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Pediatric endodontic materials

Department of Pediatric & Preventive Dentistry

Presented By: Nilesh Deshpande, Junior Resident-II.

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Contents

Introduction Definition Different Obturating materials Recent advances Conclusion Bibliography

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Introduction

The final of endodontic treatment is to fill the entire root canal system and all its complex anatomic pathways completely and closely with non irritating hermatic sealing agents.

Obturation of a root canal should result in a complete seal from the coronal aspect to the apex preventing the entry of microorganisms and fluid

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Pulpectomy

Mathewson in 1995 defined it as the complete removal of necrotic pulp from the root canals of primary teeth and filling them with an inert restorable material so as to maintain the tooth in the dental arch.

Finn defines it as removal of all pulpal tissues from the coronal and radicular portions of the tooth.

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Ideal Requisites (by Castagnola et al):

The material should resorb as the roots of primary teeth resorbs.

Should not irritate periapical tissues. Should not coagulate any organic

remnants in the canal. Should be able to adequately disinfect and

seal the canals. Should be non toxic. Should not get dissolve in oral fluids. If surplus material has been filled in

periapical area then it should be easily resorbed.

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Should have proper consistency on mixing so that it can be adequately pushed into the canal.

It should not discolour the tooth. Should be radiopaque. Should be retrievable if required. Should be harmless to the adjacent tooth

bud.

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Materials used for Obturation:

Primary Teeth Permanent Teeth

- Zinc oxide eugenol - Gutta percha

- Ca(OH2) - Silver Cones

- Iodoform paste - Stainless Steel

File

method

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Commercial Products Available...

B. KRI paste: Iodoform 80% Camphor 4.86% Parachlorophenol

2.025% Menthol 1.215%

A. Walkhoff Paste:ParachlorophenolCamphorPhenol

C. Vitapex / Metapex:Calcium HydroxideIodoform Oily Additives

D. Endoflas:Barium SulphateCalcium HydroxideIodoform ZnOE

E. Maisto Paste:ZnOIodoform ThymolChlorophenolLenolin

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ZINC OXIDE EUGENOL PASTE

It is the most frequently used oburant. The filling material of choice is ZnOE

without a catalyst. Lack of catalyst gives adequate working

time for filling the canals.

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NOTE: The most popular of all root canal filling material for primary teeth are ZnO and eugenol (ZnOE), calcium hydroxide [Ca(OH)2] and iodoform pastes.

Both ZnOE & Metapex/ Vitapex have shown encouraging results.

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Review of Literature

Few studies have reported that ZnOE sets into a harder cement that resists resorption when extruded beyond the apices.

Investigation by Mani et al reported 67% of all overfilled canals showed over-retained ZnOE at 6 months follow-up.

Flaitz et al 1964reported that 20% of the permanent teeth showed deflection in case of overfilling of canals with ZnOE.

Eransqun & Munuzabul 1972 reported that ZnOE irritates the periapical tissue of rats and may produce necrosis of bone and cementum.

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Months/years to resorb Grossman, 1974woods, 1984

Jevell & Ronk 1982 reported that premolar eruption was arrested due to toxic effects of ZnOE.

According to Reddy et al 1985 lack of ZnOE’s antibacterial properties may aggravate residual infection of root canal instead of promoting healing of infected tissue.

Coll et al 1992 reported it has no significant effect on exfoliation of primary teeth in any of the case.

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Goerig et al in their study reported that ZnOE when mixed with other root canal filling materials like calcium hydroxide & iodoform has good antimicrobial activity and resorption capabilities as when used alone.

In 1985 Coll reported that ZnOE could alter the path of eruption of succedneous teeth.

Wright KJ 1994 did a study on comparison and antimicrobial effects of ZnOE & KRI paste (ZnOE+Iodoform). Results suggested that ZnOE has better antimicrobial activity then KRI paste. It had lower cytotoxicity.

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Coll et al 1998in their study reported that gross own filling was related to failure of pulpectomy with ZnOE.

According to Sadiuan et al 2000 tooth overfilled with ZnOE and those filled up to the apex did not show resorption as compared to those which were filled 1 mm or short of the apex.

Holan et al 2001 reported that 100% of the tooth filled to the apex with KRI paste and 85% of those filled with ZnOE were successful and not statistically different.

