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Tricalcium silicate-based cements: properties and modifications

Abstract:

Mineral trioxide aggregate (MTA) has been widely used for different reparative procedures in endodontics. The extensive use of this cement for pulp capping, apexifications, apical surgeries, and revascularization is related to its ability to induce tissue repair and to stimulate mineralization. Several research studies have tested modifications in the composition of MTA-based cements in order to enhance their clinical performance. Novel formulations have been introduced in the market with the aim of increasing flowability. Important properties such as appropriate radiopacity and setting time, color stability, alkaline pH, release of calcium ions, and biocompatibility have to be considered in these new formulations. The latest research studies on the physical, chemical, and biological properties of tricalcium silicate-based cements are discussed in this critical review.

Keywords:
Dental Materials; Endodontics; Root Canal Filling Materials; Biocompatible Materials

Introduction

Reparative procedures are of paramount importance in endodontics,11. Banchs F, Trope M. Revascularization of immature permanent teeth with apical periodontitis: new treatment protocol? J Endod. 2004 Apr;30(4):196-200. https://doi.org/10.1097/00004770-200404000-00003
https://doi.org/10.1097/00004770-2004040...
and conservative procedures allow maintaining teeth in good health.22. Roig M, Espona J, Mercadé M, Duran-Sindreu F. Horizontal root fracture treated with MTA, a case report with a 10-year follow-up. Dent Traumatol. 2011 Dec;27(6):460-3. https://doi.org/10.1111/j.1600-9657.2011.01018.x
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Mineral trioxide aggregate (MTA) has been widely used for these purposes since its development in the 1990s.33. Torabinejad M, Hong CU, Lee SJ, Monsef M, Pitt Ford TR. Investigation of mineral trioxide aggregate for root-end filling in dogs. J Endod. 1995 Dec;21(12):603-8. https://doi.org/10.1016/S0099-2399(06)81112-X
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,44. Cehreli ZC, Sara S, Uysal S, Turgut MD. MTA apical plugs in the treatment of traumatized immature teeth with large periapical lesions. Dent Traumatol. 2011 Feb;27(1):59-62. https://doi.org/10.1111/j.1600-9657.2010.00941.x
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MTA has been used for conservative management of root fractures,22. Roig M, Espona J, Mercadé M, Duran-Sindreu F. Horizontal root fracture treated with MTA, a case report with a 10-year follow-up. Dent Traumatol. 2011 Dec;27(6):460-3. https://doi.org/10.1111/j.1600-9657.2011.01018.x
https://doi.org/10.1111/j.1600-9657.2011...
sealing of perforations,55. Hashem AA, Hassanien EE. ProRoot MTA, MTA-Angelus and IRM used to repair large furcation perforations: sealability study. J Endod. 2008 Jan;34(1):59-61. https://doi.org/10.1016/j.joen.2007.09.007
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pulp capping,66. Farsi N, Alamoudi N, Balto K, Al Mushayt A. Clinical assessment of mineral trioxide aggregate (MTA) as direct pulp capping in young permanent teeth. J Clin Pediatr Dent. 2006;31(2):72-6. https://doi.org/10.17796/jcpd.31.2.n462281458372u64
https://doi.org/10.17796/jcpd.31.2.n4622...
apical plug in apexifications,77. Simon S, Rilliard F, Berdal A, Machtou P. The use of mineral trioxide aggregate in one-visit apexification treatment: a prospective study. Int Endod J. 2007 Mar;40(3):186-97. https://doi.org/10.1111/j.1365-2591.2007.01214.x
https://doi.org/10.1111/j.1365-2591.2007...
root-end filling material in apical surgeries,88. Baek 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 Jun;31(6):444-9. https://doi.org/10.1097/01.don.0000148145.81366.a5
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and as a coronal barrier in revascularization.11. Banchs F, Trope M. Revascularization of immature permanent teeth with apical periodontitis: new treatment protocol? J Endod. 2004 Apr;30(4):196-200. https://doi.org/10.1097/00004770-200404000-00003
https://doi.org/10.1097/00004770-2004040...
All of these procedures imply contact with living tissues and body fluids, an environment that favors physical modifications and chemical/biological interactions with the material.99. Nekoofar MH, Stone DF, Dummer PM. The effect of blood contamination on the compressive strength and surface microstructure of mineral trioxide aggregate. Int Endod J. 2010 Sep;43(9):782-91. https://doi.org/10.1111/j.1365-2591.2010.01745.x
https://doi.org/10.1111/j.1365-2591.2010...
,1010. Camilleri J, Formosa L, Damidot D. The setting characteristics of MTA Plus in different environmental conditions. Int Endod J. 2013 Sep;46(9):831-40. https://doi.org/10.1111/iej.12068
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,1111. Guimarães BM, Tartari T, Marciano MA, Vivan RR, Mondeli RF, Camilleri J et al. Color stability, radiopacity, and chemical characteristics of white mineral trioxide aggregate associated with 2 different vehicles in contact with blood. J Endod. 2015 Jun;41(6):947-52. https://doi.org/10.1016/j.joen.2015.02.008
https://doi.org/10.1016/j.joen.2015.02.0...

