The Open Dentistry Journal




ISSN: 1874-2106 ― Volume 13, 2019

Sealing Ability of MTA Used in Perforation Repair of Permanent Teeth; Literature Review



Kusai Baroudi*, Samah Samir
Department of Restorative Dental Sciences, Al-Farabi College, Riyadh, Saudi Arabia.

Abstract

There were several materials used to seal different types of perforation defects. MTA is one of these restorative materials that is considered the most effective, biocompatible, non-toxic, and non-irritant; promote bone healing and cementum regeneration. The objective of this article was to review and summarize the sealing ability of MTA compared with the other materials used for sealing different types of root perforations of permanent teeth. A literature search was conducted using Medline, accessed via the National Library of Medicine Pub Med from 2005 to 2015 searching for articles related to sealing ability of MTA. This study found that factors affecting prognosis are the size, site of the perforation and time elapsed as well as the repair material. MTA is an important filling material to be used for sealing different types of perforations when perforated sites sealed immediately with MTA.

Keywords: Micro leakage, MTA, Perforation, Sealing ability.


Article Information


Identifiers and Pagination:

Year: 2016
Volume: 10
First Page: 278
Last Page: 286
Publisher Id: TODENTJ-10-278
DOI: 10.2174/1874210601610010278

Article History:

Received Date: 12/5/2015
Revision Received Date: 30/3/2016
Acceptance Date: 26/04/2016
Electronic publication date: 09/06/2016
Collection year: 2016

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open-access license: This is an open access article licensed under the terms of the Creative Commons Attribution-Non-Commercial 4.0 International Public License (CC BY-NC 4.0) (https://creativecommons.org/licenses/by-nc/4.0/legalcode), which permits unrestricted, non-commercial use, distribution and reproduction in any medium, provided the work is properly cited.


* Address correspondence to these authors at the Department of Restorative Dental Sciences Al-Farabi College, Riyadh 11691, P.O.Box 85184, Kingdom of Saudi Arabia; Tel: 00966-12273151; Fax: +966 1 2324580; E-mail: d_kusai@yahoo.co.uk




1. INTRODUCTION

Perforations of the pulp chamber floor or the root can occur accidentally during root canal treatment or restorative procedures [1Tsesis I, Fuss Z. Diagnosis and treatment of accidental root perforations. Endod Top 2006; 13: 95-107.]. Such perforations resulted in the formation of granulation tissue as a chronic inflammatory reaction of the periodontium that either led to irreversible loss of attachment or tooth [2Al-Daafas A, Al-Nazhan S. Histological evaluation of contaminated furcal perforation in dogs’ teeth repaired by MTA with or without internal matrix. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2007; 103(3): e92-9.
[http://dx.doi.org/10.1016/j.tripleo.2006.09.007] [PMID: 17208469]
]. The treatment of these perforations is either surgically or nonsurgically depends on the case [3Roda RS. Root perforation repair: surgical and nonsurgical management. Pract Proced Aesthet Dent 2001; 13(6): 467-72.
[PMID: 11544819]
]. A good prognosis obtained when the problem is correctly diagnosed and treated with a suitable material of sealing ability and biocompatibility while it will be questionable when the perforation is at the level of radicular furcation [1Tsesis I, Fuss Z. Diagnosis and treatment of accidental root perforations. Endod Top 2006; 13: 95-107.]. Prognosis of perforation depends on the time of contamination, location and size of the lesion [4Fuss Z, Trope M. Root perforations: classification and treatment choices based on prognostic factors. Endod Dent Traumatol 1996; 12(6): 255-64.
[http://dx.doi.org/10.1111/j.1600-9657.1996.tb00524.x] [PMID: 9206372]
].

Many materials used for managing perforations such as: glass ionomer and resin modified glass ionomer, zinc oxide–eugenol, amalgam, calcium hydroxide and composite resin [1Tsesis I, Fuss Z. Diagnosis and treatment of accidental root perforations. Endod Top 2006; 13: 95-107.-4Fuss Z, Trope M. Root perforations: classification and treatment choices based on prognostic factors. Endod Dent Traumatol 1996; 12(6): 255-64.
[http://dx.doi.org/10.1111/j.1600-9657.1996.tb00524.x] [PMID: 9206372]
].The material of choice for treating radicular perforations should be nontoxic, non-absorbable, radiopaque, bacteriostatic, bactericidal and provide a seal against micro leakage [5De-Deus G, Reis C, Brandão C, Fidel S, Fidel RA. The ability of Portland cement, MTA, and MTA Bio to prevent through-and-through fluid movement in repaired furcal perforations. J Endod 2007; 33(11): 1374-7.
[http://dx.doi.org/10.1016/j.joen.2007.07.024] [PMID: 17963967]
].