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No difference was observed when the teeth were under filled with ZnOE or KRI paste.

Overfilling of canals, however, resulted in a much higher success rate of KRI (75%) then ZnOE (41%), which was statistically significant difference.

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Advantages:

Easily available.

Radiopaque material.

Cheaper/ cost effective.

Effective antimicrobial agent.

Also less cytotoxic to cells in direct or indirect contact.

Good plasticity

Insoluble in tissue fluids

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Disadvantages:

Excessive filling - it leads to mild foreign body reaction.

Muruzabul found that ZnOE cement was “highly irritating” to the periradicular tissues and caused necrosis of bone and cementum.

Rate of resorption does not coincide with rate of resorption of root ( a little slow).

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Coll and Sadrian reported that ZnOE retained material alter the path of eruption of succedeneous teeth in 20% of cases.

(However it has been shown that optimally filled and overfilled canals showed a statistically higher success rate compared to underfilled root canals).

It has been found that Eugenol is not only cytotoxic but is neurotoxic also.

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NOTE:

Canals are said to be underfilled when the material is filled 2 mm short of radiographic apex.

Lentulo-spiral if chosen for obturation then it should be smaller by 2 size from the last H/K file used and 1mm short of working length.

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Composition of ZnOE Cement

Consists of: Powder: ZnO+ Staybelite resin+ Bismuth

subcarbonate + Sodium borate + BaSO4

Liquid : Eugenol

Note: At the time of placement pH of cement is 7 which potentially makes them as the least irritating of all dental materials.

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Manipulation

It consists of powder containing ZnO and liquid containing Eugenol.

Powder contains finely ground ZnO which enhances flow of cement.

It has been shown that 1 mm of ZnO Eugenol cement has a radiopacity corresponding to 4.5 mm of Aluminum sheet, which is slightly lower than G.P.

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Resin acids (Monobasic carboxylic acids) when mixed with ZnOE it renders it less soluble than regular ZnOE cement.

Consistency of paste when used for filling should be 1 scoop powder : 1 drop liquid.

Consistency for temporary filling ZnOE cement should be 2:1.

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CALCIUM HYDROXIDE

Ca(OH)2 a colourless crystal or white powder.

Prepared by reacting Ca oxide (lime) with water, a process called slaking and is also known as hydrated lime or slaked lime.

When heated above 5800C it dehydrates forming the oxide.

Hermann introduced Ca(OH)2 in endodontics in 1930.

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PROPERTIES OF Ca(OH)2

1)Antibacterial action

2)Heals peri apical lesions

3)Resorbs easily

4)Does not set into hard mass

5)No discoloration of teeth

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Review of Literature

In 1938, Teuscher and Zander introduced the rationale that Ca(OH)2 has ability to form reparative dentin.

Seltzer and Benden identified the osteogenic potential of Ca(OH)2.

Tanburic et al summarized the mineralizing effects of Ca(OH)2 .

Estrela et al summarized the antibacterial properties of Ca(OH)2

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There was some controversy regarding the source of Calcium ions in the dentin bridge repair at exposure site:

Sciaky and Pisanti, Attalla and Norjain demonstrated that Ca ions from capping materials were not involved in bridge formation.

Stark and his colleagues, however believed that Ca ions come from the blood circulation which they have shown by presence of radiolabelled Ca ions.

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Tuan T.J. in 1957, reported that Ca(OH)2 could inhibit macrophage function and reduces inflammatory reaction in periapical tissue or in pulp when it is used in pulpectomy or in DPC.

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Mechanism of Action of Calcium Hydroxide

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Composition of Ca(OH)2 Sealer

Base Paste Catalyst Paste Glycol salicylate (40%) - Ca(OH)2 (50% ) Ca(SO4)2 -

ZnO (10%) Titanium dioxide (Inert filler) - Zn stearate

(0.55%); accelerator

Calcium tungstate or Ba sulphate - Ethyl toluene (Provides radiopacity) - Sulphonamide

(39.5%); oily compound, acts as a carrier

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Advantages

Has got an antibacterial action (Initially bactericidal than bacteriostatic) :

Hydrolyses bacterial cell wall lipopolysaccharides thus making them incapable of producing biologic effects such as toxicity, pyrogenecity and complement activation.

Neutralizes bacterial endotoxins.

Reduces anaerobic organisms through CO2 absorption.