The physical, chemical, and biological properties of MTA have been studied for decades and novel substances were eventually introduced, but improvements are still required to obtain an ideal composition.1212. Santos AD, Moraes JC, Araújo EB, Yukimitu K, Valério Filho WV. Physico-chemical properties of MTA and a novel experimental cement. Int Endod J. 2005 Jul;38(7):443-7. https://doi.org/10.1111/j.1365-2591.2005.00963.x
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,1313. Gandolfi MG, Taddei P, Siboni F, Modena E, Ciapetti G, Prati C. Development of the foremost light-curable calcium-silicate MTA cement as root-end in oral surgery. Chemical-physical properties, bioactivity and biological behavior. Dent Mater. 2011 Jul;27(7):e134-57. https://doi.org/10.1016/j.dental.2011.03.011
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,1414. Gandolfi MG, Siboni F, Prati C. Chemical-physical properties of TheraCal, a novel light-curable MTA-like material for pulp capping. Int Endod J. 2012 Jun;45(6):571-9. https://doi.org/10.1111/j.1365-2591.2012.02013.x
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A perfect endodontic restorative material should present physical characteristics such as sealing, dimensional1515. Camilleri J, Mallia B. Evaluation of the dimensional changes of mineral trioxide aggregate sealer. Int Endod J. 2011 May;44(5):416-24. https://doi.org/10.1111/j.1365-2591.2010.01844.x
https://doi.org/10.1111/j.1365-2591.2010...
and color stability,1616. Marciano MA, Costa RM, Camilleri J, Mondelli RF, Guimarães BM, Duarte MA. Assessment of color stability of white mineral trioxide aggregate angelus and bismuth oxide in contact with tooth structure. J Endod. 2014 Aug;40(8):1235-40. https://doi.org/10.1016/j.joen.2014.01.044
https://doi.org/10.1016/j.joen.2014.01.0...
,1717. Marciano MA, Camilleri J, Costa RM, Matsumoto MA, Guimarães BM, Duarte MA. Zinc oxide inhibits dental discoloration caused by white mineral trioxide aggregate angelus. J Endod. 2017 Jun;43(6):1001-7. https://doi.org/10.1016/j.joen.2017.01.029
https://doi.org/10.1016/j.joen.2017.01.0...
radiopacity,1818. Islam I, Chng HK, Yap AU. Comparison of the physical and mechanical properties of MTA and portland cement. J Endod. 2006 Mar;32(3):193-7. https://doi.org/10.1016/j.joen.2005.10.043
https://doi.org/10.1016/j.joen.2005.10.0...
,1919. Vivan RR, Ordinola-Zapata R, Bramante CM, Bernardineli N, Garcia RB, Hungaro Duarte MA et al. Evaluation of the radiopacity of some commercial and experimental root-end filling materials. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2009 Dec;108(6):e35-8. https://doi.org/10.1016/j.tripleo.2009.07.037
https://doi.org/10.1016/j.tripleo.2009.0...
insolubility in contact with fluids,2020. Fridland M, Rosado R. Mineral trioxide aggregate (MTA) solubility and porosity with different water-to-powder ratios. J Endod. 2003 Dec;29(12):814-7. https://doi.org/10.1097/00004770-200312000-00007
https://doi.org/10.1097/00004770-2003120...
,2121. Cavenago BC, Pereira TC, Duarte MA, Ordinola-Zapata R, Marciano MA, Bramante CM et al. Influence of powder-to-water ratio on radiopacity, setting time, pH, calcium ion release and a micro-CT volumetric solubility of white mineral trioxide aggregate. Int Endod J. 2014 Feb;47(2):120-6. https://doi.org/10.1111/iej.12120
https://doi.org/10.1111/iej.12120...
flowability, and easy insertion;2222. Hungaro Duarte MA, Minotti PG, Rodrigues CT, Zapata RO, Bramante CM, Tanomaru Filho M et al. Effect of different radiopacifying agents on the physicochemical properties of white Portland cement and white mineral trioxide aggregate. J Endod. 2012 Mar;38(3):394-7. https://doi.org/10.1016/j.joen.2011.11.005
https://doi.org/10.1016/j.joen.2011.11.0...
,2323. Duque JA, Fernandes SL, Bubola JP, Duarte MA, Camilleri J, Marciano MA. The effect of mixing method on tricalcium silicate-based cement. Int Endod J. 2018 Jan;51(1):69-78. https://doi.org/10.1111/iej.12774
https://doi.org/10.1111/iej.12774...
and also chemical and biological properties such as alkaline pH, release of calcium ions,2424. Duarte MA, Demarchi AC, Yamashita JC, Kuga MC, Fraga SC. pH and calcium ion release of 2 root-end filling materials. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2003 Mar;95(3):345-7. https://doi.org/10.1067/moe.2003.12
https://doi.org/10.1067/moe.2003.12...
bioactivity,2525. Gandolfi MG, Ciapetti G, Taddei P, Perut F, Tinti A, Cardoso MV et al. Apatite formation on bioactive calcium-silicate cements for dentistry affects surface topography and human marrow stromal cells proliferation. Dent Mater. 2010 Oct;26(10):974-92. https://doi.org/10.1016/j.dental.2010.06.002
https://doi.org/10.1016/j.dental.2010.06...
cell attachment,2626. Balto HA. Attachment and morphological behavior of human periodontal ligament fibroblasts to mineral trioxide aggregate: a scanning electron microscope study. J Endod. 2004 Jan;30(1):25-9. https://doi.org/10.1097/00004770-200401000-00005
https://doi.org/10.1097/00004770-2004010...
and biocompatibility.2727. Camilleri J, Montesin FE, Papaioannou S, McDonald F, Pitt Ford TR. Biocompatibility of two commercial forms of mineral trioxide aggregate. Int Endod J. 2004 Oct;37(10):699-704. https://doi.org/10.1111/j.1365-2591.2004.00859.x
https://doi.org/10.1111/j.1365-2591.2004...