In 1998 the U.S. Food and Drug Administration approved MTA (Mineral trioxide aggregate)[6Schwartz RS, Mauger M, Clement DJ, Walker WA III. Mineral trioxide aggregate: a new material for endodontics. J Am Dent Assoc 1999; 130(7): 967-75.
[http://dx.doi.org/10.14219/jada.archive.1999.0337] [PMID: 10422400]
]. This material showed good results in treating cases of lateral radicular and furcal perforation, root-end surgery, direct pulpal coverage, apexification and radicular resorption [7Torabinejad M, Chivian N. Clinical applications of mineral trioxide aggregate. J Endod 1999; 25(3): 197-205.
[http://dx.doi.org/10.1016/S0099-2399(99)80142-3] [PMID: 10321187]
]. This is because of its characteristics as biocompatibility, low induction of inflammation, solubility, creating a seal between the pulp chamber and periodontal tissues and repair capacity [8Roberts HW, Toth JM, Berzins DW, Charlton DG. Mineral trioxide aggregate material use in endodontic treatment: a review of the literature. Dent Mater 2008; 24(2): 149-64.
[http://dx.doi.org/10.1016/j.dental.2007.04.007] [PMID: 17586038]
]. It is the only material which allows the overgrowth of cementum, bone formation and facilitates the regeneration of the periodontal ligament [9Torabinejad M, Hong CU, Lee SJ, Monsef M, Pitt Ford TR. Investigation of mineral trioxide aggregate for root-end filling in dogs. J Endod 1995; 21(12): 603-8.
[http://dx.doi.org/10.1016/S0099-2399(06)81112-X] [PMID: 8596081]
-12Abedi HR, Ingle JI. Mineral trioxide aggregate: a review of a new cement. J Calif Dent Assoc 1995; 23(12): 36-9.
[PMID: 9052026]
].

Composition and Physical Properties of MTA

MTA is a fine hydrophilic powder [13Camilleri J, Montesin FE, Brady K, Sweeney R, Curtis RV, Ford TR. The constitution of mineral trioxide aggregate. Dent Mater 2005; 21(4): 297-303.
[http://dx.doi.org/10.1016/j.dental.2004.05.010] [PMID: 15766576]
]. It is available in two types grey and white MTA. These two types are similar but have slight differences in chemical composition [14Dammaschke T, Gerth HU, Züchner H, Schäfer E. Chemical and physical surface and bulk material characterization of white ProRoot MTA and two Portland cements. Dent Mater 2005; 21(8): 731-8.
[http://dx.doi.org/10.1016/j.dental.2005.01.019] [PMID: 15935463]
], the presence of the trace minerals gives the dark grey appearance of grey MTA[15Lee YL, Lee BS, Lin FH, Yun Lin A, Lan WH, Lin CP. Effects of physiological environments on the hydration behavior of mineral trioxide aggregate. Biomaterials 2004; 25(5): 787-93.
[http://dx.doi.org/10.1016/S0142-9612(03)00591-X] [PMID: 14609667]
]. Clinical studies found that these two forms of MTA can respond differently as the white preparation resulting in less tooth discoloration in anterior teeth [10Torabinejad M, Pitt Ford TR, McKendry DJ, Abedi HR, Miller DA, Kariyawasam SP. Histologic assessment of mineral trioxide aggregate as a root-end filling in monkeys. J Endod 1997; 23(4): 225-8.
[http://dx.doi.org/10.1016/S0099-2399(97)80051-9] [PMID: 9594770]
]. Also White MTA has less levels of tetra calcium aluminoferrite than the grey preparation which is responsible for discoloration [16Ferris DM, Baumgartner JC. Perforation repair comparing two types of mineral trioxide aggregate. J Endod 2004; 30(6): 422-4.
[http://dx.doi.org/10.1097/00004770-200406000-00011] [PMID: 15167471]
].

