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al Triox ide Aggregate: A R eview of

cal P roperties

otra, MDS, PGDHHM; Antara Agarwal, MDS; and Kundabala Mala, MDS
Figure 1

two-part series is to review the composition, properties, products, and

cts of mineral trioxide aggregate (MTA) materials. Electronic search of
pers from January 1991 to May 2010 was accomplished using PubMed and
arch engines to include relevant scientific citations from the peer-reviewed
lished in English. MTA is a refined form of the parent compound, Portland
. It demonstrates a strong biocompatible nature owing to the high pH and its
m hydroxyapatite. MTA materials provide a better seal than traditional
materials as observed in dye leakage, fluid filtration, protein leakage, and
netration leakage studies, and it has been recognized as a bioactive material.

variety of MTA commercial products are available, including Proroot Gray

hite MTA both from DENTSPLY Tulsa Dental Specialties
), and MTA Angelus (Angelus, www.angelus.ind.br). Although these
e indicated for various dental uses/applications, long-term in-vivo clinical
still needed to claim the same. This first of this series highlights and discusses
ion, physical, and/or chemical properties of MTA. A subsequent article will
view of the material aspect (commercial products) and clinical considerations

ailures may occur as a result of leakage of irritants into the periapical tissues.1 Therefore, an ideal
and/or retrograde filling material should seal the pathways of communication between the root canal
ts surrounding tissues; thus, this material should be biocompatible and dimensionally stable.2,3 This led
opment of mineral trioxide aggregate (MTA) materials possessing these ideal characteristics. The initial
garding the material was published in 1993 by Lee et al.4 Following this, the material received Food and
stration (FDA) approval in 1998.5,6 Initially recommended as a root-end filling material, it is currently
or pulp capping, pulpotomy, apexogenesis and apexification, apical barrier formation, repair of root

and resorptive defects, and as a root canal and root-end filling material.6,7 It is mainly composed of
ate, tricalcic aluminate, and bismuth oxide, and consists of fine hydrophilic particles that harden in the
dampness or blood.5,6,8 It has a better sealing capacity and biocompatibility compared to other classic
ch as amalgam, cements, super ethoxy benzoic acid (EBA), and interim restorative material (IRM). This
ghts the compositional characteristics and featured properties of MTA materials.

c search of scientific papers was accomplished using PubMed and MedLine search engines and
atabases using selected keywords and with appropriate medical subject headings (MeSH). The search
ords/headings) used were: mineral trioxide aggregate (MTA); White MTA (WMTA); Gray MTA (GMTA);
s (AMTA); Portland cement (PC); properties of MTA (physical, chemical, bacterial, biological,
lity); pulp capping agents; retro-filling materials; perforation repairs (lateral and furcation); root-end
als; recent advances in endodontic materials; newer obturation materials; apexogenesis; and
. Only articles relevant to the topic (MTA) and published in English in peer-reviewed journals from
1 to May 2010 were included. Following this, a hand-search was conducted for the available issues of
journals pertaining to the topic.

sh-colored powder made up of fine hydrophilic particles.6,10 Available as Gray MTA (GMTA) and White
A), both formulae basically are 75% Portland cement, 20% bismuth oxide, and 5% gypsum (Ca) by
hus, MTA is a mixture of a refined Portland cement and bismuth oxide (17% to 18%) with trace
SiO2, CaO MgO, K2SO4, and Na2SO4.5,13 Bismuth oxide is added to make the material radiopaque.
cts calcium hydroxide precipitation after MTA hydration; and under acidic conditions (inflammation),
e can be released in the environment decreasing MTAs biocompatibility as it inhibits cell
Gray MTA (GMTA) principally consists of tricalcium silicate, dicalcium silicate, tricalcium oxide,
uminate, tetracalcium aluminoferrite, calcium sulphate, silicate oxide, and bismuth oxide,12,13 with a
ce of calcium and phosphorus ions (as per earlier reports).16 However, recent investigations using
be microanalysis suggested that phosphorus levels in MTA products are very low.17,18 White MTA
ically lacks the tetracalcium aluminoferrite component with a lesser quantity/content of iron, aluminium,
12,17
Another commercially available MTA material is MTA-Angelus, which is 80% Portland
20% bismuth oxide, and is more radiopaque than GMTA.12