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Protection of pulp (If used in pulpotomy procedure) Is an ideal pulp protection agent. If used beneath acid containing

bases/cements, it neutralizes the acid due to its high alkalinity.

Should be used in a very thin layer over or near pulp exposures.

Obliterating the canal space with Ca(OH)2 during treatment may minimize the ingress of tissue fluid used as a nutrient by microorganisms.

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Blocks patent dentinal tubules, neutralizing attack of inorganic acids and leached products from certain cements and filling materials.

Promotes healing and repair.

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Disadvantages

Pulp Obliteration:

Due to osteogenic potential, it is capable of inducing calcific metamorphosis, resulting in obliteration of pulp chamber and root canals.

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Internal resorption: Induces internal resorption in primary teeth.

However investigations have reported that mixture of Ca(OH)2 and iodoform (Metapex/vitapex) is easy to apply, resorbs at a slightly faster rate than roots and has no toxic effects on the permanent successor and is radiopaque also.

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Internal resorption results due to overstimulation of Undifferentiated mesenchymal cells leading to formation of odontoclasts. These odontoclasts then resorb the dentin.

Although it has been documented that internal resorption occurs due to Ca(OH)2 in primary teeth, it does not appear to be a problem in permanent teeth.

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Lack of adhesion to hard tissue:

It is a major shortcoming of Ca(OH)2.

This leads to inadequate seal against microleakage.

Furthermore, Ca(OH)2 materials have been found to dissolve under restorations where microleakage has occurred, resulting in bacterial access to the pulp.

Does not adhere to dentin or resin restoration.

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IODOFORM PASTEReview of Literature:

Castagnola and Urley in 1952 demonstrated that KRI paste got resorbed with root at the same rate which was seen as a success.

It is bactericidal to microorganism in root canals and loses only 20% of potency over a 10 year period.

Maisto in 1967 introduced a mixture of ZnOE and Iodoform (Maisto paste) as a RC filling material in permanent teeth, but was used by Tagger and Sarnet in 1984 in primary teeth.

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Garcia Godoy in 1987 found that KRI paste is bactericidal in root canals, resorbs from the apical tissues in one or two weeks, is apparently harmless to tooth germs, is radiopaque, does not get to a hard mass and is easily inserted and removed.

Mass in 1989 found Maisto’s paste to be successful in treating an infected primary posterior teeth. He reported that iodoform containing pastes are easily resorbed from the periradicular region and causes no foreign body reaction like ZnOE.

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Doninguez in 1989 reported that when iodoform and Ca(OH)2 are combined excellent clinical, radiographic and histological results were obtained.

Matsuzuki in 1996 reported that iodoform improved antiseptic and radiographic effects.

Reddy and Fernandes in 1996 found Maisto paste to be 100% successful. 93% should bone regeneration with complete healing of interradicular pathology and complete resorption of excess material.

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Nucko and Godoy in 1999 evaluated effectiveness of vitapex Ca(OH)2 +iodoform paste and found that it is radiopaque, does not set to a hard mass, resorbs from the apical tissues in 1 week to 2 mos., apparently harmless to permanent tooth germ and can be easily inserted and removed.

Chawla HS in 2001 evaluated the effect of mixture of ZnO powder, Ca(OH)2 paste and distilled water as a root canal filling material. They found that material resorbed at the same rate as the root.

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Fuks et al 2002 conducted a study using endoflas as filling material. After 52 months, overfilling led to a success rate of 58%, underfilling showed a success rate of 83%. The paste also got resorbed extra radicularly.

In a study conducted on 96 primary molars for clinical and radiographic evaluation of pupectomies using ZnOE and iodoform (RC fill), Ca(OH)2 and iodoform (vitapex), ZnOE+ Ca(OH)2 +Iodoform (endoflas) in 72 children of age group 4-7 years, it was reported that success rate was:

90.6% with Metapex 84.7% with RCfill 95.1% with Endoflas

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It is preparation of iodine. Obtained by the action of chlorinated lime upon

an alcoholic solution of iodide of potassium heated at 1040 deg F.

The product being iodoform and iodate of lime.

Iodoform has no irritant action.

In small doses it relives pain, disinfectant  having great influence on the nervous system.

IODOFORM

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Highly resorbable, bacteriocidal.