MTA sets in the presence of fluids such as the blood. A colloidal mixture results by mixing sterile water and powder preparation forms which set to form hardened cement. Initial setting obtained approximately three to four hours [17Torabinejad M, Hong CU, McDonald F, Pitt Ford TR. Physical and chemical properties of a new root-end filling material. J Endod 1995; 21(7): 349-53.
[http://dx.doi.org/10.1016/S0099-2399(06)80967-2] [PMID: 7499973]
]. MTA slowly releases calcium hydroxide at least 3 months after initial mixing and placement [18Fridland M, Rosado R. MTA solubility: a long term study. J Endod 2005; 31(5): 376-9.
[http://dx.doi.org/10.1097/01.DON.0000140566.97319.3e] [PMID: 15851933]
]. Heithersay suggested that calcium hydroxide released by MTA can activate the pyrophosphatase enzyme that interacts with precapillary sphincters to reduce local blood flow and induce hard tissue formation [19Rafter M. Apexification: a review. Dent Traumatol 2005; 21(1): 1-8.
[http://dx.doi.org/10.1111/j.1600-9657.2004.00284.x] [PMID: 15660748]
, 20Heithersay GS. Calcium hydroxide in the treatment of pulpless teeth with associated pathology. J Br Endod Soc 1975; 8(2): 74-93.
[http://dx.doi.org/10.1111/j.1365-2591.1975.tb01000.x] [PMID: 1058189]
].

Initial pH of MTA is 10.2 that increase during setting reaction to a pH of 12.5 due to the calcium hydroxide release from the setting material [13Camilleri J, Montesin FE, Brady K, Sweeney R, Curtis RV, Ford TR. The constitution of mineral trioxide aggregate. Dent Mater 2005; 21(4): 297-303.
[http://dx.doi.org/10.1016/j.dental.2004.05.010] [PMID: 15766576]
]. The therapeutic mechanism of MTA is due to the high pH of the setting material [21Duarte MA, Demarchi AC, Yamashita JC, Kuga MC, Fraga SdeC. pH and calcium ion release of 2 root-end filling materials. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2003; 95(3): 345-7.
[http://dx.doi.org/10.1067/moe.2003.12] [PMID: 12627108]
].

Micro Leakage Properties of MTA

The successful endodontic treatment is highly dependent on minimizing micro-leakage in root canal [2Al-Daafas A, Al-Nazhan S. Histological evaluation of contaminated furcal perforation in dogs’ teeth repaired by MTA with or without internal matrix. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2007; 103(3): e92-9.
[http://dx.doi.org/10.1016/j.tripleo.2006.09.007] [PMID: 17208469]
]. Many researches evaluated the sealing ability of MTA in perforation repair and root end filling and this was obtained through an In vitro dye, fluid filtration or an In vitro bacterial penetration method [22Khoury J. Endodontic essay. Aust Endod J 2011; 37(1): 6-11.
[http://dx.doi.org/10.1111/j.1747-4477.2011.00305.x] [PMID: 21418408]
].

The sealing ability of dental materials can be evaluated by Dye penetration techniques [23Camps J, Pashley D. Reliability of the dye penetration studies. J Endod 2003; 29(9): 592-4.
[http://dx.doi.org/10.1097/00004770-200309000-00012] [PMID: 14503834]
, 24Torabinejad M, Rastegar AF, Kettering JD, Pitt Ford TR. Bacterial leakage of mineral trioxide aggregate as a root-end filling material. J Endod 1995; 21(3): 109-12.
[http://dx.doi.org/10.1016/S0099-2399(06)80433-4] [PMID: 7561650]
]. These techniques were used due to their ease of use without sophisticated materials. Also they were commonly used because of the many disadvantages of dye leakage methods such as: (a) Molecular size of dye particles is smaller than bacteria. (b) Most studies measure penetration in one plane rather than total leakage. (c) Studies showed static interaction rather than the dynamic interaction with periradicular tissues. Dye-extraction has the most reliable results as it measures all of the dye taken up in the root [24Torabinejad M, Rastegar AF, Kettering JD, Pitt Ford TR. Bacterial leakage of mineral trioxide aggregate as a root-end filling material. J Endod 1995; 21(3): 109-12.
[http://dx.doi.org/10.1016/S0099-2399(06)80433-4] [PMID: 7561650]
].