Several of the ideal properties of a restorative material were present in MTA, but others are lacking.2828. Parirokh M, Torabinejad M. Mineral trioxide aggregate: a comprehensive literature review. Part I: chemical, physical, and antibacterial properties. J Endod. 2010 Jan;36(1):16-27. https://doi.org/10.1016/j.joen.2009.09.006
https://doi.org/10.1016/j.joen.2009.09.0...
Color and the consistency are some widely discussed and studied properties of MTA that need improvements.1717. Marciano MA, Camilleri J, Costa RM, Matsumoto MA, Guimarães BM, Duarte MA. Zinc oxide inhibits dental discoloration caused by white mineral trioxide aggregate angelus. J Endod. 2017 Jun;43(6):1001-7. https://doi.org/10.1016/j.joen.2017.01.029
https://doi.org/10.1016/j.joen.2017.01.0...
,2222. Hungaro Duarte MA, Minotti PG, Rodrigues CT, Zapata RO, Bramante CM, Tanomaru Filho M et al. Effect of different radiopacifying agents on the physicochemical properties of white Portland cement and white mineral trioxide aggregate. J Endod. 2012 Mar;38(3):394-7. https://doi.org/10.1016/j.joen.2011.11.005
https://doi.org/10.1016/j.joen.2011.11.0...
,2929. Marciano MA, Duarte MA, Camilleri J. Calcium silicate-based sealers: assessment of physicochemical properties, porosity and hydration. Dent Mater. 2016 Feb;32(2):e30-40. https://doi.org/10.1016/j.dental.2015.11.008
https://doi.org/10.1016/j.dental.2015.11...
Novel materials have been developed in an attempt to overcome these drawbacks.3030. Gandolfi MG, Siboni F, Primus CM, Prati C. Ion release, porosity, solubility, and bioactivity of MTA Plus tricalcium silicate. J Endod. 2014 Oct;40(10):1632-7. https://doi.org/10.1016/j.joen.2014.03.025
https://doi.org/10.1016/j.joen.2014.03.0...
,3131. Cintra LT, Benetti F, Queiroz ÍOA, Lopes JMA, Oliveira SHP, Araújo GS et al. Cytotoxicity, Biocompatibility, and Biomineralization of the New High-plasticity MTA Material. J Endod. 2017 May;43(5):774-8. https://doi.org/10.1016/j.joen.2016.12.018
https://doi.org/10.1016/j.joen.2016.12.0...
,3232. Silva GF, Guerreiro-Tanomaru JM, Fonseca TS, Bernardi MI, Sasso-Cerri E, Tanomaru-Filho M et al. Zirconium oxide and niobium oxide used as radiopacifiers in a calcium silicate-based material stimulate fibroblast proliferation and collagen formation. Int Endod J. 2017 Dec;50 Suppl 2:e95-108. https://doi.org/10.1111/iej.12789
https://doi.org/10.1111/iej.12789...
The aim of this critical review is to discuss the physical, chemical, and biological properties of MTA and advancements in novel tricalcium silicate-based cements.

Clinical aspect and properties

The clinical aspect of tricalcium silicate-based cements is the first point to be considered.99. Nekoofar MH, Stone DF, Dummer PM. The effect of blood contamination on the compressive strength and surface microstructure of mineral trioxide aggregate. Int Endod J. 2010 Sep;43(9):782-91. https://doi.org/10.1111/j.1365-2591.2010.01745.x
https://doi.org/10.1111/j.1365-2591.2010...
,3333. Torabinejad M, Chivian N. Clinical applications of mineral trioxide aggregate [Review]. J Endod. 1999 Mar;25(3):197-205. https://doi.org/10.1016/S0099-2399(99)80142-3
https://doi.org/10.1016/S0099-2399(99)80...
,3434. Vanderweele RA, Schwartz SA, Beeson TJ. Effect of blood contamination on retention characteristics of MTA when mixed with different liquids. J Endod. 2006 May;32(5):421-4. https://doi.org/10.1016/j.joen.2005.09.007
https://doi.org/10.1016/j.joen.2005.09.0...
The site of placement has a direct influence on the properties of this cement.3535. Camilleri J, Sorrentino F, Damidot D. Investigation of the hydration and bioactivity of radiopacified tricalcium silicate cement, Biodentine and MTA Angelus. Dent Mater. 2013 May;29(5):580-93. https://doi.org/10.1016/j.dental.2013.03.007
https://doi.org/10.1016/j.dental.2013.03...
MTA is a dynamic material and its interaction with tissues and fluids is constant, starting at insertion and persisting for years after its placement.1515. Camilleri J, Mallia B. Evaluation of the dimensional changes of mineral trioxide aggregate sealer. Int Endod J. 2011 May;44(5):416-24. https://doi.org/10.1111/j.1365-2591.2010.01844.x
https://doi.org/10.1111/j.1365-2591.2010...
,2525. Gandolfi MG, Ciapetti G, Taddei P, Perut F, Tinti A, Cardoso MV et al. Apatite formation on bioactive calcium-silicate cements for dentistry affects surface topography and human marrow stromal cells proliferation. Dent Mater. 2010 Oct;26(10):974-92. https://doi.org/10.1016/j.dental.2010.06.002
https://doi.org/10.1016/j.dental.2010.06...
,3636. Reyes-Carmona JF, Felippe MS, Felippe WT. Biomineralization ability and interaction of mineral trioxide aggregate and white portland cement with dentin in a phosphate-containing fluid. J Endod. 2009 May;35(5):731-6. https://doi.org/10.1016/j.joen.2009.02.011
https://doi.org/10.1016/j.joen.2009.02.0...
Calcium hydroxide is leached out of hydrated MTA by the release of calcium ions and the bioactivity of MTA is related to such release.2424. Duarte MA, Demarchi AC, Yamashita JC, Kuga MC, Fraga SC. pH and calcium ion release of 2 root-end filling materials. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2003 Mar;95(3):345-7. https://doi.org/10.1067/moe.2003.12
https://doi.org/10.1067/moe.2003.12...
,3737. Camilleri J. Characterization of hydration products of mineral trioxide aggregate. Int Endod J. 2008 May;41(5):408-17. https://doi.org/10.1111/j.1365-2591.2007.01370.x
https://doi.org/10.1111/j.1365-2591.2007...
MTA can be used mostly in procedures where there is contact with blood.11. Banchs F, Trope M. Revascularization of immature permanent teeth with apical periodontitis: new treatment protocol? J Endod. 2004 Apr;30(4):196-200. https://doi.org/10.1097/00004770-200404000-00003
https://doi.org/10.1097/00004770-2004040...
,77. Simon S, Rilliard F, Berdal A, Machtou P. The use of mineral trioxide aggregate in one-visit apexification treatment: a prospective study. Int Endod J. 2007 Mar;40(3):186-97. https://doi.org/10.1111/j.1365-2591.2007.01214.x
https://doi.org/10.1111/j.1365-2591.2007...

