| Abstract|| |
Aim: OrthoMTA and RetroMTA are newly developed mineral trioxide aggregates that were developed to achieve maximum benefits and clinical performance. This systematic review aimed at assessing and describing the constituents, properties and uses of OrthoMTA and RetroMTA. Methodology: Literature search was performed using the keywords, “OrthoMTA”, “RetroMTA”, “BioMTA”, “constituents” and “properties” in the databases, PubMed, Cochrane, Semantic scholar and Europe PubMed Central. Original articles in English describing the properties, constituents, uses/indications, history and recent advances on OrthoMTA and RetroMTA were considered for the study. Results: A total of 35 articles were selected for the systematic review based on keywords selected. Among the 35 articles, 5 articles described the composition and properties of OrthoMTA and RetroMTA, 7 articles depicted the usage of OrthoMTA and RetroMTA and the remaining articles discussed on the various properties of both OrthoMTA and RetroMTA. Conclusion: The present review confirmed that RetroMTA exhibits an excellent property, namely, short setting time, less tooth discoloration, high compressive strength, higher shear bond strength with time, higher push-out bond strength, low solubility, low cytotoxicity, biocompatibility, antibacterial property, and can be used in reparative processes in case of blood contamination. However, even OrthoMTA showed less microleakage, is biocompatible and possesses antibacterial properties.
Keywords: BioMTA, constituents, OrthoMTA, properties, RetroMTA
|How to cite this article:|
Maru V, Dixit UB. Constituents, properties and clinical applications of OrthoMTA & RetroMTA: A systematic review. Indian J Dent Res 2021;32:514-23
|How to cite this URL:|
Maru V, Dixit UB. Constituents, properties and clinical applications of OrthoMTA & RetroMTA: A systematic review. Indian J Dent Res [serial online] 2021 [cited 2022 Aug 17];32:514-23. Available from: https://www.ijdr.in/text.asp?2021/32/4/514/345431
| Introduction|| |
The need for development of newer materials, to achieve maximum benefits and clinical performance in endodontics is never ending. An ideal restorative material should possess various properties such as adherence, good sealing ability, stability, radiopacity and biocompatibility. Mineral Trioxide Aggregate (MTA) is a biomaterial that was introduced by Mohmoud Taorabinejad at Loma Linda University, California, USA in 1993 for endodontic applications. It was given approval for endodontic use by the U.S. Food and Drug Administration in 1998.
MTA has shown great clinical success because of its properties such as high compressive strength, radio-opacity, low solubility, good sealing ability, antimicrobial property, high stability, biocompatibility, tissue regeneration and mineralization property. Therefore, it finds applications in pulp capping, pulpotomy, root canal filling, perforation repair, resorption repair, repair of fracture, coronal barrier for regenerative endodontics and root canal sealer. Although MTA has many advantages, the main disadvantages of MTA are discoloration potential, presence of toxic elements in the material composition, difficult handling features, long setting time, high material cost, an absence of a known solvent for this material, and the difficulty of its removal after curing.
OrthoMTA and RetroMTA are commercially available MTAs manufactured by BioMTA, Seoul, Korea developed to overcome the drawbacks of MTA. OrthoMTA is an innovative orthograde root canal material that is unaffected by moisture or blood. It provides good sealing ability, biocompatibility, good radio-opacity, anti-bacterial effect, has no heavy metal, no expansion, easy handling and retrievability, with a setting time of 3 minutes. On the other hand, RetroMTA is also a recently developed material with rapid setting time of 150 seconds. It also provides excellent sealing ability, anti-bacterial effect, good radio-opacity with no discoloration, no heavy metals and no cytotoxicity.
However, literature search gives little information about OrthoMTA and RetroMTA with respect to its constituents, properties and clinical applications. Hence the present review aims at assessing the constituents, properties and uses of OrthoMTA and RetroMTA.
| Materials and Methods|| |
The protocol for this systematic review has been registered with the PROSPERO International prospective register of systematic reviews, registry No CRD 42020221251 and this review followed PRISMA guidelines.
A review of the literature was performed from Jan 2000 to December 2020 in various databases including, PubMed, Cochrane, Semantic scholar and Europe PubMed Central. The following keywords were used to search through the database search: “OrthoMTA”, “RetroMTA”, “BioMTA”, “constituents” and “properties”. The search was restricted to only humans and literatures in English only were considered. Manual search on bibliographies of included studies and review articles were also performed.