on and Setting

able either as a box of five 1-gram single-use packets or as premeasured water packs for easy
and application. ProRoot liquid microampules (sterile water) and a carrier are also provided with the
ould be stored in closed sealed containers away from moisture.5,10

is mixed with supplied sterile water in a 3:1 powder/liquid ratio. A paper pad or a glass slab and a
metal spatula is used to mix the material to obtain a putty-like consistency. The mixing time should be
minutes, as prolonged mixing can cause dehydration of the mixture.10,19 The mixture can be carried with
The unused portion of MTA powder can be stored in sterilized empty film canisters.

hibited by blood or water, as moisture is required for a better setting of the material.21 The required
setting is provided by a moist cotton pellet placed temporarily (until the next appointment) in direct
or on the surrounding tissues.22 The hydration reaction during setting occurs between tricalcium
OSiO2) and dicalcium silicate (2CaOSiO2) to form a calcium hydroxide and calcium silicate hydrate
ng an alkaline pH.12,20,23 However, Dammaschke et al reported that calcium hydroxide is a product of
uminate hydrogenation.12,24 A further reaction forms a high-sulphate calcium sulphoaluminate during
with tricalcium aluminate and calcium phosphate.25 The released calcium ions diffuse through dentinal

increase their concentration over time as the material cures.26 Upon hydration, the poorly crystallized
solid gel (hydrated forms of components)14 that is formed solidifies to a hard structure in approximately
(initial set), with mean setting time of 165 5 minutes.8,27,28 Although moisture is needed for setting of
excess moisture can result in a soupy mix that is difficult to use.5

d set material consists of interlocked cubic and needle-like crystals. The needle-like crystals exist as
eated thick bundles filling the inter-grain space between the cubic crystals.13,29 MTA retention and
ength increase with time, extending from 72 hours to 21 days, indicating a prolonged maturation
10,13,19
This slower setting time may reduce the setting shrinkage, contributing to the low
e shown by the material. X-ray photoelectron spectroscopy (XPS) examination of WMTA has reported a
rease in surface sulphur and potassium species during the setting reaction.24 Thus, a passivating
pecies layer may aid in prolonging the setting time of the material (WMTA) and also serve a protective

the main drawbacks of MTA is the extended setting period and the prolonged maturation phase. Use
quids and additives for the manipulation of MTA powder can influence the setting time and
strength of the material.13,30 However, it is imperative that the manipulation liquid have adequate water
necessary diffusion ability to allow the hydration reaction to occur.13 Calcium chloride solutions (3% to
ium hypochlorite gels decrease the setting time, whereas saline and 2% lidocaine increase the setting
exidine gluconate affects the surface hardness of MTA (WMTA) during the initial 24 hours.31 However,
m chloride and sodium hypochlorite reduce the final compressive strength (as compared to sterile
aline and 2% lidocaine, having no significant affect on it.30 Accelerators such as sodium phosphate
) also reduce the setting time.5,30

A is pressed into the desired location and not really condensed. The mixture is usually condensed with
cotton pellet using light gentle strokes.5 Either hand or ultrasonic instruments can be used for
nd/or condensation of MTA. Hand instruments like Tulsa Carrier (DENTSPLY Tulsa Dental Specialties,
), amalgam carrier, pluggers, paper points, messing gun MTA carriers, large bore needles, or
als can be used.5,8,10 In ultrasonic condensation, a hand instrument (condenser) placed in direct
MTA is activated by ultrasonics placed in contact with the shaft of the hand instrument. Different results
from different studies regarding the best condensation technique for placement of MTA. Some
med that hand condensation techniques offer less porosity and better adaptation than ultrasonicwhereas others suggested that a denser MTA-fillboth in straight and curved-root canals
resistance to bacterial penetration is achieved with a combination of hand and ultrasonic
Though the amount of condensation pressure did not affect the compressive strength, an increase
tion pressure can interfere with the ingress of water required to hydrate the cement, which in turn may
urface hardness.8,34 Also, irrigation should be performed before the placement, because following
rrigation can cause significant washout of the material.