Contamination of MTA with blood affects the morphology of the set material and reduces the release of calcium ions.99. Nekoofar MH, Stone DF, Dummer PM. The effect of blood contamination on the compressive strength and surface microstructure of mineral trioxide aggregate. Int Endod J. 2010 Sep;43(9):782-91. https://doi.org/10.1111/j.1365-2591.2010.01745.x
https://doi.org/10.1111/j.1365-2591.2010...
,3838. Nekoofar MH, Davies TE, Stone D, Basturk FB, Dummer PM. Microstructure and chemical analysis of blood-contaminated mineral trioxide aggregate. Int Endod J. 2011 Nov;44(11):1011-8. https://doi.org/10.1111/j.1365-2591.2011.01909.x
https://doi.org/10.1111/j.1365-2591.2011...
Furthermore, blood can change the color of the material and interfere in radiopacity over time.1111. Guimarães BM, Tartari T, Marciano MA, Vivan RR, Mondeli RF, Camilleri J et al. Color stability, radiopacity, and chemical characteristics of white mineral trioxide aggregate associated with 2 different vehicles in contact with blood. J Endod. 2015 Jun;41(6):947-52. https://doi.org/10.1016/j.joen.2015.02.008
https://doi.org/10.1016/j.joen.2015.02.0...

Setting time and solubility are directly affected by moisture. A large amount of water increases both the setting time and solubility of MTA.

MTA is known for its chemical interaction with tissues. The alkalinization of the medium and release of calcium ions are related to the formation of portlandite (calcium hydroxide) by tricalcium silicate and dicalcium silicate during the setting time of MTA.3939. Camilleri J, Kralj P, Veber M, Sinagra E. Characterization and analyses of acid-extractable and leached trace elements in dental cements. Int Endod J. 2012 Aug;45(8):737-43. https://doi.org/10.1111/j.1365-2591.2012.02027.x
https://doi.org/10.1111/j.1365-2591.2012...
MTA Angelus and ProRoot MTA presented in vitro calcium release and alkaline pH when immersed in water2424. Duarte MA, Demarchi AC, Yamashita JC, Kuga MC, Fraga SC. pH and calcium ion release of 2 root-end filling materials. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2003 Mar;95(3):345-7. https://doi.org/10.1067/moe.2003.12
https://doi.org/10.1067/moe.2003.12...
and calcium release was identified by Von Kossa staining of rat subcutaneous tissues.4040. Holland R, Souza V, Nery MJ, Faraco Júnior IM, Bernabé PF, Otoboni Filho JA et al. Reaction of rat connective tissue to implanted dentin tubes filled with a white mineral trioxide aggregate. Braz Dent J. 2002;13(1):23-6. These properties favor mineralization on MTA surface when used in pulpotomy,4141. Holland R, de Souza V, Murata SS, Nery MJ, Bernabé PF, Otoboni Filho JA 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.,4242. Menezes R, Bramante CM, Garcia RB, Letra A, Carvalho VG, Carneiro E et al. Microscopic analysis of dog dental pulp after pulpotomy and pulp protection with mineral trioxide aggregate and white Portland cement. J Appl Oral Sci. 2004 Jun;12(2):104-7. https://doi.org/10.1590/S1678-77572004000200004
https://doi.org/10.1590/S1678-7757200400...
the formation of mineralized tissue in the apical tissues of dog's teeth, and the sealing of furcation perforation.4343. Holland R, de Souza V, Nery MJ, Otoboni Filho JA, Bernabé PF, Dezan Júnior E. Reaction of dogs’ teeth to root canal filling with mineral trioxide aggregate or a glass ionomer sealer. J Endod. 1999 Nov;25(11):728-30. https://doi.org/10.1016/S0099-2399(99)80118-6
https://doi.org/10.1016/S0099-2399(99)80...
,4444. Yildirim T, Gençoğlu N, Firat I, Perk C, Guzel O. Histologic study of furcation perforations treated with MTA or Super EBA in dogs’ teeth. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2005 Jul;100(1):120-4. https://doi.org/10.1016/j.tripleo.2004.09.017
https://doi.org/10.1016/j.tripleo.2004.0...

Color stability

The first formulation of MTA was gray, which limited its application to anterior teeth.4545. Bortoluzzi EA, Araújo GS, Guerreiro Tanomaru JM, Tanomaru-Filho M. Marginal gingiva discoloration by gray MTA: a case report. J Endod. 2007 Mar;33(3):325-7. https://doi.org/10.1016/j.joen.2006.09.012
https://doi.org/10.1016/j.joen.2006.09.0...
Although white MTA has been introduced in order to eliminate tooth discoloration, several studies have shown changes in tooth color.4646. Belobrov I, Parashos P. Treatment of tooth discoloration after the use of white mineral trioxide aggregate. J Endod. 2011 Jul;37(7):1017-20. https://doi.org/10.1016/j.joen.2011.04.003
https://doi.org/10.1016/j.joen.2011.04.0...
,4747. Felman D, Parashos P. Coronal tooth discoloration and white mineral trioxide aggregate. J Endod. 2013 Apr;39(4):484-7. https://doi.org/10.1016/j.joen.2012.11.053
https://doi.org/10.1016/j.joen.2012.11.0...