Therefore the aim of this paper divided into two parts:

Part I: reviewing and summarizing the current literatures that evaluate the sealing ability of MTA as a perforation repair material of permanent teeth.

Part II: comparing the sealing ability of MTA with the other materials used in perforation repair.

MATERIALS AND METHODS

With the help of currently available literature, this paper attempted to point out the sealing ability of MTA comparing it with the other materials used to seal different types of root and crown perforations. The electronic database PubMed was searched for scientific articles on sealing ability of MTA and other materials that were used in repair of crown and root perforations. The search was carried out in papers between2005 to 2015 to represent the latest developments in the last 10 years. The search words MTA, root perforations, sealing ability and micro-leakage were used. The search was done for papers discussing sealing of crown and root perforations using MTA and other materials. Total 58 papers were selected out of 70 papers. The selection was done on the basis of papers that discuss and compare sealing ability of MTA with other materials used to repair crown and root perforations. The rejected papers discussed other aspects as well which are not related to the scope of the review. The results of selected studies are presented in tables 1and 2. The papers were listed in the tables with ascending arrangement according to the year of publication.

DISCUSSION

Part I of this review is discussing the sealing ability of MTA when used in repair of different types of root and crown perforations (Table 1) [25Saha S, Shrivastava R, Neema H, Saha M. Furcal perforation repair with MTA: A report of two cases. JPFA 2011; 25: 196-9.-42Sinkar RC, Patil SS, Jogad NP, Gade VJ. Comparison of sealing ability of ProRoot MTA, RetroMTA, and Biodentine as furcation repair materials: An ultraviolet spectrophotometric analysis. J Conserv Dent 2015; 18(6): 445-8.
[http://dx.doi.org/10.4103/0972-0707.168803] [PMID: 26752836]
].

Table 1

Studies that investigating Sealing ability of MTA used to repair different types perforations of permanent teeth.




Perforation is defined as "the mechanical or pathological communication between the root canal system and the external tooth surface"[25Saha S, Shrivastava R, Neema H, Saha M. Furcal perforation repair with MTA: A report of two cases. JPFA 2011; 25: 196-9.]. Owing to factors affecting perforation repair Saha et al., 2011 [25Saha S, Shrivastava R, Neema H, Saha M. Furcal perforation repair with MTA: A report of two cases. JPFA 2011; 25: 196-9.] and Silva et al., 2012 [26Silva E, Morante D, Júnior E. Repair of iatrogenic perforation with Mineral Trioxide Aggregate under operating microscope. Int J Dent Clin 2012; 4: 47-9.] reported that the successful perforation repair is affected by the etiology, perforation location, size and time elapsed before repair.

Perforations are successfully treated when they immediately sealed to prevent infection [27Fuss Z, Trope M. Root perforations: classification and treatment choices based on prognostic factors. Endod Dent Traumatol 1996; 12(6): 255-64.
[http://dx.doi.org/10.1111/j.1600-9657.1996.tb00524.x] [PMID: 9206372]
]. Time passed, size of the perforation [27Fuss Z, Trope M. Root perforations: classification and treatment choices based on prognostic factors. Endod Dent Traumatol 1996; 12(6): 255-64.
[http://dx.doi.org/10.1111/j.1600-9657.1996.tb00524.x] [PMID: 9206372]
, 28Lemon RR. Nonsurgical repair of perforation defects. Internal matrix concept. Dent Clin North Am 1992; 36(2): 439-57.
[PMID: 1349289]
] and the material used for repair all are important factors affecting better prognosis of perforation healing [27Fuss Z, Trope M. Root perforations: classification and treatment choices based on prognostic factors. Endod Dent Traumatol 1996; 12(6): 255-64.
[http://dx.doi.org/10.1111/j.1600-9657.1996.tb00524.x] [PMID: 9206372]
]. Froughreyhani et al., 2013[29Froughreyhani M, Salem Milani A, Barakatein B, Shiezadeh V. Treatment of strip perforation using root MTA: A case report. Iran Endod J 2013; 8(2): 80-3.
[PMID: 23717336]
] found a successful use of Root (MTA) in repair of strip root perforation as the time elapsed between perforation and repair was short. Menezes et al., 2005[30Menezes R, da Silva Neto UX, Carneiro E, Letra A, Bramante CM, Bernadinelli N. MTA repair of a supracrestal perforation: a case report. J Endod 2005; 31(3): 212-4.
[http://dx.doi.org/10.1097/01.don.0000137639.85637.67] [PMID: 15735473]
] described a successful immediate sealing of an iatrogenic supra crystal perforation case with hemorrhage inside canal with pro-Root MTA.