aracteristic properties of MTA include superior sealing ability, biocompatibility, antimicrobial effect,
dimensional stability, and tolerance to moisture over other dental materials such as IRM, amalgam,
per EBA, ZOE, etc.5,8-10,13,20,35 Thus, MTA has gained popularity among dental practitioners, especially
s, in recent times. Among the above-mentioned properties, the sealing ability and biocompatibility of
en studied extensively9,13 (Figure 1).

ssive strength of set MTA is about 70 MPa, which equals IRM and super EBA, but is less than that of
Owing to the low compressive strength, placement of MTA in functional areas should be avoided.
ressive strength is not significantly affected by condensation pressure.8 As discussed earlier, MTA has
maturation process, with increased compressive strength, push-out strength, and retention strength of

with time (up to 21 days) in the presence of moisture. The initial compressive strength following 24
MPa, which increases to 67.3 MPa after 21 days. Thus, after 3 weeks, no significant difference in
strength was observed between super EBA, IRM, and MTA.8,27 A similar increase in flexure and pushwas also observed under moist conditions with the passage of time.36,37 This is because the dicalcium
ation rate is slower than that of tri- calcium silicate.24 Thus, optimal physical properties are gained with
is enough moisture following placement at the operation site.5,8,10

acanal irrigants/oxidizing agents can affect the push-out strength/retention strength of GMTA. Use of
e water, or lidocaine has no effect on the retention strength of the material. However, it is more
o oxidizing agents such as sodium perborate mixed with saline, 30% hydrogen peroxide, and sodium
xed with 30% hydrogen peroxide, whereas 2% chlorhexidine and 5.25% sodium hypochlorite did not
affect the strength.38,39 Also, the retention strength of the material is affected by blood-contaminated
Investigations also suggested a significant decrease in compressive strength following
acid (37%) etching. Therefore, restoration with resin-based composite should be postponed for at least
owing placement of MTA.41

S tr ength and Bond S tr ength

e strength of MTA is significantly less than that of glass ionomer or zinc phosphate cement and, thus, it
ered to be a suitable luting agent.42 Studies have shown that a 4-mm thickness of MTA (apical barrier)
e resistance to displacement than a 1-mm thickness,43,44 as GMTA-dentin bond strength increases with
A total-etch single-bottle adhesive with a resin-based composite or compomer produced
strength than a single-step self-etch system over MTA.45

to acidic pH (pH5), as observed in inflammatory environment, has an adverse effect on the

ss of both GMTA and WMTA.29 It is attributed to the absence and growth of needle-like crystals
cubic crystals during the hydration phase. A 5-mm thickness of MTA is significantly harder than a 2Ethylenediaminetetraacetic acid (EDTA), BioPure MTAD (DENTSPLY Tulsa Dental Specialties),
hing produce surface roughness and significantly reduce the microhardness of MTA.41,47 An increase
tion pressure results in a more compact mass with fewer micro channels available for water uptake,
g the microhardness of the material.8

TA has an initial pH of 10.2, which rises to 12.5 (similar to calcium hydroxide) 3 hours after mixing and
The high pH is theorized to be responsible for the antimicrobial action and biological activity of
This high pH is attained due to the constant release of calcium from MTA and the formation of
he usual pH (11 to 12) of MTA materials decreases slightly with time.48

i l i ty (Mi cr ol eak age)