White MTA is mainly composed of dicalcium and tricalcium silicate with 20% of bismuth oxide.3737. Camilleri J. Characterization of hydration products of mineral trioxide aggregate. Int Endod J. 2008 May;41(5):408-17. https://doi.org/10.1111/j.1365-2591.2007.01370.x
https://doi.org/10.1111/j.1365-2591.2007...
,4848. Camilleri J, Montesin FE, Brady K, Sweeney R, Curtis RV, Ford TR. The constitution of mineral trioxide aggregate. Dent Mater. 2005 Apr;21(4):297-303. https://doi.org/10.1016/j.dental.2004.05.010
https://doi.org/10.1016/j.dental.2004.05...
Reductioin of bismuth oxide in bismith and contact with the tooth structure result in a change in the color of the material and, consequently, in the color of the adjacent tooth structure.1616. Marciano MA, Costa RM, Camilleri J, Mondelli RF, Guimarães BM, Duarte MA. Assessment of color stability of white mineral trioxide aggregate angelus and bismuth oxide in contact with tooth structure. J Endod. 2014 Aug;40(8):1235-40. https://doi.org/10.1016/j.joen.2014.01.044
https://doi.org/10.1016/j.joen.2014.01.0...
The loss of stability of bismuth oxide molecules when in contact with a strong oxidizing agent has been pointed out as the cause for color change.1616. Marciano MA, Costa RM, Camilleri J, Mondelli RF, Guimarães BM, Duarte MA. Assessment of color stability of white mineral trioxide aggregate angelus and bismuth oxide in contact with tooth structure. J Endod. 2014 Aug;40(8):1235-40. https://doi.org/10.1016/j.joen.2014.01.044
https://doi.org/10.1016/j.joen.2014.01.0...
,4949. Camilleri J. Color stability of white mineral trioxide aggregate in contact with hypochlorite solution. J Endod. 2014 Mar;40(3):436-40. https://doi.org/10.1016/j.joen.2013.09.040PMID:24565667
https://doi.org/10.1016/j.joen.2013.09.0...
Replacement of the radiopacifying agent has been suggested to prevent discoloration.5050. Húngaro Duarte MA, de Oliveira El Kadre GD, Vivan RR, Guerreiro Tanomaru JM, Tanomaru Filho M, de Moraes IG. Radiopacity of portland cement associated with different radiopacifying agents. J Endod. 2009 May;35(5):737-40. https://doi.org/10.1016/j.joen.2009.02.006
https://doi.org/10.1016/j.joen.2009.02.0...
,5151. Camilleri J, Gandolfi MG. Evaluation of the radiopacity of calcium silicate cements containing different radiopacifiers. Int Endod J. 2010 Jan;43(1):21-30. https://doi.org/10.1111/j.1365-2591.2009.01621.x
https://doi.org/10.1111/j.1365-2591.2009...
Zirconium oxide and calcium tungstate have been tested, but large amounts are required to provide similar radiopacity to that of bismuth oxide, and deterioration of the physical and chemical properties of the material would therefore be expected.2929. Marciano MA, Duarte MA, Camilleri J. Calcium silicate-based sealers: assessment of physicochemical properties, porosity and hydration. Dent Mater. 2016 Feb;32(2):e30-40. https://doi.org/10.1016/j.dental.2015.11.008
https://doi.org/10.1016/j.dental.2015.11...
,5050. Húngaro Duarte MA, de Oliveira El Kadre GD, Vivan RR, Guerreiro Tanomaru JM, Tanomaru Filho M, de Moraes IG. Radiopacity of portland cement associated with different radiopacifying agents. J Endod. 2009 May;35(5):737-40. https://doi.org/10.1016/j.joen.2009.02.006
https://doi.org/10.1016/j.joen.2009.02.0...
,5252. Holland R, Mazuqueli L, Souza V, Murata SS, Dezan Júnior E, Suzuki P. Influence of the type of vehicle and limit of obturation on apical and periapical tissue response in dogs’ teeth after root canal filling with mineral trioxide aggregate. J Endod. 2007 Jun;33(6):693-7. https://doi.org/10.1016/j.joen.2007.02.005
https://doi.org/10.1016/j.joen.2007.02.0...

As previously discussed, the environment exercises some influence over MTA. Contact with blood and color were tested.

The first formulation of MTA was gray, which caused intense discoloration when in contact with the teeth. To overcome this problem, the tooth color formula was introduced in the market. The reduction in the quantity of some components in this material resulted in a white composition. However, this formula also caused tooth discoloration. Thus, studies were carried out to detect the component involved in this interaction and bismuth oxide was found to be associated with tooth discoloration.

To prevent color changes, there are two alternatives. The first one is the replacement of bismuth oxide with calcium tungstate or with zirconium oxide.1616. Marciano MA, Costa RM, Camilleri J, Mondelli RF, Guimarães BM, Duarte MA. Assessment of color stability of white mineral trioxide aggregate angelus and bismuth oxide in contact with tooth structure. J Endod. 2014 Aug;40(8):1235-40. https://doi.org/10.1016/j.joen.2014.01.044
https://doi.org/10.1016/j.joen.2014.01.0...
MTA HP and other new calcium silicate cements such as Biodentine and BC Sealer change the radiopacifying agent into calcium tungstate or zirconium oxide. These substances do not cause color changes.1717. Marciano MA, Camilleri J, Costa RM, Matsumoto MA, Guimarães BM, Duarte MA. Zinc oxide inhibits dental discoloration caused by white mineral trioxide aggregate angelus. J Endod. 2017 Jun;43(6):1001-7. https://doi.org/10.1016/j.joen.2017.01.029
https://doi.org/10.1016/j.joen.2017.01.0...
The second alternative is to associate 5% zinc oxide with MTA. Zinc oxide prevents the change in color caused by conversion of bismuth oxide to bismite.1717. Marciano MA, Camilleri J, Costa RM, Matsumoto MA, Guimarães BM, Duarte MA. Zinc oxide inhibits dental discoloration caused by white mineral trioxide aggregate angelus. J Endod. 2017 Jun;43(6):1001-7. https://doi.org/10.1016/j.joen.2017.01.029
https://doi.org/10.1016/j.joen.2017.01.0...

Consistency

The consistency of MTA also comes into question. The powder-to-water ratio is an important factor to consider. However, the increase in the amount of water in the mixture reduces radiopacity.