Also location of the perforation is an important factor affecting perforation prognosis (better prognosis with the more apically located perforations while the lesser prognosis with coronal perforations) [31Sinai IH. Endodontic perforations: their prognosis and treatment. J Am Dent Assoc 1977; 95(1): 90-5.
[http://dx.doi.org/10.14219/jada.archive.1977.0531] [PMID: 267659]
]. Vijetha et al., (2012) [32Vijetha B, Rangappa J, Reddy K, Aspalli N. Management of external cervical resorption using mineral trioxide aggregate. Indian J Oral Sci 2012; 3: 161-4.
[http://dx.doi.org/10.4103/0976-6944.111179]
] reported that the successful treatment depends on the location and severity of perforation lesion when treated ECR (external cervical resorption) with MTA under a full-thickness periosteal flap to allow access to the ECR.

Perforations of the crown or root result in an inflammatory process that breaks down the periodontium, extending to the gingival sulcus, forming a deep and unmanageable periodontal defect, so that coronal perforations have lesser prognosis compared to those are apically located [33Alhadainy HA. Root perforations. A review of literature. Oral Surg Oral Med Oral Pathol 1994; 78(3): 368-74.
[http://dx.doi.org/10.1016/0030-4220(94)90070-1] [PMID: 7970600]
]. Silveira et al., 2008 [34Silveira CM, Sánchez-Ayala A, Lagravère MO, Pilatti GL, Gomes OM. Repair of furcal perforation with mineral trioxide aggregate: long-term follow-up of 2 cases. J Can Dent Assoc 2008; 74(8): 729-33.
[PMID: 18845064]
] illustrated a successful use of MTA with complete osseous healing on long term follow up in treating two cases of perforations with different causes (one is accidentally during access cavity and the other is caries-related). Both had periradicular periodontitis and bone loss at area adjacent to perforation site secondary to the perforation. Saha et al., 2011[25Saha S, Shrivastava R, Neema H, Saha M. Furcal perforation repair with MTA: A report of two cases. JPFA 2011; 25: 196-9.] also reported a successful use of MTA in treatment of two cases with untreated infected furcation perforation that led to an abscess formation, large inflammation and subsequent proliferation of the crevicular epithelium. Amaral et al., 2009 [35Amaral G, Kattenbach R, Fidel R, Fidel S. MTA as a filling material in internal root resorption. Braz J Dent Traumatol 2009; 1: 40-4.] showed two cases with large internal root resorption due to dental trauma communicating with periodontal ligament repaired with MTA as a filling material and there were stop of resorption progress and complete healing.

Mehta et al., 2011 [36Mehta L, Gupta N, Gulati M, Kathuria N. Non-surgical approach for root perforation and resorption - A case report. J Innovat Dent 2011; p. 1.] observed widening of the periodontal ligament space and periapical abscess followed by external root resorption associated with a lateral root perforation that were successfully treated with MTA which provided better seal of root perforations and resorption. Silveira et al., 2008 [34Silveira CM, Sánchez-Ayala A, Lagravère MO, Pilatti GL, Gomes OM. Repair of furcal perforation with mineral trioxide aggregate: long-term follow-up of 2 cases. J Can Dent Assoc 2008; 74(8): 729-33.
[PMID: 18845064]
] also reported chronic periodontium inflammation and granulation tissue formation that led to the loss of attachment due to furcation perforation.