ined from dye leakage, fluid filtration, protein leakage, and bacterial leakage and endotoxin leakage
pidermis, S. salivaris, S. marcescens, E. coli, F. nucleatum) indicated that overall MTA showed less
e and better sealing ability than traditional materials like amalgam, zinc oxide eugenol-based materials,
glass-ionomer, gutta-percha, etc., when used for root-end restoration, root canal obturation, furcation
reatment of immature apices.6,9,13 Expansion of MTA during setting can be responsible for its excellent
Usually a thickness of 3 mm to 5 mm is sufficient to provide a good seal. In the presence of blood
n, MTA has also been shown to leak significantly less compared to amalgam, IRM, and super EBA.21
e in microleakage is reported when used either in an orthograde manner (root-canal filling) or in a
manner (root-end filling).50 However, the presence of residual calcium hydroxide, from the prior
s an intracanal dressing, can interfere with the adaptation and reduce the sealing ability of MTA. It can
hanical obstacle or can chemically react with MTA.51 In dye leakage investigations, MTA mixed with

chloride showed a better sealing ability, with no significant difference in microleakage on addition of

lity studies in general considered both GMTA and WMTA as biocompatible.9,54 No genetic damage,
ation, chromosomal breakage, altered DNA repair capacity, or cellular transformation was observed with
as shown to posses neither mutagenic (Ames mutagenicity assay, Salmonella typhimurium) nor
ects (single cell gel/comet assay).55,56 Neither freshly mixed nor set MTA displayed neurotoxicity.57 It
be less cytotoxic than amalgam, super EBA, and IRM, with set MTA being less cytotoxic than fresh
nhanced attachment and proliferation of periodontal ligament and gingival fibroblasts were observed
urfaces of MTA.58,59 Similarly, cell cultures studies (animal and human) using human alveolar bone
preosteoblasts, osteoblasts, dentinoblasts, and mouse cementoblasts have shown good survival,
and attachment, with a faster and better growth of cells on the MTA surface.9,35,54 MTA has also shown
tter stimulating effect on human dental pulp cells than a commercial calcium hydroxide preparation. It
d that cellular proliferation is via intra- and extracellular Ca2+ and Erk-dependent pathways, and cell
a the Pl3K/Akt signaling pathway.35 Animal cells (rat bone marrow cells, mouse preosteoblasts) and
(gingival fibroblasts, periodontal ligament fibroblasts, alveolar bone cells) exposed to MTA have been
press alkaline phosphatase, bone sialoprotein, periostin, and osteocalcin, along with the formation of
llagenous matrix.60-62 Addition of enamel matrix derivative to MTA has been shown to improve human
cell differentiation, alkaline phosphatase activity, and mineralization.63 Although addition of
e improved the antibacterial properties of MTA, it adversely affected the biocompatibility of the

human studies have shown minimal or no inflammation to bone and connective tissue following
When used (in a canine model) for root-end restoration or for the repair of lateral/furcation
MTA has shown favorable healing characteristics, such as lack of inflammation, no ankylosis, cellular
ormation (overgrowth), and PDL regeneration between the cementum and alveolar bone.6,9,13 MTA
ytokine release and interleukin production, which may actively promote hard-tissue formation.9,64
et al observed that MTA induced hard-tissue formation more often than osteogenic protein-1 and

s implantation of MTA showed a relatively mild-to-minor inflammatory response, which is more

mpared to amalgam, super EBA, and IRM.66

s considered that the biocompatibility of MTA is attributable to the release of hydroxyl ions and
calcium hydroxide during the hydration process.23,48 Other reports had observed the formation of a
cial material (precipitates) between GMTA and tooth structure within 1 to 2 hours when exposed to
luids (phosphate-buffered physiologic solution) in vivo or with simulated body fluids in vitro.18,20 SEM
fraction (XRD) analysis of these precipitates revealed the presence of chemically and structurally
xyapatite (HA)-like structure with a chemical composition of oxygen, calcium, and phosphorus, along
mounts of bismuth, silicon, and aluminum.18 However, the calcium-to-phosphorus ratios reportedly
m that of natural hydroxyapatite.67 This HA-like structure can release calcium and phosphorus
, promoting the regeneration and remineralization of hard tissues and increasing the sealing ability of
A-layer also creates a chemical bond between MTA and the dentinal walls.7 The particle size and
shape of MTA can also occlude dentinal tubules, which might harbor microorganisms.68 GMTA has a
unt of HA-crystal formation than WMTA with the presence of lower levels of silica and phosphorus in
als and more calcium ions in WMTA crystals.67

