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Why MTA Obturation is the Chosen Technique as a Sealer in Root Canal Therapy

You have a choice when applying a sealer during endodontic treatment such as a root canal. MTA obturation is known to promote a level of osteogenesis and healing not previously possible prior to the availability of MTA (Mineral Trioxide Aggregate). [1] The following will summarize some of the key components and benefits of MTA obturation. A more detailed clinical treatise is available if you desire to explore the finer points of the procedure. [2] That said, let’s proceed.

The evolution of MTA and it’s application for MTA obturation

The world of bioceramic based sealers has evolved within the medical and dental industries. You’re accustomed to using sealant materials such as alumina, zirconia, bioactive glass, glass ceramics, hydroxyapatite, and calcium phosphates. [3]

You’ll also recognize that bioceramic based sealers are typically grouped in two categories: calcium silicate based sealers (MTA based and non-MTA based) and calcium phosphate based sealers. Materials can be considered bioactive or bio-inert. The outcome you achieve depends on their interaction with the surrounding viable tissue.

To date, two formulations of MTA have existed:

The “grey” version: composed of silicate, bismuth oxide, tricalcium aluminate, calcium sulphate, dehydrate (gypsum), and calcium aluminoferrite.

The “white” version: composed of tricalcium silicate, dicalcium silicate, bismuth oxide, tricalcium aluminate, calcium oxide, aluminum oxide, and silicon dioxide.

As a bioactive material, MTA was first introduced as a sealant between roots and the external surfaces of teeth. Its ability to promote healing and osteogenesis makes MTA the leading choice for endodontic therapies.

  • Excellent biocompatibility and sealing ability in the presence of moisture
  • Hydrophilic nature and good capacity of marginal adaptation
  • Good antibacterial properties as result of high pH
  • Ability to stimulate cementum-like formation, osteoblastic adherence, and bone regeneration

”Moreover, its sealing, mineralizing, dentinogenic and osteogenic potentials make it the preferred choice for numerous clinical applications such as direct pulp capping, root-end filling, apexogenesis and apexification in immature teeth with necrotic pulp, filling of root canals, treatment of horizontal root fractures, treatment of internal and external resorption, and repair of perforations. [4]

What outcomes are expected with MTA obturation?

A variety of influences impact outcomes when you use MTA. It’s common to fill endodontic perforations with amalgam, zinc oxide-eugenol cements, calcium hydroxide, and composite resin and glass-ionomer cements.

Beyond materials used, your experience as a practitioner is a factor as well. Treatment can also be negatively impacted by post placement following treatment, the presence of preoperative lesions and their interaction with the perforation site and your patient’s mouth, and your patient’s gender.

More specifically, the perforation’s location and the quality of the final restoration are discovered to have a significant influence on the outcome. At a measurable level, the perforation site (mid-root and apical) and the perforation’s size (larger than 3 mm) provided a major prediction for progressive inflammation to reoccur.

What about the use of MTA obturation for apical surgery?

Your surgical outcomes will be influenced by the materials you use for root-end filling. As you’re aware amalgam has been the most popular material. But an increase in blood mercury levels within one week of the procedure is to be noted.

Also keep in mind that amlagam’s sealing ability can be compromised on occasion when used for apical surgery. This qualifies MTA as a “gold-standard” for endodontic procedures.

  • Its excellent sealing ability
  • Its hard tissue induction and conduction

You can also expect MTA to provide better regeneration outcomes when applied to periapical tissues. You’ll find the results much better than compared with SuperEBA, amalgam, intermediate restorative material, 4-META/MMA-TBB resin, and thermoplasticized gutta-percha.

Overall, the biocompatibility of MTA gives it the advantage for filling the apex in large root canals. And you’ll experience the same advantages with apexification/apexiogenesis in immature teeth that contain necrotic pulp.

Are there any disadvantages associated with MTA obturation?

The problem of discoloration

The potential for discoloration as the main disadvantage during vital pulp therapy and perforation repair has prompted some alternatives. One option you have is using bioactive cements in similar procedures. You’ll discover that this alternative can reduce the setting time.

Even so, be aware that discoloration can occur when alternatives to MTA are used. This is primarily due to contact with sodium hypochlorite and other formulations containing tricalcium silicate, dicalcium silicate, tricalcium aluminate, calcium oxide, and tungstate as an opacifier.

There is a solution to discoloration. The use of PDTM MTA White (Produits Dentaires) has produced no staining or discoloration. And it accomplished this without changing the biological or chemical features of MTA.