Ideal material used for perforation sealing should promote regeneration of peri-radicular tissues, as it should have antimicrobial activity; prevent leakage of microorganisms and their byproducts [37Ingle JI. A standardized endodontic technique utilizing newly designed instruments and filling materials. Oral Surg Oral Med Oral Pathol 1961; 14: 83-91.
[http://dx.doi.org/10.1016/0030-4220(61)90477-7] [PMID: 13717698]
]. It should also be dimensionally stable, radiopaque, insensitive to moisture, adhesive to dentine, non-toxic, nonirritant, non-carcinogenic, biocompatible [38Main C, Mirzayan N, Shabahang S, Torabinejad M. Repair of root perforations using mineral trioxide aggregate: a long-term study. J Endod 2004; 30(2): 80-3.
[http://dx.doi.org/10.1097/00004770-200402000-00004] [PMID: 14977301]
] and promote osteogenesis and cementogenesis [25Saha S, Shrivastava R, Neema H, Saha M. Furcal perforation repair with MTA: A report of two cases. JPFA 2011; 25: 196-9.]. Saha et al., 2011[25Saha S, Shrivastava R, Neema H, Saha M. Furcal perforation repair with MTA: A report of two cases. JPFA 2011; 25: 196-9.] reported that (MTA) is the best material for furcal perforation repair when used it in the treatment of two cases with furcation perforation. Silva et al., 2012 [26Silva E, Morante D, Júnior E. Repair of iatrogenic perforation with Mineral Trioxide Aggregate under operating microscope. Int J Dent Clin 2012; 4: 47-9.] found that the ideal material for perforation repair, retrograde filling, pulp capping and apexification is (MTA) when used to repair a case with coronal perforation. Upadhyay et al., 2012 [39Upadhyay Y. Mineral trioxide aggregate repair of perforated internal resorption: A case report. J Oral Health Comm Dent 2012; 6: 149-50.] found that MTA has many good properties as biocompatibility, good sealing ability, radiopacity and moisture resistance when used in a case of internal resorption with buccal perforation and healing was satisfactory at 2-years follow-up with cease of the symptoms and signs. Nunes et al., 2012 [40Nunes E, Silveira FF, Soares JA, Duarte MA, Soares SM. Treatment of perforating internal root resorption with MTA: a case report. J Oral Sci 2012; 54(1): 127-31.
[http://dx.doi.org/10.2334/josnusd.54.127] [PMID: 22466897]
] reported successful use of MTA that showed good sealing ability, biocompatibility and potential induction of cementogenesis and osteogenesis in filling a perforating internal root resorption area with the help of surgical microscope during root canal treatment of the apical third. Machado et al., 2013 [41Machado R, Tomazinho L, Randazzo M, Silva E, Vansan L. Repair of a large furcal perforation with mineral trioxide aggregate:a 21-month follow-up. Endod Pract Today 2013; 7: 239-42.] described the successful use of mineral trioxide aggregate (MTA) in the management of large furcal perforation due to its sealing capacity, biocompatibility, bactericidal effect, radiopacity, and ability to set in the presence of tissue fluids or blood. In contrast to all of the previous studies Sinkar et al., 2015 [42Sinkar RC, Patil SS, Jogad NP, Gade VJ. Comparison of sealing ability of ProRoot MTA, RetroMTA, and Biodentine as furcation repair materials: An ultraviolet spectrophotometric analysis. J Conserv Dent 2015; 18(6): 445-8.
[http://dx.doi.org/10.4103/0972-0707.168803] [PMID: 26752836]
] reported that MTA has numerous clinical problems such as difficult handling characteristics, prolonged setting time, and prospective discoloration.

Part II of this review is comparing the sealing ability of MTA to other materials used in repair of different types of root and crown perforations (Table 2) [43De-Deus G, Petruccelli V, Gurgel-Filho E, Coutinho-Filho T. MTA versus Portland cement as repair material for furcal perforations: a laboratory study using a polymicrobial leakage model. Int Endod J 2006; 39(4): 293-8.
[http://dx.doi.org/10.1111/j.1365-2591.2006.01096.x] [PMID: 16584492]
-58De-Deus G, Reis C, Brandão C, Fidel S, Fidel RA. The ability of Portland cement, MTA, and MTA Bio to prevent through-and-through fluid movement in repaired furcal perforations. J Endod 2007; 33(11): 1374-7.
[http://dx.doi.org/10.1016/j.joen.2007.07.024] [PMID: 17963967]
].

Table 2

Studies compared the sealing ability of MTA to other materials used in perforation repair of permanent teeth.