Iodoform 80% Parachlorophenol 2%, Camphor 5%, Menthol 1%.

Fuks et al 2000 found that1. Success rates of 84% with the Kri paste group

versus 65% with the ZOE group. 2. Overfills more successful (Kri paste 79% vs. ZOE

41%). The excess paste will resorb without causing any adverse side effects.

KRI paste

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Composition1. Camphorated Parachlorophenol : 4-8%2. Eugenol: 24 to 22%3. Zinc oxide: 48 to 58%4. Di-iodothymol: 12 to 18%5. Menthol crystals: 1.40 to 2.90%6. Silver powder: 0.70 to 1.45% approx.

WALKHOFF PASTE

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Antiseptic agent Dissolve albumins and which can therefore

progressively penetrate into the canaliculi of the tooth.

Major disadvantage is its total resorption, which occurs both in the periapical area and in the canal area of the tooth.

Even in the most favourable cases, there is no longer any trace of paste in the previously filled canals, one year after filling of the canals has taken place.

Parachlorophenol

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To allay the pain arising from the near exposure of the pulps of teeth

Also the pain of sensitive dentine

Also to arrest the hemorrhage and allay the pain of wounded pulps of teeth.

Camphor

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Anodyne Antispasmodic Antiseptic

Menthol has given satisfaction as an external remedy in facial neuralgia, odontalgia, as an obtunder of sensitive dentine, and as a local anesthetic

Menthol

ENDOFLAS

Endoflas is root canal sealer material

Composed of zinc oxide,barium sulfate,iodoform,calcium hydroxide,eugenol and pentchlorophenol

One condition for success of endoflas is prevention of microleakage.

A permanent restoration should be placed as soon as possible after clinical signs and symptoms of inflammation are eliminated.

PROPERTIES ZOE VITAPEX KRI PASTE

Rate of resorption Slower than that of tooth root

Slightly faster than that of tooth root

Faster than that of tooth root

Toxicity None None None

Overfill resorption Occurs Occurs Occurs

Antiseptic action Present Present Present

Application Easy

Adherence to canal wall Good Good Good

Removal Easy Easy

Radioopacity Radioopaque Radioopaque Radioopaque

Discoloration of tooth None None None

COMPARISION OF MATERIALS FOR PULPECTOMY

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Chawla H.S et al in 2008 performed endodontic treatment on 25 pulpally involved mandibular primary molars in 4-9 yrs old children, the root canals were obturated with new root canal filling material consisting of mixture of calcium hydroxide ,zinc oxide and 10% sodium fluoride solution.

All cases were clinically and radio graphically evaluated after 3 months and 6 months.

It was observed that the rate of resorption of this new root canal obturating mixture was quite similar to rate of physiologic root resorption in primary teeth.

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NON-RESORBABLE OBTURATING MATERIALS

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GUTTA-PERCHA

Introduced by Bownaan in 1867.

Chemically, gutta-percha is a polyterpene, a polymer of isoprene, or polyisoprene, specifically (trans-1,4-polyisoprene)

Gutta-percha (Palaquium) is a genus of tropical trees native to Southeast Asia

It is an inelastic natural latex produced from the sap of these trees, particularly from the species Palaquium gutta.

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As it is obtained from tree, gutta percha is white in color.

By the addition of dyes it may be turned to any color of the rainbow.

For many years it was dyed pink or red for endodontic use because that was the color of the pulp, which it replaced.

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Composition

According to Friedman and associates: - Gutta Percha (Matrix): 18 - 22 % - ZnO (filler) : 59 – 76 %. - Heavy metal sulfates (radiopacifiers):1 – 10 % - Waxes or resin (plasticizer): 1 – 4 % Because of the poor sealing ability of GP,

regardless of technique, it must be combined with a root canal cement or sealer to ensure proper filling and sealing of the root canal.

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Phase transitions of trans-polyisoprene

Guttapercha at room temperature is considered to be in the beta phase. In this stage gutta-percha is solid, compatible and elongatible.

When heated to 42° to 49°C it undergoes a phase change to alpha phase. In this phase it is runny, tacky, sticky, non-compatible and non-elongatible.

The 3rd or gamma phase occurs when heating is raised to 56° to 62°C. The properties are similar to the 2nd phase.