The problem of bleeding management

You’ll discover that blood contamination could be a factor that increases discoloration in calcium silicate-based materials. Bismuth oxide-free Portland cement can also reveal diminished color when bleeding is present.

Unset MTA and its surface porosity is what commonly leads to the presence of blood elements. This could explain the discoloration associated with calcium-silicate based cements. Even more specific is understanding that erythrocyte can penetrate the material and following hemolysis the cement and tooth can reveal discoloration.

What protocols can help assure success with MTA obturation?

Following detailed manufacturer instructions can lead to problem-free usage of MTA. Carrier specific recommendations are necessary for MTA obturation.

Dedicated carriers are available for your use. Keep in mind that size differentials determine the amount of material placed into the root canal.

Carriers should allow fast, efficient, and precise positioning of the material. MAP System (Produits Dentaires) is one such dedicated carrier that adapts to every clinical situation. It accommodates needles of differing sizes, angles, and materials:

  • The MAP System advantage involves NiTi Needles
  • Useful in both orthograde and surgical procédures
  • They can be bent to allow precise material placement
  • Shape of the needle is retained after sterilization

Overall, when using an MTA carrier it’s mandatory to avoid allowing the material to harden inside of the applicator. Once hardening occurs it’s next to impossible to remove.

Instrument efficiency can be maintained with proper cleaning of the needle immediately after MTA extrusion. Clinical procedures should determine the amount of MTA used.

Generally speaking, it’s not necessary to completely fill the root canal with MTA. Once it’s set, material removal would be more difficult. Follow accurate protocols and use specifically designed tools. This will lead to good outcomes when using MTA obturation for primary and secondary endodontic treatments.

A more comprehensive clinical treatise is available from Produits Dentaires SA that outlines the clinical applications of MTA in endodontics. [5]

This article was based on the paper “Clinical applications of mineral trioxide aggregate in endodontics” by dr Arnaldo Castellucci. The original document (in English) is available on our e-Learning platfom.


[1]  Torabinejad M, Parirokh M. Mineral trioxide aggregate: a comprehensive literature review–part II: leakage and biocompatibility investigations. J Endod. 2010;36(2):190-202.

[2] Clinical applications of MTA in endodontics Arnaldo Castellucci, Matteo Papaleoni, Francesca Cerutti

[3] Jafari F, Jafari S. Composition and physicochemical properties of calcium silicate based sealers: A review article. Journal of clinical and experimental dentistry. 2017;9(10):e1249-55

[4] Parirokh M, Torabinejad M, Dummer PMH. Mineral trioxide aggregate and other bioactive endodontic cements: an updated overview – part I: vital pulp therapy. Int Endod J. 2017

[5] Clinical applications of MTA in endodontics, Arnaldo Castellucci, Matteo Papaleoni, Francesca Cerutti

Coronavirus recommendations for dental practice

The following article is based on the paper “Coronavirus Disease 2019 (COVID-19): Emerging and Future Challenges for Dental and Oral Medicine”, released by the researchers from Wuhan University School and Hospital of Stomatology on 12 March 2020.

The epidemic of coronavirus disease 2019 (COVID-19), originating in Wuhan, China, has become a major public health challenge for not only China but also countries around the world. On 11 March 2020, WHO declared COVID-19 a pandemic, pointing to “alarming levels” of spread and severity and confirmed that it is a first pandemic caused by a coronavirus. Owing to the characteristics of dental settings as well as transmission routes of the virus, the risk of cross contamination can be high between patients and dental practitioners. For dental practices and hospitals in areas that are (potentially) affected with COVID-19, strict and effective infection control protocols are urgently needed.

What is coronavirus and how does it impact dental procedures?

According to WHO, “Coronavirus disease (COVID-19) is an infectious disease caused by a newly discovered coronavirus. The COVID-19 virus spreads primarily through droplets of saliva or discharge from the nose when an infected person coughs or sneezes.” Due to the unique characteristics of dental procedures, the standard protective measures applied in daily practice are not effective enough to prevent the spread of COVID-19, especially for patients who are not aware of being infected, or for those who decide to conceal their infection.

Infection control protocols

coronavirus dental treatment

Since the virus can persist on surfaces for a few hours or up to several days, depending on the type of surface, the temperature, or the humidity of the environment, it is crucial to thoroughly disinfect all surfaces within the dental clinic. In parallel to respecting the good hand hygiene, it is recommended to use personal protective equipment, such as masks, gloves, gowns, and goggles or face shields which can help protect skin and mucosa from infected blood or secretion.