Particle size is assumed to play a role in this case since new silicate cements have been prepared with calcium silicate nanoparticles. BC sealer and Biosealer contain calcium silicate nanoparticles with the addition of a polymer, which favors the manipulation and consistency of the material. Propylene glycol was associated with MTA and did not interfere in its biological properties.5252. Holland R, Mazuqueli L, Souza V, Murata SS, Dezan Júnior E, Suzuki P. Influence of the type of vehicle and limit of obturation on apical and periapical tissue response in dogs’ teeth after root canal filling with mineral trioxide aggregate. J Endod. 2007 Jun;33(6):693-7. https://doi.org/10.1016/j.joen.2007.02.005
https://doi.org/10.1016/j.joen.2007.02.0...
,5353. Duarte MA, Aguiar KA, Zeferino MA, Vivan RR, Ordinola-Zapata R, Tanomaru-Filho M, et al. Evaluation of the propylene glycol association on some physical and chemical properties of mineral trioxide aggregate. Int Endod J. 2012 Jun;45(6):565-70. https://doi.org/10.1111/j.1365-2591.2012.02012.x
https://doi.org/10.1111/j.1365-2591.2012...
The association with propylene glycol using different ratios was evaluated in terms of physical and chemical properties, and 20% propylene glycol mixed with 80% distilled water favored the manipulation of MTA, pH, calcium release, and flowability, causing minor changes in setting time.5353. Duarte MA, Aguiar KA, Zeferino MA, Vivan RR, Ordinola-Zapata R, Tanomaru-Filho M, et al. Evaluation of the propylene glycol association on some physical and chemical properties of mineral trioxide aggregate. Int Endod J. 2012 Jun;45(6):565-70. https://doi.org/10.1111/j.1365-2591.2012.02012.x
https://doi.org/10.1111/j.1365-2591.2012...
Another study showed that propylene glycol increased the adhesion of MTA.

New formulations

New formulations that enhance flowability include MTA HP, MTA Flow, and Biodentine, and those which incorporate ceramic compounds are Biodentine and Endosequence.

Biological properties of calcium silicate-based cements and new calcium silicate-based cements

MTA basically consists of calcium silicates. Calcium silicate-based cements with various chemical compositions are, in general, bioactive.5454. Parirokh M, Torabinejad M, Dummer PM. Mineral trioxide aggregate and other bioactive endodontic cements: an updated overview - part I: vital pulp therapy. Int Endod J. 2018 Feb;51(2):177-205. https://doi.org/10.1111/iej.12841
https://doi.org/10.1111/iej.12841...
New calcium silicate-based restorative cements that offer alternatives to bismuth oxide have been developed, such as Biodentine (Septodont, Saint-Maur-des-Fossés, France), Neo MTA Plus (Avalon Biomed Inc, Bradenton, USA),5555. Camilleri J. Staining potential of neo MTA Plus, MTA Plus, and biodentine used for pulpotomy procedures. J Endod. 2015 Jul;41(7):1139-45. https://doi.org/10.1016/j.joen.2015.02.032
https://doi.org/10.1016/j.joen.2015.02.0...
and MTA Repair HP3131. Cintra LT, Benetti F, Queiroz ÍOA, Lopes JMA, Oliveira SHP, Araújo GS et al. Cytotoxicity, Biocompatibility, and Biomineralization of the New High-plasticity MTA Material. J Endod. 2017 May;43(5):774-8. https://doi.org/10.1016/j.joen.2016.12.018
https://doi.org/10.1016/j.joen.2016.12.0...
(Angelus Soluções Odontológicas, Londrina, Brazil).

Calcium silicate-based endodontic cements have also been developed, such as MTA Fillapex (Angelus, Londrina, Brazil), Neo MTA Plus (Avalon Biomed, USA), iRoot SP (Inovate BioCeramix, Inc., Vancouver, Canada), and TotalFill BC sealer (FKG Dentaire, La-Chaux-de-Fronds, Switzerland).5656. Rodríguez-Lozano FJ, García-Bernal D, Oñate-Sánchez RE, Ortolani-Seltenerich PS, Forner L, Moraleda JM. Evaluation of cytocompatibility of calcium silicate-based endodontic sealers and their effects on the biological responses of mesenchymal dental stem cells. Int Endod J. 2017 Jan;50(1):67-76. https://doi.org/10.1111/iej.12596
https://doi.org/10.1111/iej.12596...
MTA Fillapex is a paste-paste endodontic cement, composed of salicylate resin, natural resin, silica nanoparticles, MTA, and calcium tungstate as radiopacifying agent. Neo MTA Plus cement is a dicalcium silicate-based powder-gel system that may be used as restorative or endodontic cement with varying powder-gel ratios. iRoot SP is composed of zirconium oxide, calcium silicates, calcium phosphate, calcium hydroxide, and thickening agents, made available in a ready-for-use formula and used for root canal filling. EndoSequence BC sealer (Brasseler USA, Savannah, USA) and TotalFill BC sealer (FKG, La Chaux-de-Fonds, Switzerland; Brasseler, Savannah, USA) are composed of zirconium oxide, calcium silicates, monobasic calcium phosphate, calcium hydroxide, and thickening agents. This (type of) cement is made available in a ready-to-use formula, sets with dentin moisture, and was developed for root canal filling.

iRoot SP endodontic cement showed no cytotoxicity to rat fibroblasts (L929).5757. Zhang W, Li Z, Peng B. Ex vivo cytotoxicity of a new calcium silicate-based canal filling material. Int Endod J. 2010 Sep;43(9):769-74. https://doi.org/10.1111/j.1365-2591.2010.01733.x
https://doi.org/10.1111/j.1365-2591.2010...
The cytocompatibility of iRoot SP endodontic cement was also observed by Zoufan et al.5858. Zoufan K, Jiang J, Komabayashi T, Wang YH, Safavi KE, Zhu Q. Cytotoxicity evaluation of gutta flow and endo sequence bc sealers. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2011 Nov;112(5):657-61. https://doi.org/10.1016/j.tripleo.2011.03.050
https://doi.org/10.1016/j.tripleo.2011.0...
in fresh cement and after the cement had set. The iRoot SP cement could induce greater osteoblast differentiation and a lower level of inflammatory response in periodontal ligament cells than did Sealapex.5959. Güven EP, Yalvaç ME, Kayahan MB, Sunay H, Şahın F, Bayirli G. Human tooth germ stem cell response to calcium-silicate based endodontic cements. J Appl Oral Sci. 2013 Jul-Aug;21(4):351-7. https://doi.org/10.1590/1678-775720130047
https://doi.org/10.1590/1678-77572013004...