De-Deus et al., (2006) [43De-Deus G, Petruccelli V, Gurgel-Filho E, Coutinho-Filho T. MTA versus Portland cement as repair material for furcal perforations: a laboratory study using a polymicrobial leakage model. Int Endod J 2006; 39(4): 293-8.
[http://dx.doi.org/10.1111/j.1365-2591.2006.01096.x] [PMID: 16584492]
] reported that many materials have been used for sealing root perforations as: amalgam, zinc oxide eugenol, IRM, Super EBA, Cavit, zinc polycarboxylate, zinc phosphate, glass ionomer cement, dentine chips, tricalcium phosphate, calcium hydroxide, hydroxyapatite and mineral trioxide aggregate (MTA) [44ElDeeb ME, ElDeeb M, Tabibi A, Jensen JR. An evaluation of the use of amalgam, Cavit, and calcium hydroxide in the repair of furcation perforations. J Endod 1982; 8(10): 459-66.
[http://dx.doi.org/10.1016/S0099-2399(82)80151-9] [PMID: 6958784]
-46Breault LG, Fowler EB, Primack PD. Endodontic perforation repair with resin-ionomer: a case report. J Contemp Dent Pract 2000; 1(4): 48-59.
[PMID: 12167950]
].

Although amalgam has been widely used for long time in restorative dentistry and apical retrograde filling techniques, its use is limited in recent years due to the following phenomena of ions release, mercury toxicity, corrosion and electrolysis, marginal leakage, delayed expansion, and tattoo formation [47Baek SH, Plenk H Jr, Kim S. Periapical tissue responses and cementum regeneration with amalgam, SuperEBA, and MTA as root-end filling materials. J Endod 2005; 31(6): 444-9.
[http://dx.doi.org/10.1097/01.don.0000148145.81366.a5] [PMID: 15917684]
, 48Torabinejad M, Hong CU, Pitt Ford TR, Kettering JD. Cytotoxicity of four root end filling materials. J Endod 1995; 21(10): 489-92.
[http://dx.doi.org/10.1016/S0099-2399(06)80518-2] [PMID: 8596067]
]. Yazdi et al., 2006 [49Yazdi K, Masoodi M, Shokouhinejad N. Comparison of tissue reaction of pulp chamber perforations in dogs’ teeth treated with MTA, light- cured glass ionomer and amalgam. Iran J Dent 2006; 3: 57-62.] found that MTA and GI were more suitable materials for experimental pulp chamber perforation repair in dogs’ teeth than amalgam that showed the highest level of inflammation without bone regeneration. Abdul Hamed et al., 2011[50Abdul Hamed S. Repair of root canal perforation by different materials. J Bagh Coll Dent 2011; 23: 30-5.] reported that MTA showed the lowest dye leakage and best sealing ability than Glass ionomer followed by Epiphany obturation system that showed the highest dye leakage when used to seal root perforations in extracted human teeth.

Ghanbari et al., 2008 [51Ghanbari H, Ghoddusi J, Mohtasham N. A comparison between amalgam and MTA in repairing furcal perforation. Iran J Dent 2008; 5: 115-9.] found that the immediate use of MTA produced less inflammation and better sealing than amalgam, in repairing the pulp chamber floor perforation of cats’ molar teeth. Holland et al., 2001[52Holland R, Filho JA, de Souza V, Nery MJ, Bernabé PF, Junior ED. Mineral trioxide aggregate repair of lateral root perforations. J Endod 2001; 27(4): 281-4.
[http://dx.doi.org/10.1097/00004770-200104000-00011] [PMID: 11485268]
] reported that the acceleration of Portland cement made it shows good sealing ability, adequate physical and mechanical properties as a restorative material.

MTA and Portland cement had similar mechanism of action and components except for bismuth oxide which gives MTA its radiopacity. Both of them contain calcium oxide that forms calcium hydroxide when mixed with water. Calcium hydroxide and the carbon dioxide stimulate pulp tissue to produce calcite crystals. Calcite crystals and fibronectin initiate the formation of a hard tissue barrier [53Holland R, de Souza V, Murata SS, et al. Healing process of dog dental pulp after pulpotomy and pulp covering with mineral trioxide aggregate or Portland cement. Braz Dent J 2001; 12(2): 109-13. b
[PMID: 11445912]
]. Bayram et al., 2015 [54Bayram HM, Saklar F, Bayram E, Orucoglu H, Bozkurt A. Determination of the apical sealing Abilities of mineral trioxide aggregate, portland Cement, and bioaggregate after irrigation with different solutions. J Int Oral Health 2015; 7(6): 13-7.
[PMID: 26124593]
] reported that Portland cement and MTA had the same tissue reactions.

