cases showing the management of traumatized immature teeth with wide open apices and significant periapical changes using MTA & Biodentine respectively.

12. CASE REPORT

13. CASE 1: A 18-year-old female patient reported to Dept. of Conservative Dentistry & Endodontics in Dr. R. Ahmed Dental College & Hospital Kolkata, with chief complaint of pain in upper front teeth. On clinical examination, patient had discolored maxillary left centr al incisor and she gave history of trauma 9 years back. Presence of tenderness on vertical percussion in both left central and lateral incisor.

14. CONTD… Radiographic evaluation revealed an open apex with a wide canal and marked periapical radiolucency in relation to left central incisor. (Fig. 1) On vitality test – both central & lateral incisor gave – ve response than adjacent contralateral teeth. Non-contributory past medical history. Diagnosis – Clinical & radiographic examination indicated pulp necrosis with acute exacerbation of chronic apical periodontitis .

15. Fig. 1 - PRE-OPERATIVE RADIOGRAPH

16. CONTD… 1 ST APPOINTMENT – a conventional endodontic access was prepared with endo access bur from palatal approach with 21. Initial working length was predicted by using #110 K file. Then radiograph was made and working length was confirmed (Fig. 2). Gentle instrumentation of the canal was done with #110 K-file. Irrigation with 2.5% sodium hypochlorite was done with side vented tips (Mac’s Eye Probe) throughout the shaping and cleaning procedures. And final irrigation with normal saline. Canal was dried with absorbent points and a Ca(OH)2 dressing ( Apexical , Ivoclar Vivadent ) was placed (Fig. 3). Access was sealed with Cavit -G and patient was recalled after two weeks.

17. Fig. 2 – WORKING LENGTH DETERMINATION Fig. 3 - INTRACANAL DRESSING OF Ca(OH)2

18. CONTD… 2 ND APPOINTMENT – Two weeks later, tooth was again isolated and canal thoroughly irrigated with saline to remove any remnants of calcium hydroxide and 17% liquid EDTA to remove smear layer. Final irrigation was done with 2% chlorhexidine . After drying canal, Biograft -HT (MI Ref. Ltd., South Yorkshire, UK) was used for the artificial barrier formation. The powder mixed with saline was placed and packed against the bone and allowed to be pushed beyond the apex into the bony space formed due to the periapical lesion in order to achieve a matrix for the placement of MTA. Then, white MTA- Angelus (Angelus, Londrina, PR, Brazil) powder was mixed with distilled water (according to manufacturer’s instructions) which was then carried into canal with the help of sterilized amalgam carrier and packed to form an apical plug of approximately 5 mm (Fig. 4)

19. CONTD… Over this moist cotton pellet was placed and access cavity was sealed. 3 rd APPOINTMENT - After 24 hrs, cotton pellet was removed and canal was thoroughly dried with multiple absorbent points. Plugger was used to check the consistency of MTA and to examine if it was completely set. Subsequently, backfill was performed using warmed gutta-percha (E & Q Plus, META Biomed Co. Ltd., Korea) and the access cavity sealed. Postobturation radiograph taken (Fig. 5) Subsequently, monthly follow-up radiographs were taken. (Fig. 6 & Fig. 7)

20. Fig. 4 - MTA APICAL PLUG Fig. 5 - POST OBURATION RADIOGRAPH

21. Fig. 6 - 3-MONTH FOLLOW-UP RADIOGRAPH

22. CASE 2: A 28-year-old male patient reported to Dept. of Conservative Dentistry & Endodontics in Dr. R. Ahmed Dental College & Hospital Kolkata, with chief complaint of pain in upper front teeth. On clinical examination, patient had coronally fractured, discolored & luxated maxillary right centr al incisors with wide open cavity while left C. I. was found slightly discolored. History of trauma at the age of 8 years. Presence of tenderness on vertical percussion in both the central incisors.

23. Radiographic examination showed open apices with large blunderbuss canals (apically divergent walls) and marked periapical radiolucency in relation to both central incisors. (Fig. 1) On vitality test – both central incisors gave – ve response than adjacent contralateral teeth. Non-contributory past medical history. Diagnosis – Clinical & radiographic examination indicated pulp necrosis with acute exacerbation of chronic apical periodontitis .

24. Fig. 1 - PRE-OPERATIVE RADIOGRAPH

25. 1 ST APPOINTMENT – a conventional endodontic access was prepared with endo access bur from palatal approach in #21 while tooth #11 had direct access to the apical portion. Initial working length was predicted by using #140 K- file and was confirmed with radiograph (Fig. 2). Gentle instrumentation was done with #140 K-file. Irrigation with 2.5% sodium hypochlorite was done using Mac’s Eye Probe throughout the shaping and cleaning procedures. And final irrigation with normal saline. Canal was dried with absorbent points and an intracanal medicament of Ca(OH)2 ( Apexical , Ivoclar Vivadent ) was placed. (Fig. 3). Access was sealed with Cavit -G and patient was recalled after two week.

26. Fig. 2 - WORKING LENGTH DETERMINATION Fig. 3 - APEXICAL INTRACANAL MEDICAMENT

27. 2 ND APPOINTMENT – Two week later, teeth isolated with rubber dam and canal thoroughly irrigated with saline to remove any remnants of calcium hydroxide and 17% liquid EDTA to remove smear layer. Final irrigation was done with 2% chlorhexidine . After drying canals with paper points, Biograft -HT (MI Ref. Ltd., South Yorkshire, UK) was used for the artificial barrier formation. Then, Biodentine ( Septodont , St. Maur -des- Fossés , France) powder & liquid was mixed in an amalgamator for 30 sec. (according to manufacturer’s instructions) and then incrementally placed into the canals with sterilized amalgam carrier to form an apical plug of approximately 5 mm (Fig. 4).

