12-Mta-Failures After Vital Pulp Therapy

Pediatric Dentistry
5 th
Year
Lec. 12
-MTA
- FAILURES
FAILURES AFTER
AFTER VITAL
VITAL
PULP PULP THERAPY
THERAPY
Assistant
Assistant Professor
Professor
Aseel Haidar
Aseel Haidar
Lec.12 Pedodontics Fifth stage
Assist Prof Dr. Aseel Haidar

MINERAL TRIOXIDE AGGREGATE
MTA is emerging as a popular product for pulpotomies secondary to a variety
of factors. Torabinejad described the physical and chemical properties of MTA in 1995.
It is ash colored powder made primarily of fine hydrophilic particles of:
1) Tricalcium silicate
2) Tricalcium aluminate
3) Tricalcium oxide
4) Silicate oxide and bismuth oxide is added for radio-opacity.
MTA should mixed with sterile water or other sterile liquids in 3: 1

(powder /liquid) ratio to obtain a putty consistency or a thick grainy paste. If the paste
is, too dry it will fall when one try to pick it up. Hydration of the powder results in a
colloidal gel composed of calcium oxide crystals in an amorphous structure. This gel
solidifies into a hard structure in less than three hours (2 hours and 45 minutes).
MTA has an antibacterial effect on some facultative bacteria but no effect on
strict anaerobic bacteria. This limited antibacterial effect is less than that demonstrated by
calcium hydroxide pastes. The ability of MTA to resist the penetration of microorganisms
appears to be high. – The use of MTA as an agent for pulp capping or for providing
apical seal is well documented. Recent studies have indicated that MTA can be used
successfully as a pulpotomy agent also.
Properties of MTA
It is biocompatible material and its sealing ability is better than that of amalgam or
ZOE.
Initial pH is 10.2 and set pH is 12.5
Antimicrobial activity.
The setting time of cement is 4 hours
The ability to set in the presence of moisture and blood.
Low cytotoxicity
It presents with minimal inflammation if extended beyond the apex.
The negative attributes include:

 Difficulty of handling
 Exceptional cost.
 MTA can cause pulp canal obliteration.
Baghdad College of dentistry

25/2/2021 1
MECHANISM OF ACTION
The successful usage of MTA in endodontic applications can be
attributed to its biocompatibility, bioactivity and mechanism of action. The four actions
of MTA after direct placement in contact with living tissues are:
(i) Creation of an unfavorable environment for growth of bacteria due to its alkaline pH.
(ii) Formation of hydroxyapatite like mineral structure on its surface and provide the
biological seal.
(iii) Formation of calcium hydroxide, which dissociates to release Ca ions, to promotes
cellular attachment and proliferation.
(iv) Modulation of cytokine production and encouragement of hard tissue forming cells to
differentiate and migrate.
Clinical applications of MTA

1) Pulp capping:
a) Direct Pulp Capping:
MTA is suitable as a pulp capping because it stimulates dental bridge
formation and the bridge formed adjacent to MTA will be thick and continuous with
regional dentin. No bacteria were observed on the cavity wall when MTA was used,
due to sealing ability, biocompatibility, alkalinity, and ability of MTA to stimulate
dentin bridge formation.
b) Pulpotomy of immature permanent teeth:
The pulp responds favorably to the protection provided by an MTA layer,
and the reparative dentin is consistently uniform and thicker under MTA
more than that with Ca (OH) 2.
c) Pulpotomy of primary teeth
MTA seems to be a suitable replacement for T.C.F.
2) Root resorption
3) Apexification
4)Furcal repair
5) Perforation repair
6) Root ending filling

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FAILURES AFTER VITAL PULP THERAPY

Factors that may lead to failure in the formation of a calcified bridge across the vital
pulp may involve:
1) The age of the patient
2) Degree of surgical trauma
3) Sealing pressure
4) Improper choice of capping material
5) Low threshold of host resistance
6) Presence of microorganisms with subsequent infection.
This failure may appears as:

Internal resorption
Alveolar abscess
Early exfoliation or over retention of primary teeth with pulp treatment
INTERNAL RESORPTION
One of the most frequently seen evidence of an abnormal response in primary
teeth within the pulp canal several months after the pulpotomy procedure is the
radiographic evidence of internal resorption.
Internal resorption is a destructive process
generally caused by odontoclastic activity, and it
may progress slowly or rapidly. Occasionally,
secondary repair of the resorbed dentinal area
occurs. No satisfactory explanation for the post
pulpotomy type of internal resorption has been
given. However, that with a true carious exposure of
the pulp, an inflammatory process will be present to
some degree. The inflammation may be limited to
the exposure site, or it may be diffused throughout
the coronal portion of the pulp. Amputation of all
pulp showing the inflammatory change may be difficult or impossible, and abnormal
pulp tissue may be allowed to remain. If the inflammation extended to the entrance
of the pulp canal, odontoclasts may have been attracted to the area; if it were possible
to examine the tooth histologically; small bays of resorption would be evident. This
condition may exist at the time of pulp therapy, although there is no way to detect it.
The only indication would be the clinical evidence of a hyperemic pulp.
Inflammatory cells drawn to the area because of the placement of an irritating

25/2/2021 3
capping material might well attract odontoclastic cells and initiate internal resorption.
This may explain the occurrence of internal resorption even though the pulp is
normal at the time of treatment. Because the roots of primary teeth are undergoing
normal physiologic resorption, vascularity of the apical region is increased. When an
irritant in the form of a pulp-capping material is placed on the pulp, odontoclastic
activity present in the area and may predispose the tooth to internal resorption.
ALVEOLAR ABSCESS
Some months after pulp therapy has been
completed, an alveolar abscess occasionally
develops. The tooth usually remains asymptomatic,
and the child is unaware of the infection, which may
be present in the bone surrounding the root apices or
in the area of the root bifurcation.
A fistulous opening may be present,
which indicates the chronic condition of the infection.
Primary teeth that show evidence of an alveolar abscess should be removed.
Endodontic treatment may be considered for permanent teeth that have previously
been treated by pulp capping or by pulpotomy and later show evidence of pulpal
necrosis and apical infection.
EARLY EXFOLIATION OR OVER-RETENTION OF PRIMARY

TEETH WITH PULP TREATMENTS
Occasionally a pulpally treated tooth previously believed to be successfully
managed will loosen and exfoliate (or require extraction) prematurely for no apparent
reason. It is believed that such a condition results from low-grade, chronic,
asymptomatic, localized infection. Usually, abnormal and incomplete root resorption
patterns of the affected teeth are also observed. When this occurs, space management
must be considered.
Another sequela requiring close
observation is the tendency for primary teeth
undergoing successful pulpotomies or
pulpectomies to be over-retained. This situation
may have the untoward result of interfering with
the normal eruption of permanent teeth and
adversely affecting the developing occlusion.

25/2/2021 4
Close periodic observation of pulpally treated teeth is necessary to intercept such a

developing problem. Extraction of the primary tooth is usually sufficient. This
phenomenon may occur when normal physiologic exfoliation is delayed by the bulky
amount of cement contained in the pulp chamber. Even though the material is
resorbable, its resorption is slowed significantly when large quantities are present.

25/2/2021 5

12-Mta-Failures After Vital Pulp Therapy

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Pediatric Dentistry

Assist Prof Dr. Aseel Haidar

MTA should mixed with sterile water or other sterile liquids in 3: 1

The negative attributes include:

Baghdad College of dentistry

Clinical applications of MTA

Baghdad College of dentistry

FAILURES AFTER VITAL PULP THERAPY

This failure may appears as:

Baghdad College of dentistry

EARLY EXFOLIATION OR OVER-RETENTION OF PRIMARY

Baghdad College of dentistry

Close periodic observation of pulpally treated teeth is necessary to intercept such a

Baghdad College of dentistry

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