Recommendations for dental practice

Based on experience and relevant guidelines and research, the researchers from Wuhan University School and Hospital of Stomatology prepared a number of recommendations for dental practitioners and students in (potentially) affected areas. Those include:

Evaluation of patients: during the outbreak of COVID-19, dental clinics are recommended to establish precheck triages to measure and record the temperature of every staff and patient as a routine procedure. In the areas where the virus spreads, nonemergency procedures should be postponed.

Oral examination: all procedures which are likely to provoke coughing or excessive saliva secretion should be avoided or performed cautiously. “Intraoral x-ray examination is the most common radiographic technique in dental imaging; however, it can stimulate saliva secretion and coughing (Vandenberghe et al. 2010). Therefore, extraoral dental radiographies, such as panoramic radiography and cone beam CT, are appropriate alternatives during the outbreak of COVID-19.”

Treatment of emergency cases: dental emergencies can occur and deteriorate quickly requiring immediate treatment. Rubber dams and high-volume saliva ejectors can help minimize aerosol or spatter in dental procedures. If the tooth needs to be extracted, absorbable suture is preferred. Preoperative antimicrobial mouth rinse could reduce the number of microbes in the oral cavity.

Recommendations for dental education: in order to avoid unnecessary exposure to the virus, the researchers suggest opting for online courses, webinars and problem-based learning tutorials.

“For dental practices and hospitals in countries and regions that are (potentially) affected with COVID-19, strict and effective infection control protocols are urgently needed,” prof. Zhuan Bian and coauthors stated. “Dentists should take strict personal protection measures and avoid or minimize operations that can produce droplets or aerosols. Four-handed technique is beneficial for controlling infection. The use of saliva ejectors with low volume or high volume can reduce the production of droplets and aerosols.”

EssenSeal: R&D path to a new product

The development of a new product requires a good dose of openness and curiosity.  To dig deeper, to go to the source, to seek and find the information necessary to bring the product to life. The process can take several years, depending on its complexity. What matters in this case is the flexibility and reactiveness of the team involved. Like in the case of EssenSeal, a new generation zinc oxide eugenol sealer featuring tea tree essential oil (Melaleuca) launched by Produits Dentaires in 2019.

Interview with David Brendlen, Biomaterials Engineer in charge of R&D team and Baptiste Reuse, R&D Project Manager at Produits Dentaires.

Why EssenSeal?

David: The initial idea was to provide dental professionals with a cement which strictly meets the ISO 6876 standard requirements. This standard specifies requirements and test methods for endodontic sealing materials used for permanent obturation of the root canal. We focused on testing the physicochemical properties of liquid and solid components and the synergy between them. The objective was to enhance the potential of eugenol by testing its interaction with different essential oils, whose properties could further enhance our new sealer. As a result, we developed a product with ideal consistency and smooth texture, contributing to a controlled setting time, without surprises, and validated long term efficiency.

How long does it take to develop a new product? How does the development process look like?

David: It takes several years to develop a new product, depending on its complexity. We start the process putting ourselves in the users’ shoes. We need to understand a dentist who will be using our product, take into consideration the data and clinical research as well as actual needs of the users. The next step is to forget what we know exists, start fresh. It’s a blank page which will be filled with new drafts and concepts aimed at facilitating the clinical procedure.

EssenSeal from Produits Dentaires

What was the biggest challenge when developing EssenSeal?

Baptiste: One of the biggest challenges faced when developing EssenSeal was to remaster the properties of zinc oxide eugenol, one of the most popular materials used in dentistry, without adding unnecessary complexity to the product. Simplicity was our objective and at the same time challenge here. The EssenSeal’s formula contains no excessive components. Every element has been studied, tested and verified. We controlled the particles’ size, tested the properties of various essential oils before eventually opting for tea tree essential oil. By giving each component of EssenSeal an opportunity to express its full potential and generate positive synergy with other elements, we achieved our goal: to offer dentists simple, effective and efficient sealer with safe and predictable sealing properties over long term.

Did you discover any unexpected properties of EssenSeal while developing it?