28. At the same visit, after one hour, plugger was used to check the setting & consistency of biodentine . Subsequently, tooth #21 was backfilled using flowable cold filling system (Gutta Flow 2, Coltene Whaledent , Switzerland) and the access cavity was sealed. (Fig. 5) Tooth #11 was restored with fiberpost cemented with dual cured resin ( Paracore , Coltene Whaledent ) followed by core build-up with same material. (Fig. 5) Finally, both the incisors were restored with porcelain fused to metal crowns. Subsequently, monthly follow-up radiographs were taken. (Fig. 6 )

29. Fig. 4 - BIODENTINE APICAL PLUG Fig. 5 - POST-OPERATIVE RADIOGRAPH

30. Fig. 6 - 3-MONTH FOLLOW-UP RADIOGRAPH

31. PRE-OPERATIVE PHOTOGRAPH POST-OPERATIVE PHOTOGRAPH

32. DISCUSSION

33. The treatment of teeth with incomplete root development is aimed at sealing a sizeable communication between the root canal system and the periapical tissues. 7 Without creating a calcified apical barrier through apexification , obtaining an apical seal with gutta-percha and root canal sealer as obturation materials cannot offer a good long-term prognosis for such teeth. 7 Many materials have been used to form apical barriers such as: 5 - Ca(OH)2 paste, Ca(OH)2 powder; mixed with CMCP, Tricalcium phosphate , Collagen calcium phosphate , Osteogenic protein-1, Bone growth factor, Decalcified allogenic bone matrix & Barium hydroxide , True bovine bone ceramics and dentine chips as plugs and MTA.

34. Apexification with use of Ca(OH)2 has shown a great success. The mean time for the formation of apical barrier being 12-19 months. (Dominguez rayes et al, 2005) 1 Ca(OH)2 therapy has some inherent disadvantages - 3 delayed treatment & variability of treatment time (increasing risk of root fracture) unpredictability of apical closure, difficulty in patient follow-up, and Also, tissue altering and dissolving effects.9

35. Advantages of bioactive silicate materials like MTA & Biodentine – High biocompatibility Hydrophilic Radiopaque Highly alkaline pH ( Bacteriostatic ) Excellent sealing ability (low marginal leakage) Low solubility

36. Mechanism of Action : Forms CH that releases calcium ions for cell attachment and proliferation Creates an antibacterial environment by its alkaline pH Modulates cytokines production Encourage differentiation and migration of hard tissue producing cells and Forms HA (or carbonated apatite) on the surface and provides a biological seal

37. MTA BIODENTINE COMPOSITION POWDER-   Tri-calcium Silicate Di-calcium Silicate Tri-calcium aluminate Tetra-calcium aluminoferrite Calcium sulphate Bismuth oxide LIQUID- Sterile Water POWDER- Tri-calcium Silicate Di-calcium Silicate Calcium Carbonate Iron Oxide Zirconium Oxide LIQUID- Calcium chloride Hydrosoluble polymer MTA Vs BIODENTINE

38. MTA BIODENTINE P:L RATIO 3:1 1 capsule powder : 5 drops of liquid MANIPULATION In amalgamator for 30 sec. Manually on glass slab with mixing spatula SETTING TIME (Minutes) Initial – 70 Final - 175 Initial – 6 Final - 10-12 DENSITY (g/cm3) 1.88 2.26 POROSITY (%) 22.6 6.8 COMPRESSIVE STRENGTH ( MPa ) - (1 hr.) 7.5 (24 hr.) 131.5 (1 hr.) 241.1 (24 hr.) MECHANICAL RESISTANCE Lower Higher MTA Vs BIODENTINE

39. In this case reports – INCLUSION CRITERIA EXCLUSION CRITERIA HISTORY OF TRAUMA WITH PRESENCE OR ABSENCE OF FRACTURE REPLANTED AVULSED TOOTH NECROTIC IMMATURE INCISORS EXTERNAL ROOT RESORPTION OPEN APEX WITH WIDE CANAL PERIAPICAL RADIOLUCENCY PRESENCE OF DISCOLORATION

40. The clinical cases reported here demonstrate that when MTA and Biodentine are used as apical plug in necrotic teeth with immature apices, the canal can be effectively sealed. These bioactive cements represent a primary monoblock . Appetite like interfacial deposits form during the maturation of cements and fill the gap resulting in seal of canal. ( Torabinejad M et al, JOE 1999) Apical barrier of 5mm is significantly stronger and shows less leakage than 2 mm barrier. (Matt GD et al, JOE 2004). Because of delayed setting and initial low mechanical resistance of MTA, in case 1, backfilling was performed after 24 hrs. While in case 2, backfilling was done after 1 hr because of faster setting and high mechanical strength of Biodintine .

41. On clinical follow-ups, the patients were completely asymptomatic. Radiography follow-ups in the reported cases showed healing of the periapical lesion and new hard tissue formation in the apical area of affected teeth. Finally, the 6-months follow-up radiographs in both the cases show complete root end closure with the evidence of calcific barrier fomation .

42. CONCLUSION The novel approach of apexification using bioactive silicates materials lies in thorough cleaning of root canal followed by apical seal with these materials that favors regeneration. Because of the lack of data regarding the predictability and healing outcomes of regenerative endodontic therapy compared to these bioactive cements, the use of MTA & Biodentine is currently recommended as our first choice for the treatment of teeth with pulp necrosis and immature apices. Although validated experimentally, the efficacy of Biodentine as a dentin substitute is yet to be clinically proven for each of its therapeutic indications.

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