Both MTA and iRoot SP could induce cell differentiation in osteoblast cells in the human dental germ.5959. Güven EP, Yalvaç ME, Kayahan MB, Sunay H, Şahın F, Bayirli G. Human tooth germ stem cell response to calcium-silicate based endodontic cements. J Appl Oral Sci. 2013 Jul-Aug;21(4):351-7. https://doi.org/10.1590/1678-775720130047
https://doi.org/10.1590/1678-77572013004...
Satisfactory antibacterial action of iRoot SP was observed against Enterococcus faecalis.6060. Zhang H, Shen Y, Ruse ND, Haapasalo M. Antibacterial activity of endodontic sealers by modified direct contact test against Enterococcus faecalis. J Endod. 2009 Jul;35(7):1051-5. https://doi.org/10.1016/j.joen.2009.04.022
https://doi.org/10.1016/j.joen.2009.04.0...
Zhu et al.6161. Zhu L, Yang J, Zhang J, Peng B. A comparative study of BioAggregate and ProRoot MTA on adhesion, migration, and attachment of human dental pulp cells. J Endod. 2014 Aug;40(8):1118-23. https://doi.org/10.1016/j.joen.2013.12.028
https://doi.org/10.1016/j.joen.2013.12.0...
observed that BioAggregate cement (Innovative Bioceramix, Vancouver, BC, Canada) was capable of promoting cell adhesion, migration, and fixation of human dental pulp cells (HDPCs), indicating its cytocompatibility.

Endosequence BC sealer is a bioceramic endodontic cement that promotes greater cell viability than does AH Plus Jet.6262. Willershausen I, Callaway A, Briseño B, Willershausen B. In vitro analysis of the cytotoxicity and the antimicrobial effect of four endodontic sealers. Head Face Med. 2011 Aug;7(1):15. https://doi.org/10.1186/1746-160X-7-15
https://doi.org/10.1186/1746-160X-7-15...
EndoSequence BC sealer presented a higher level of biocompatibility than recently manipulated AH Plus and MTA Fillapex, both fresh and after setting. BC sealer has shown adequate adhesion to fibroblasts.6363. Zhou HM, Du TF, Shen Y, Wang ZJ, Zheng YF, Haapasalo M. In vitro cytotoxicity of calcium silicate-containing endodontic sealers. J Endod. 2015 Jan;41(1):56-61. https://doi.org/10.1016/j.joen.2014.09.012.
https://doi.org/10.1016/j.joen.2014.09.0...
When EndoSequence BC sealer cement came into contact with the physiological solution, there was leaching of calcium and formation of the calcium phosphate phase.6464. Xuereb M, Vella P, Damidot D, Sammut CV, Camilleri J. In situ assessment of the setting of tricalcium silicate-based sealers using a dentin pressure model. J Endod. 2015 Jan;41(1):111-24. https://doi.org/10.1016/j.joen.2014.09.015
https://doi.org/10.1016/j.joen.2014.09.0...

The use of 5% sodium hypochlorite associated with EndoSequence BC sealer promoted greater antibacterial action against biofilm formed on dentin than did the use of irrigant solution only.6565. Du T, Wang Z, Shen Y, Ma J, Cao Y, Haapasalo M. Combined antibacterial effect of sodium hypochlorite and root canal sealers against Enterococcus faecalis biofilms in dentin canals. J Endod. 2015 Aug;41(8):1294-8. https://doi.org/10.1016/j.joen.2015.04.023
https://doi.org/10.1016/j.joen.2015.04.0...
Wang et al.,6666. Wang Z, Shen Y, Haapasalo M. Dentin extends the antibacterial effect of endodontic sealers against Enterococcus faecalis biofilms. J Endod. 2014 Apr;40(4):505-8. https://doi.org/10.1016/j.joen.2013.10.042
https://doi.org/10.1016/j.joen.2013.10.0...
in a confocal laser scanning microscopy study, found that in the period of 30 days BC sealer was capable of eliminating 45% of Enterococcus faecalis from dentinal tubules, demonstrating that the antimicrobial action of BC sealer persisted even after the material had set.

TotalFill BC sealer is an endodontic cement similar to EndoSequence BC sealer, but it promotes significantly greater cell proliferation than do AH Plus and MTA Fillapex. The morphology of the cells seeded on TotalFill BC Sealer and AH Plus presented similar characteristics, with extracellular matrix production, whereas the fixation of cells on MTA Fillapex discs was limited, with only some cells on the surface of the material.5656. Rodríguez-Lozano FJ, García-Bernal D, Oñate-Sánchez RE, Ortolani-Seltenerich PS, Forner L, Moraleda JM. Evaluation of cytocompatibility of calcium silicate-based endodontic sealers and their effects on the biological responses of mesenchymal dental stem cells. Int Endod J. 2017 Jan;50(1):67-76. https://doi.org/10.1111/iej.12596
https://doi.org/10.1111/iej.12596...

MTA-Ang (Angelus, Londrina, Brazil), MTA-HP (Angelus, Londrina, Brazil), and Neo MTA-P (Avalon Biomed Inc, Bradenton, USA) showed cell viability and a high degree of cell proliferation and adhesion.6969. Tanomaru-Filho M, Andrade AS, Rodrigues EM, Viola KS, Faria G, Camilleri J et al. Biocompatibility and mineralized nodule formation of Neo MTA Plus and an experimental tricalcium silicate cement containing tantalum oxide. Int Endod J. 2017 Dec;50 Suppl 2:e31-9. https://doi.org/10.1111/iej.12780
https://doi.org/10.1111/iej.12780...
When HDPCs were used, MTAP (MTA Plus) had greater cell viability than did MTAF (MTA Fillapex) and FC (Fillcanal). MTAP showed a higher level of alkaline phosphatase activity than did MTAF and FC.6868. Mestieri LB, Gomes-Cornélio AL, Rodrigues EM, Salles LP, Bosso-Martelo R, Guerreiro-Tanomaru JM et al. Biocompatibility and bioactivity of calcium silicate-based endodontic sealers in human dental pulp cells. J Appl Oral Sci. 2015 Oct;23(5):467-71. https://doi.org/10.1590/1678-775720150170
https://doi.org/10.1590/1678-77572015017...