Baptiste: Yes. EssenSeal’s formula has been gradually refined through extensive testing and all the ingredients were carefully chosen for their properties. However, what surprised us was the strong synergy between the components, such as the combination of the powder’s smoothness and the tea tree essential oil’s properties, which allows the cement to flow and penetrate the canal anatomy in a very thin layer, up to less than 10µm. This is five times finer than the golden standard for zinc oxide eugenol known so far. It greatly improved the final sealing properties, as even root canal crevices and complex anatomies can now be reached. Combined with the interaction of the different essential oils and their properties, this three-dimensional sealing limits the development of residual bacteria and prevents the risk of infection.

What makes EssenSeal so special?

Baptiste: The majority of the eugenol-based sealers available on the market were developed many years ago. But the users’ needs evolved in the meantime. That is why we turned to dental professionals and sought their insights when developing EssenSeal. The feedback we received helped us understand their needs and expectations. One of the remarks received most often concerned the consistency of the existing sealers, as well as their smell. This is why EssenSeal is the only sealer available on the market which combines a pleasant refreshing scent, smoothness and whiteness of the powder when mixed with optimal consistency. On top of that, its mixing ratio is as simple as one drop of liquid for one spoon of powder, which greatly improves the user experience.

EssenSeal meets the ISO 6876 standard requirements, making it an ideal cement for ensuring safe long-term sealing. What makes EssenSeal so special is the fact it explores the properties of essential oils, not only eugenol. This synergy has a significant impact on the quality of the treatment and helps the product meet the clinical expectations associated with endodontic treatment.

Irrigation in Endodontics— New Standards in the Dental Office

The interview with Dr Uwe Radmacher originally appeared in Roots International, issue 3/2019.

A main goal of endodontic treatment is to effectively irrigate the canal and thus prevent reinfection of the periapical tissue. Recently, a range of new products have appeared, many of them claiming to provide effective and safe irrigation. We spoke to German endodontist Dr Uwe Radmacher about his experience with the new IrriFlex irrigation needle launched by PD (Produits Dentaires) in March last year.

The success of endodontic treatment depends on the eradication of microbes from the root canal system and prevention of reinfection. How important is irrigation in this process?

Irrigation is like a 3D file. I liken it to drilling pipelines in a generally complicated root canal system with many variations and flooding these with an effective irrigant, which is still sodium hypochlorite, able to reach anastomoses and lateral canals. The infected tissue can be removed and sufficient cleaning and disinfection can occur. The 3D cavity is prepared.

Mechanical devices have been developed to improve the penetration of irrigants and effectiveness of irrigation in the most apical part of the main root canal in order to overcome the limitations of conventional metal needles. Could you tell us what these limitations are, and how these have impacted on your day-to-day treatment workflow and irrigation protocol?

First of all, chemical and mechanical disinfection have the same impact on successful outcomes in endodontics. Currently, there is none without the other.

The main claim of mechanical shaping is the creation of a tapered, funnel-like preparation to support an effective eradication of microbes and to support proper sealing. At the same time, the apical foramen should not be unnecessarily enlarged and should be kept as small as is practical. Discussion about the preparation sizes to be reached is as old as endodontics itself.

Previously, irrigation needles were mostly not able to reach the most apical part and prevent blocking due to remaining debris. Furthermore, there is a present risk of blocking the needle and over-extruding fluid, especially with a front-vented design. Personally, I did not like the common single-side-vented needles for my irrigation protocol because I did not feel comfortable with the penetration of the fluid at the most apical point. Owing to the existing needle diameters and a small apex size, it is frequently not possible to reach working length and rinse the debris out. This back-draft can’t be compensated for by activating the fluid with sonic and ultrasonic devices just when a particular block of remaining debris has already appeared is frequently not as easy to detect as it is in an endodontic training glass block. Thus, the prevention of residual debris by irrigating the critical parts of the root canal system copiously and continually is essential for successful treatment outcome.

You have recently begun using IrriFlex, a new revolutionary 30-gauge irrigation needle. What is the main benefit of this new product, and how has it affected your irrigation procedure?

I did some trials before the official launch with the new TruNatomy shaping files (Dentsply Sirona). Previously, it was almost impossible to create proper delivery and exchange of the fluid in the apical third of the root canal. This changed totally when the new IrriFlex became part of the game. The needle is totally flexible and comes in size 30/.04 and perfectly fits even the tiny TruNatomy Prime shaping file with a size of 26/.04 v.The efficient delivery up to working length and the minimised risk of over-extrusion of the double-side-vented design is the final building block of sustainable disinfection.

IrriFlex features two back-to-back side vents and thus delivers a greater volume of irrigant compared with conventional side-vented needles. How can this feature improve the endodontic irrigation procedure?