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Significance

The materials expands when heated from the beta to the gamma or alpha phase from less than 1% to almost 3% when cooled down to the beta phase, a shrinkage takes place, of similar percentiles, but the degree of shrinkage almost always is greater than the degree of expansion and may differ by as much as 2%.

That means if gutta-percha is heated above 42 to 49°C and then inserted into a prepared canal, a condensation procedure should be applied / some method used to lesser the problem of shrinkage.

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Guttapercha is available as:STANDARDIZED GUTTAPERCHA

They approximate the diameter and taper of root canal instruments.

Available as primary cones (No. 15 to 140)

NON-STANDARDIZED GUTTAPERCHA More tapered in shape, hence used as auxiliary

cones in lateral and vertical condensations.

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Advantages

1. Compressibility or Compatibility: 2. Inertness: - least reactive of all the materials. - Considerably less reactive than gold and silver.

3. Dimensional Stability: - undergoes almost no dimensional change

after completion of condensation in the canal.

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4. Tissue tolerance:

5. Radiopacity: - It is radiopaque and therefore easily recognized

on dental film.

6. Becomes plastic when warmed : - When heated above 420 to 490C, some

changes occur in GP. - According to Marchin and Schilder after heating,

GP could be packed with pluggers and its mass increases in volume.

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7. Has known solvent: - The most common being chloroform and

Xylene. - It may be dissolved completely by chloroform

allowing retreatment if required.

8. Elongatable when fresh, brittle when old: - Fresh Gutta percha when stretched elongates. - Old GP breaks off when stretched indicating that

old GP would not be as compact as fresh one on obturation.

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9. Does not shrink after placement.

10. Is easily sterilized prior to insertion and does not allow bacterial growth.

11. Probably the least toxic and least irritating to periapical tissues, of all the root canal filling materials.

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Disadvantages

1. Lack of Rigidity: - Bends easily when subjected to lateral

pressure. - Makes it difficult to use in smaller sizes (i.e.

less than 30).

2. Lack of Length Control: - It permits vertical distortion by stretching,

unless it meets an obstruction i.e. it has little control over what depth it will reach.

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3. Inability to seal the canal apically unless it is combined with a root canal cement or a sealer.

4. It has got limited shelf life, becomes brittle with age (process hastened with warmth and delayed when refrigerated).

Note: Soin and Oliet described a technique to rejuvenate the aged brittle cone by momentary immersion in hot tap water (550C) followed by instant cooling in cold tap water.

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SEMISOLID FILLING MATERIALS FOR OBTURATION:

Guttapercha (beta-phase).

Compacted gutta-percha.

Injection moulded Obtura II, Ultrafil.

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INDICATIONS TO USE SEMI-SOLID FILLING MATERIALS

When the canal has irregular walls and has a non-circular shape.

Whenever a condensation technique is utilized that requires a flare preparation to size 30.

In cases where a lateral / or an auxiliary canal is anticipated / multiple apical foramen present.

Whenever there is a strong possibility of occurrence of an overfilling (as semi-solid materials are well tolerated by tissues).

In cases of internal resorption. In cases where apical surgery has to be

performed.

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Techniques of use

Warm GP Technique.

Thermoplastic GP delivery system (Thermafil).

Compacted GP (Mc Spadden Compactor)

Injection molded techniques (e.g.. Obtura II, Ultrafil).

Chemically plasticized GP (Eucapercha and Chloropercha).

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SILVER CONES / POINTS

Introduced in dentistry in 1930’s.

It was pure silver molded in conical shape.

Was often used for the obturation of very narrow canals in which GP was difficult to insert (because of lack of stiffness of GP).

Also the technique was less time consuming.

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Did not require much of canal enlargement.

In 1941 Jasper introduced silver wires later called as Ag points/cones.

Most silver cones contain small amounts of other trace metals (0.1- 0.2%) such as Cu and Ni along with Ag.

This adds to the cohesion of Ag cones (most common clinical complication).

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Indicated in mature teeth with small or well confined round tapered canals:

1. Maxillary I premolars with 2 or 3 canals, 2. Buccal roots of mature maxillary molars 3. Mesial roots of mandibular molars if they are

straight.

Not indicated for filling anterior teeth, single canal premolars or large single canals in molars.

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Review of Literature

Seltzer and Colleagues have shown that if failed they appear black when removed from the canals.

