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Endo tips    Better Endo    Endo abstracts    Endo discussions

  Perforation-MTA the basics

The opinions within this web page are not ours. Authors have been credited for the individual posts where they are. photographs courtesy: Jörg Schröder

From: "Jörg Schröder"
To: "ROOTS"
Sent: Friday, October 03, 2008 2:00 AM
Subject: Re: [roots] Perforation-MTA the basics

Question:

I have been using MTA for perforation repairs for quite some time successfully now and
I am convinced that "it works". However tongue-in-cheek I would like to ask some very
basic questions here (and I hope I am not made to feel embarrassed & ridiculed).

Why MTA why not anything else? Why won't GIC, amalgam, AH plus sealer work

Why does a perforation not behave like an apical foramen? Isn't the peri-perforation
micro anatomy similar  to that of an apical foramen? We don't seal the apical foramen
with MTA and neither is it needed. So why doesn't sealing a perforation with sealer
and GP cones work? Cutting off the apex during an Apico-ectomy surgery with or with
out retrograde filling works, then why can't the tooth tolerate a perforation sealed
with GP and sealer? I am curious about what is so peculiar about a perforation that
it behaves differently from an apical foramen.

This is one of the questions in endodontics that I wanted to ask but was too shy
to admit my ignorance.

Please enlighten me. - Dr Sanjay Jamdade

Dear Sanjay,

as the perforations i see everday in my office already exist for weeks
or even months within poor disinfected root canal systems and in teeth
with leaking fillings/crowns in almost all of these cases there is no
tissue of any kind at the periodontal side of the perforation. So it
will be very difficult to controll extrusion of sealer/GP atleast in
my hands. As in most of the cases there also exists a
"periperforational" inflammation drying of the perforation side is not
very easy. MTA does not need dry conditions to set. I am afraid most
of our sealers do. What about biocompatibilty of GIC, Amalgam,
Sealer ? BTW: If I have to seal a foramen with ISO 60 or larger I use
MTA because of the better control and the let's say moist conditions
in foramen sizes like this. I know these are "only" arguments related
to the practical work, but that is atleast, to me,  as important as
the scientific background. Attached a case I posted some weeks ago.
How will you get healing with GIC, Amalgam or Sealer in this case?

Just my 2 Cents

Best regards from Berlin - Jörg Schröder

  
  
  
  
  
Beautiful work and images Jörg, I wish the prosthesis was going to be replaced... Also the pH of MTA favors healing--- and the attachment of fibroblasts, seems as though the tissues love the stuff. - Kendel Thank you Kendel, unfortunately as it is a referred pt. so it is not in my hands ;((. Sometimes it's a sad (dental) life. - Jörg Dear Sanjay, Please refer to the below information on your questions. It's not exact answers, but for your reference. Why MTA why not anything else? Why won't GIC, amalgam, AH plus sealer work? MTA is a biocompatible cement, which has a consistent property for perforation. The others you mentioned are flowable, it is easy to be extruded through periperforation. There are two peforations, Furcation Perforation and Root Perforation (or Radicular Reabsorption). In Furcation Perforation, MTA or Bio-cement is better for perioperforation for cell and perio-environment. (biocompatibility and consistency) - MTA, MTA Angelus, BioA DiaRoot, IRM, etc. Why does a perforation not behave like an apical foramen? It's very difficult to answer because of behavior meaning. But we can consider these of perforation and apical foramen as house-wall damange and door. So perforation (Furcation or Root) is damaged (Vital), as apical foramen is not damaged by itself. So a peforation doesn't behave like an apcial foramen. Isn't the peri-perforation micro anatomy similar to that of an apical foramen? Yes. The periperforation micro anantomy is similar to that of an apical foramen. But perforation was damaged or broken by any external casues. We don't seal the apical foramen with MTA and neither is it needed. In wide open apical foramen, we need to seal it with MTA or fibroblasts as apex plugger not to extrude the sealer or in order to prevent from reinfection. So why doesn't sealing a perforation with sealer and GP cones work? This question is about Root Perforation or radicular resorption. It's possible to seal a perforation with sealer and GP cones. It depends on the sealer material. ZOE or Resin sealers are not penetrated to the perforation. But if you use specific bio-sealers, you can seal the root perforation with sealer and GP. For example: MTA Sealer (Denstply), Dentalcrete sealer (Dentsply), BioCeramic Sealer (Brasseler USA) for root peforation or radicular resorption. Cutting off the apex during an Apico-ectomy surgery with or with out out retrograde filling works, then why can't the tooth tolerate a perforation sealed with GP and sealer? This is the same as Furcation Perforation. After surgical apicoectomy, the surgical part of root end is vital. You consider the perio-evironment of surgical apicoectomy. In case, you need retrograde filling or root-end plugging with MTA (MTA, MTA angelus, DiaRoot, etc.) or fibroblasts. This will prevent from overfilling and extrusion, healing of perio-inflammation. There are many biocompatible materials and sealers for perforation and root repair in the market. This is just for your reference. - Alvin Kim
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