e of hydroxyl ions, a sustained high pH for extended periods, modulation of cytokine production,
calcium hydroxide, and a mineralized interstitial layer (HA) may be responsible for the excellent
lity and biological activity of the material.7,20

bi al P r oper ti es

es have shown antibacterial activity of MTA against M. luteus, S. aureus, E. coli, P. aeruginosa, E.
A study evaluated the antimicrobial property of MTA, amalgam, and super EBA against
naerobes. MTA was found to have an antibacterial effect on five of the nine facultative bacteria, but no
y of the strict anaerobes.69 Thus, the use of MTA as an antibacterial agent may not be very beneficial
c cases. The use of 2% CHX and 0.12% CHX in combination with MTA has been reported to
ncrease the antibacterial effect of both types of MTA.70

evaluated the antifungal activity of both freshly mixed and 24-hour-set MTA using a tube
It was observed that both types were effective against Candida albicans.20 The antifungal effect of
e due to its high pH or to substances that are released from MTA and is dependent on the
n of MTA; a concentration of 25 mg/mL to 50 mg/mL is required to show an antifungal effect.72

i v e P otenti al and Bi ol ogi cal Acti v i ty

capacity to induce bone, dentin, and cementum formation and regeneration of periapical tissues
ligament and cementum).7,8,13 MTA provides a good biological seal and can act as a scaffold for the
d/or regeneration of hard tissue (periapical). It is an osteoconductive, osteoinductive, and
ic (cementoconductive and cementoinductive) agent.9,20 MTA stimulates immune cells to release
and bone coupling factors required for the repair and regeneration of cementum and healing of
iapical defects.64,73 MTA can also stimulate periodontal ligament fibroblasts to display osteogenic
nd produce osteonectin, osteopontin, and osteonidogen.20,60 Cell culture studies have shown an upvarious cytokines, biological markers, and interlukines, like IL-1, IL-1, lL-4, IL-6, osteocalcin,
sphatase, bone sialoprotein, osteopontin, BMP-2, PGE2, and cyclooxygenase-2, by MTA.9,20
et al concluded that MTA can induce the formation of apical hard tissue with significantly greater
than osteogenic protein-1 and calcium hydroxide.65 The biologic activity of MTA is attributed to the
l associated with formation of calcium hydroxide. Current studies indicated that the biological activity of
uted to the formation of hydroxyapatite-like precipitate on its surface. GMTA was observed to produce
h hydroxyapatite crystals as WMTA, suggesting different levels of bioactivity of the two materials.18,67

s low or nearly no solubility, which is attributable to addition of the bismuth oxide.5,8 Chemical analysis
fraction have demonstrated insolubility of 18.8% in water.5 Although MTA forms a porous matrix
d by internal capillaries and water channels with increased liquid/powder ratiowhich can increase the
the solubility furtherthe solubility levels of GMTA have been shown to be stable over time.13,74

mean radiopacity of 7.17 mm of equivalent thickness of aluminum, which is less than that of IRM, super
am, or gutta-percha.5,75 It has a similar radiodensity to zinc oxide eugenol and slightly greater
han dentin. Apart from these characteristics, MTA does not react to or interfere with restorative
e glass-ionomer cements or resin-based composites, which are the commonly used permanent filling

odontic material should adhere to tooth structure, maintain a good seal, be insoluble in tissue fluids,
y stable and nonresorbable, and radiopaque, and exhibit biocompatibility with a certain degree of
mong the various available endodontic materials, MTA is currently the biomaterial that posses most of
cteristics. Nevertheless, the extrapolation of results obtained in in-vitro studies should be undertaken
when applied to clinical conditions.

To read Part 2 of this series, click here.

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otra, MDS, PGDHHM

tment of Conservative Dentistry & Endodontics KDDC Mathura, U.P., India

Cosmetic Dentistry & Endodontics Indus Hygiea, Unit of Indus Speciality Health Mohali, Punjab, India

artment of Conservative Dentistry and Endodontics Manipal College of Dental Sciences Mangalore, Karnataka,