Kohoe reported a case of localized argyria of buccal gingival, a dark blue pigmented “tattoo” surrounded by a gray hole.

Guttieriez and his associates in Chile reported that corrosion in cones appear due to canal irrigants.

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Advantage

Silver has more rigidity then Gutta Percha hence can be pushed into small and thin canals in which Gutta Percha is nearly impossible to insert up to apex of the tooth.

Indicated in a tooth if it has to be restored with post and core since it difficulty in cutting the cone.

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Disadvantages

They corrode because of microleakage.

Proper apical seal is not obtained.

Poor adaptation.

Difficult to retrieve –retreatment difficult.

Lower success rate has been reported with silver cone as compared to GP.

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Stainless Steel file Method

Can be used to fill fine, tortuous canals.

Suggested by Sampeck, they have been used instead of Gutta percha.

Can be inserted into canal with greater ease as compared to silver cones.

File is inserted into the canal and once it is inserted than the handle of the file is cut off with high speed bur 3 to 4 mm below the occlusal surface to allow space for restoration.

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Fox and Colleagues have reported 6 – 7 % failure rate for root canals filled with this method.

Timpawat and associates found that silver cones or SS files when used with a sealer for obturation leaked less than GP and sealer, in severely curved canals.

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MINERAL TRIOXIDE AGGREGATE (MTA)

Mineral trioxide aggregate (MTA) was first described by M.Torabinejad et al in 1993 when it was used as a root end filling material.

It was approved by U.S. Food and Drug Administration in 1998.

Mineral trioxide aggregate is a powder that consists of fine hydrophilic particles that set in the presence of moisture.

Hydration of the powder results in a colloidal gel that solidifies to a hard structure.

ProRootTM MTAProRootTM MTA

COMPOSITION Tricalcium Silicate Dicalcium Silicate Tricalcium Aluminate Tetracalcium Aluminoferrite Bismuth Oxide – 20% Calcium Sulfate Dihydrate (gypsum)

– 5%

Available in open single pouch use entire content of water ampule hydrate all the powder add 1 to 2 drops of sterile water if too stiff 5 minute working time 4 to 6 hour set time cover mixture with moist gauze pad to extend

working time

Available in open single pouch use entire content of water ampule hydrate all the powder add 1 to 2 drops of sterile water if too stiff 5 minute working time 4 to 6 hour set time cover mixture with moist gauze pad to extend

working time

Preparation of Mineral trioxide aggregate

Working with ProRoot™ MTAWorking with ProRoot™ MTA

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REVIEW OF LITERATURE

Tarabinejad and Pitt Ford (1937) histogically assured MTA with amalgam and observed that a complete layer of cementum is formed with MTA as a root end filling material as compared to amalgam.

Tarabinejad and Talah (1955) evaluated the leakage ability of MTA and other materials like amalgam and Intermediate restorative material and reported that MTA leaked significantly less than other root end filling materials.

D.Arens and M.Tarabinejad (1956) showed the effectiveness of MTA in furcal closure (communication between pulp chamber and underlying periradicular tissue).

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Torabinejad and Hung (1960) evaluated the cytotoxic effect of MTA and reported that it is potentially a bio-compatible material.

Torabinejad and Watron (1993) showed that MTA as a root end filling material showed less leakage as compared to amalgam.

Torabinejad and Dittford (1993) reported that MTA has an antibacterial effect.

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Sluyk & Moun (1998) evaluated the retention character of MTA when used as furcal repair material and found that:

MTA resist displacement at 72 hrs of placement significantly greater than at 24 hrs.

With slight displacement at 72 hrs it demonstrates the ability to re-establish resistance to displacement from dentinal walls.

Presence of moisture in perforation during placement was advantageous as it aids in retention.

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Tarabinejad and N. Clivean (1999) concluded from their study on MTA that it can be used successfully for apexification, pulp capping with reversible pulpitis, repair of root perforations non surgically and surgically.

Eidelman (2001) used MTA in place of formocresol in pulpotomized primary molars and found it to be a suitable replacement material for formocresol.

M.Acinnehhi et al (2003) compared MTA with Ca(OH)2 when used as a pulp capping material in human teeth and evaluated less inflammation, hyperemia, necrosis and thicker dentin bridge with MTA than with Ca(OH)2.