Irrigation is now much more powerful in the critical most apical part with a tremendously decreased risk of accidentally pushing sodium hypochlorite through the apical foramen into sensitive areas like the sinus and mental nerve. This is definitely a huge improvement.

The new-generation root canal instrumentation systems respect the canal anatomy as far as possible. Can you tell us whether IrriFlex furthers this aim?

IrriFlex is fundamental for preserving the dentine using TruNatomy shaping files, for example. The orifice of the root canal, the entrance of the funnel, is about 40 per cent smaller, and the taper in the upper two-thirds is regressive. Even by using devices to agitate the irrigation fluid, there is no possibility of removing the debris without a tiny and highly flexible irrigation needle that reaches the apical end.

IrriFlex is undoubtedly a game changer in endodontic irrigation. Do you consider it your new irrigation standard?

Absolutely, IrriFlex has become a fundamental part of my irrigation protocol.

Innovations, challenges and opportunities for SMEs

This article originally appeared in Le Temps. Click to read the original version in French.

Smartphones, coffee capsules, digital music platforms: breakthrough innovations have no boundaries, changing the way industries operate. By making the existing obsolete, they give inventors competitive advantage over other companies. The fact SMEs cannot ignore. And while certainly not the easiest, this is the path start-ups should follow, according to innovation consultant Eric Fumeaux . “Managing the innovation process is much more difficult and challenging for SMEs. However, small and medium companies will have to concentrate on it more in order to survive,” Mr Fumeaux explains.

Taking the step ahead

Produits Dentaires (PD) did not need this advice to leave its comfort zone. Last March, the company launched IrriFlex, a unique solution to improve cleaning and disinfection in complex root canal anatomies. The innovation immediately appealed to practitioners. As a result, PD plans to market two million units this year.

Looking at this 80-year old company employing little more than 50 employees in its Vevey headquarters, nothing indicated such breakthrough coming up. For the past decades the company’s business models remained unchanged: providing products based on the needs of its distributors. But the times changed. And consequently so did the business model.

With the arrival of new competitors and solutions they introduced, the third-generation owners Nicolas and Yann Gehrig decided to redefine the company’s approach to the products they make. Together with David Brendlen, biomaterials engineer in charge of research and development at Produits Dentaires, they launched the innovation process aimed at refreshing the company’s product range.

Challenge turned into opportunity

In 2012, they decided to review the existing product range. “I contacted Pierre Machtou, an authority in the dental industry in Europe. It clicked. Together we analyzed the existing product portfolio and agreed that PD needs to concentrate on endodontics, the branch of dentistry dealing with the prevention and treatment of dental pulp,” says David.

Conversations he had with dental professionals helped Brendlen understand that irrigation solutions available on the market were not satisfactory. This is where he saw the opportunity.

“He arrived with a very precise sketch,” recalls Pascale Van Landuyt, Innovation Advisor at Alliance which helps initiate collaborations between industry and academia. The company was next send to Haute Ecole Arc, which could provide the necessary technical expertise and skills.

For so far, irrigation needles were mainly made of stainless steel. A semi-rigid material which limited the gesture fluidity during procedures. Plastic was a promising alternative. David Brendlen recounts long months spent working on prototypes and finding industry partners. The management supported him, investing several million francs in the project, a considerable sum for a company of this size.

IrriFlex was finally launched in 2019. It is manufactured by Cemiplast, a new company opened by PD in Saint-Imier in the canton of Bern in Switzerland. This year PD will open a second production line to further boost the production capacity.

SME: small means agile

Those examples are still rare for SMEs in Switzerland. David Brendlen points out: “Family-owned businesses need to be capable of moving beyond their heritage and history”.

“Creating innovation means being able to think outside the box, erase the past,” says Eric Fumeaux. “It’s more complicated for a small company,” he adds.

And even if companies manage to overcome those preliminary obstacles, they’ll face other, such as limited resources and the necessity to enter into partnerships with other SMEs. “And certainly it’s not something typical for the Swiss culture,” remarks Fumeaux.

But it doesn’t mean SMEs cannot be successful. On the contrary. Small and medium companies are much closer to their end-users which means they can adapt to their clients’ needs and address their concerns almost directly. They’re also more agile and flexible when it comes to reacting to changing trends, explain the experts.

In the very center of each innovation process are extraordinary people ready to take risks, think outside the box and who can move the mountains to achieve their goals. Produits Dentaires can serve as an example of a SME successfully introducing and managing innovation processes.