While in contrast Broon et al., 2006[55Juárez Broon N, Bramante CM, de Assis GF, et al. Healing of root perforations treated with Mineral Trioxide Aggregate (MTA) and Portland cement. J Appl Oral Sci 2006; 14(5): 305-11.
[http://dx.doi.org/10.1590/S1678-77572006000500002] [PMID: 19089049]
] reported that white Portland cement(WPC) and MTA-Angelus(grey MTA) showed more teeth inflammation than the ProRoot MTA (white MTA) when all of them used to evaluate the response of interradicular periodontal tissues of dogs’ teeth with root perforations. Morais et al., 2006[56de Morais CA, Bernardineli N, Garcia RB, Duarte MA, Guerisoli DM. Evaluation of tissue response to MTA and Portland cement with iodoform. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2006; 102(3): 417-21.
[http://dx.doi.org/10.1016/j.tripleo.2005.09.028] [PMID: 16920553]
] reported no differences in inflammatory response and biocompatibility between ProRoot MTA(white MTA) and Portland cement that mixed with iodoform for suitable radiopacity when both of them were implanted in rats’ tissues used for the experiment. Hamad et al., 2006[57Hamad HA, Tordik PA, McClanahan SB. Furcation perforation repair comparing gray and white MTA: a dye extraction study. J Endod 2006; 32(4): 337-40.
[http://dx.doi.org/10.1016/j.joen.2005.10.002] [PMID: 16554207]
] reported that there were no differences between gray and white MTA when used to seal furcation perforations in extracted human mandibular molars by measuring dye penetration.

De-Deus et al., 2007 [58De-Deus G, Reis C, Brandão C, Fidel S, Fidel RA. The ability of Portland cement, MTA, and MTA Bio to prevent through-and-through fluid movement in repaired furcal perforations. J Endod 2007; 33(11): 1374-7.
[http://dx.doi.org/10.1016/j.joen.2007.07.024] [PMID: 17963967]
] found that MTA Bio has superior handling and fast setting than MTA and Portland cement plus it is free of Arsenic and lead materials that present in Portland cement. But the three materials showed the same sealing ability as they could prevent through-and-through fluid movement.

Despite of all studies that supported the use of MTA in sealing root and crown perforations, Sinkar et al., 2015 [42Sinkar RC, Patil SS, Jogad NP, Gade VJ. Comparison of sealing ability of ProRoot MTA, RetroMTA, and Biodentine as furcation repair materials: An ultraviolet spectrophotometric analysis. J Conserv Dent 2015; 18(6): 445-8.
[http://dx.doi.org/10.4103/0972-0707.168803] [PMID: 26752836]
] reported that Biodentine has better sealing ability and least microleakage than RetroMTA and ProRoot MTA when used in furcation repair of mandibular molars using a dye extraction leakage method. Bayram et al., 2015[54Bayram HM, Saklar F, Bayram E, Orucoglu H, Bozkurt A. Determination of the apical sealing Abilities of mineral trioxide aggregate, portland Cement, and bioaggregate after irrigation with different solutions. J Int Oral Health 2015; 7(6): 13-7.
[PMID: 26124593]
] also reported that Bioaggregate (BA) (new bioceramic based material) showed better perforation repair and biocompatibility than MTA and Portland cement when it was used as root end filling and perforation repair material.

CONCLUSION

There are many factors affecting healing and repair of different types of root and crown perforations. Such as size of perforation, time elapsed until repair, location of perforation and type of material to be used in repair. Studies reported that MTA is the best material of choice used in repair of different types of crown and root perforations due to its biocompatibility promoting healing of inflammation, bone and cementum formation while others illustrated its clinical drawbacks such as difficult handling, prolonged sitting time and potential discoloration. MTA showed better sealing and repair of perforations than amalgam, GIC, epiphany obturation system. Some studies reported similar sealing ability of MTA and Portland cement. While others reported better inflammation healing with MTA than Portland cement that contains Arsenic and lead. In contrast to those reported best sealing ability of MTA some authors reported better sealing with BioAggregate (BA), MTA Bio and Biodentine materials. These new materials overcome the drawbacks of MTA showing best sealing ability. More studies required to compare sealing ability of MTA with these new materials.

CONFLICT OF INTEREST

The authors confirm that this article content has no conflict of interest.

ACKNOWLEDGEMENTS

Declared none.

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