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Mechanism of Action

It stimulates cytotoxin release from bone cells i.e. it actively promotes formation of biologic barrier.

It produces thicker dentinal bridge.

Produces less inflammation and pulpal necrosis as compared to Ca(OH)2 .

It produces better asepsis of lesions because of high alkalinity of MTA (12.5).

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It activates alkaline phosphatase and also increases activity of calcium dependent pyrophosphatase thus achieving asepsis and initiating the process of bone healing.

The sealing ability and biocompatibility of MTA has been attributed to the Ca ions revealed from MTA which reacts with phosphates in synthetic tissue fluid yielding hydroxyapetite which helps in sealing. The crystal grow and fill the microscopic space between MTA and dentinal wall when MTA gradually dissolves.

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MTA induces cytological and functional changes in pulpal cells, resulting in formation of fibro dentin and reparative dentin at the surface of mechanically exposed dental pulp, property useful for pulp capping procedure.

On Tissue Healing

“(the test cells)… “ were observed to have normal morphology, and indeed they were observed to be growing in intimate contact with the MTA”.

Koh, E. et all in1998

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Indications

In pulpal procedures: - Pulp capping - Pulpotomy - Root end filling

Apexification.

Root perforation. Furcation perforation Extra-radicular perforation repair Surgical root repair. Internal resorption repair

FurcationPerforation RepairFurcationPerforation Repair

Procedures• MTA• moist pellet• temp filling• complete RCT• perm filling

Procedures• MTA• moist pellet• temp filling• complete RCT• perm filling

RadicularPerforationRadicularPerforation

Extra-radicularPerforation RepairExtra-radicularPerforation Repair

ApexificationApexification

Indications• root end not developed• root end resorption• open apex

Indications• root end not developed• root end resorption• open apex

ApexificationApexification

Clinical Procedures• with apply MTA• confirm with x-ray• moist pellet• 4 hours setting time• seal canal gutta-

percha

Clinical Procedures• with apply MTA• confirm with x-ray• moist pellet• 4 hours setting time• seal canal gutta-

percha

Root End RepairRoot End Repair

• flap• osteotomy• root-end resection• root-end preparation• control bleeding• lack of moisture control

makes MTA unmanageable

• flap• osteotomy• root-end resection• root-end preparation• control bleeding• lack of moisture control

makes MTA unmanageable

Root End RepairRoot End Repair

Place MTA with small carrier• condense• moist pellet• do not rinse!• suture

Place MTA with small carrier• condense• moist pellet• do not rinse!• suture

Internal ResorptionInternal Resorption

Internal ResorptionRepairInternal ResorptionRepair

Pulp CapPulp Cap

Pulp CapPulp Cap

PulpotomyPulpotomy

Indications• large pulp exposure• no symptoms

Indications• large pulp exposure• no symptoms

PulpotomyPulpotomy

Clinical Procedures• MTA• moist pellet• temp filling• 1 week perm filling• check vitality every

3 to 6 months

Clinical Procedures• MTA• moist pellet• temp filling• 1 week perm filling• check vitality every

3 to 6 months

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Advantages

MTA does not require compaction therefore there are always less chance of extrusion of the material periapically.

It helps in one step obturation of teeth with open apex because of its property to form an immediate apical barrier.

Setting of MTA is not affected with water or blood.

MTA has proved beneficial to create an apical plug at the end of root canal system.

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MTA has got good antimicrobial effects.

It shows low solubility and has radiopacity more than that of dentin.

Promotes guided tissue regeneration of original tissues.

It has found to regenerate periodontal ligaments efficiently.

It has the property to adhere to tooth surface.

Allows for overgrowth of cementum and formation of bone.

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Disadvantages

Very long setting time about 4 hrs

It requires a wet medium for setting.

Has low compressive strength, hence cannot be placed in functional areas.

It dissolve in acidic environment.

Material such as saline and anesthetic solution affects the physical, chemical and biological properties of MTA.

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References

Pediatric Dentistry; Vol. 28, No.1, Jan/Feb. 2006; 39-48.

Pediatric Dentistry; 27, Vol. 6, 2005; 470-477. Pediatric Dentistry; Vol. 2, No.1, 2006. Textbook of Pediatric Dentistry by Shobha

Tandon: 1st Edi. 2001. Pediatric Dentistry; Infancy Through

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