NEO (Neo MTA Plus, Avalon Biomed Inc., Bradenton, USA), MTA (MTA, Angelus, Londrina, Brazil), and TSC/Ta2O5 (experimental tricalcium silicate-based cement, with tantalum oxide) had no cytotoxic effect. In an alizarin red assay, the three materials induced mineralized nodule formation; however, NEO produced a larger number of mineralized nodules than did MTA and TSC / Ta2O5.6969. Tanomaru-Filho M, Andrade AS, Rodrigues EM, Viola KS, Faria G, Camilleri J et al. Biocompatibility and mineralized nodule formation of Neo MTA Plus and an experimental tricalcium silicate cement containing tantalum oxide. Int Endod J. 2017 Dec;50 Suppl 2:e31-9. https://doi.org/10.1111/iej.12780
https://doi.org/10.1111/iej.12780...

MTA HP (Angelus Indústria de Produtos Odontológicos S/A, Londrina, Brazil) showed greater viability in comparison with White MTA-Ang. Histological analysis after subcutaneous implant in rats demonstrated that MTA HP had biocompatibility and biomineralization potentials similar to those of MTA-Ang.3131. Cintra LT, Benetti F, Queiroz ÍOA, Lopes JMA, Oliveira SHP, Araújo GS et al. Cytotoxicity, Biocompatibility, and Biomineralization of the New High-plasticity MTA Material. J Endod. 2017 May;43(5):774-8. https://doi.org/10.1016/j.joen.2016.12.018
https://doi.org/10.1016/j.joen.2016.12.0...

MTA Plus (MTA P) (Avalon Biomed Inc. Bradenton, USA) and MTA (Angelus, Londrina, Brazil) presented no cytotoxicity and induced mineralized nodule formation. By using PCR, the authors observed that exposure of HDPCs to extracts of the two cements increased the expression of osteogenic markers of these cells.7070. Rodrigues EM, Cornélio AL, Mestieri LB, Fuentes AS, Salles LP, Rossa-Junior C et al. Human dental pulp cells response to mineral trioxide aggregate (MTA) and MTA Plus: cytotoxicity and gene expression analysis. Int Endod J. 2017 Aug;50(8):780-9. https://doi.org/10.1111/iej.12683
https://doi.org/10.1111/iej.12683...

Petrović et al.7171. Petrović V, Opačić-Galić V, Živković S, Nikolić B, Danilović V, Miletić V et al. Biocompatibility of new nanostructural materials based on active silicate systems and hydroxyapatite: in vitro and in vivo study. Int Endod J. 2015 Oct;48(10):966-75. https://doi.org/10.1111/iej.12391
https://doi.org/10.1111/iej.12391...
observed that calcium silicate-based materials (CS) and hydroxyapatite (HA-CS) presented a higher level of biocompatibility than MTA (MTA Branco, Angelus Soluções Odontológicas, Londrina, Brazil). Furthermore, better results were observed for CS and HA-CS after subcutaneous implant in rats.

In an evaluation of the biocompatibility of three calcium silicate-based endodontic cements, Bioroot BC Sealer (Septodont, Saint-Maur-des-Fosses, France) (BR), Endoseal MTA (EndoSeal, Maruchi, Seoul, Korea) (ES), and Nano-ceramic Sealer (B&L Biotech, Fairfax, USA) (NCS), with human periodontal ligament stem cells (hPDLSCs), BR and NCS presented better cytocompatibility than ES.7272. Collado-González M, García-Bernal D, Oñate-Sánchez RE, Ortolani-Seltenerich PS, Lozano A, Forner L et al. Biocompatibility of three new calcium silicate-based endodontic sealers on human periodontal ligament stem cells. Int Endod J. 2017 Sep;50(9):875-84. https://doi.org/10.1111/iej.12703
https://doi.org/10.1111/iej.12703...

In addition to a high level of biocompatibility,6262. Willershausen I, Callaway A, Briseño B, Willershausen B. In vitro analysis of the cytotoxicity and the antimicrobial effect of four endodontic sealers. Head Face Med. 2011 Aug;7(1):15. https://doi.org/10.1186/1746-160X-7-15
https://doi.org/10.1186/1746-160X-7-15...
BC sealer was capable of inhibiting the release of iCGRP from trigeminal ganglion neurons, reducing the level of symptomatology after extravasation of the cement during root canal filling.7373. Ruparel NB, Ruparel SB, Chen PB, Ishikawa B, Diogenes A. Direct effect of endodontic sealers on trigeminal neuronal activity. J Endod. 2014 May;40(5):683-7. https://doi.org/10.1016/j.joen.2014.01.030
https://doi.org/10.1016/j.joen.2014.01.0...

Silva Almeida et al.7474. Silva Almeida LH, Moraes RR, Morgental RD, Pappen FG. Are premixed calcium silicate-based endodontic sealers comparable to conventional materials? A systematic review of in vitro studies. J Endod. 2017 Apr;43(4):527-35. https://doi.org/10.1016/j.joen.2016.11.019
https://doi.org/10.1016/j.joen.2016.11.0...
compared the physicochemical and biological properties of premixed calcium silicate-based endodontic sealers with other conventional root canal filling materials by systematically reviewing laboratory studies. Premixed calcium silicate-based endodontic sealers followed the ISO 6876:2012 standard for most physicochemical properties, except for solubility. The target sealers also presented favorable biological characteristics when compared with conventional sealers. Despite the lack of well-designed long-term clinical trials, the target premixed calcium silicate-based sealers showed good physicochemical and biological properties in vitro. In general, the results were similar to or better than those of conventional endodontic sealers, as observed in in vitro and in vivo animal studies.

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Publication Dates

  • Publication in this collection
    18 Oct 2018
  • Date of issue
    2018

History

  • Received
    08 May 2018
  • Reviewed
    29 May 2018
  • Accepted
    12 June 2018
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