Abstracts were screened to identify the studies that described the properties, constituents and uses of OrthoMTA and RetroMTA. The studies were chosen based on the inclusion criteria, i.e., original articles describing the properties, constituents, uses/indications, history and recent advances on OrthoMTA and RetroMTA were considered for this review. Articles printed in languages other than English were not considered for this review. Reviews and case reports were also excluded from this review.
Two independent investigators, reviewed the title and abstracts of the studies obtained by database search, applying the inclusion and exclusion criteria to select for full review. Thereafter full-length articles were collected and examined for topics on properties, constituents and uses/indications on OrthoMTA and RetroMTA. The studies were classified into articles on constituents, properties and indications of OrthoMTA and RetroMTA. Information such as author details, year of publication, parameter/property studied, and results were collected from each article.
Based on the data extracted from the included articles, it was not possible to perform meta-analysis. A descriptive analysis of the extracted data and narrative synthesis were performed. Risk of bias was not attempted, since this review was conducted to understand the physical, chemical, mechanical and biological properties of OrthoMTA and RetroMTA. Hence no randomized control trial or case control or cohort studies were assessed for the present review.
| Results|| |
The PRISMA flow diagram is shown in [Figure 1]. A total of 9027 articles were found after the keyword search from PubMed, Cochrane, Semantic scholar and Europe PubMed Central. The duplication removal yielded a total of 5183 articles. Further the title and abstracts were screened for 5183 articles and 5092 records were found unsuitable for the study. Full-text articles of the remaining 91 articles were assessed and 56 articles were excluded from the study because they did not satisfy the inclusion (3 case reports, 4 repeated articles, 7 irrelevant articles). 9 articles on animal studies, 16 articles were written in languages other than English and 17 articles on retrograde and orthograde filing technique. A total of 35 articles were selected for the systematic review based on keywords selected. Among the 35 articles, 5 articles described the composition and properties of OrthoMTA and RetroMTA, 7 articles depicted the usage of OrthoMTA and RetroMTA and the remaining articles discussed on the various properties of both OrthoMTA and RetroMTA.
Composition of OrthoMTA and RetroMTA
The composition of OrthoMTA and RetroMTA are similar; however, a small variation exists in both the endodontic materials. RetroMTA is composed of calcium carbonate, silicon dioxide, aluminum oxide and calcium zirconia complex as stated by de Souza LC and Ashofteh Yazdi. The OrthoMTA has a similar composition of calcium carbonate, silicon dioxide, aluminum oxide, except for di bismuth trioxide with abundance of calcium and silicon as suggested by Chang SW. Kum KY also confirms that OrthoMTA consists of abundance of calcium, silicon, and aluminum. Chang SW, showed that OrthoMTA meets the ISO specification 9917-1 with no traces of arsenic, hexavalent chromium and Lead. Additionally, Kum KY also showed that OrthoMTA had lower levels of Cd, Cu, Fe, Mn and Ni than ProRootMTA except Zn [Table 1].
Properties of OrthoMTA and RetroMTA
Any endodontic material should be biocompatible, antibacterial, nontoxic, radiopaque and it should be insoluble in an oral environment. These properties of OrthoMTA and RetroMTA are classified and discussed under physical, chemical, mechanical and biological properties, respectively.
The microstructure and crystalline structures of RetroMTA as explained by Ashofteh Yazdi exhibited prismatic, cubical, and needle-like crystalline structures when exposed to phosphate-buffered saline, blood, and butyric acid. The porosity of OrthoMTA was found to be small in comparison to MTA-angelus and Bio-aggregate, however, bigger than Bio-dentine, MM-MTA, and ProRootMTA as studied by Chang SW. This large surface area helps providing a favorable condition for cell adhesion. The pore volume of OrthoMTA was found to be comparatively higher than other endodontic materials except MTA-angelus. Kum KY concluded that the morphological characteristics of OrthoMTA and ProRootMTA were similar; however, the particle size of ProRootMTA was slightly smaller than that of OrthoMTA.
Microleakage is one of the major causes for endodontic failure, which may be due to weak contacts between the gutta-percha and the sealer, the sealer and the dentin, or because of voids within the sealer. Lertmalapong P studied the bacterial leakage and marginal adaptation of various bioceramic apical plugs and found that RetroMTA showed higher mean gap area and a faster bacterial leakage in comparison to Biodentine and ProRootMTA and hence showed a poor sealing ability and marginal adaptation in comparison to the other bioceramics. In addition, Sinkar showed that Biodentine had better sealing ability when compared with ProRootMTA and RetroMTA by dye-extraction leakage method. On the other hand, Kim SY showed that OrthoMTA showed less microleakage than RealSeal SE obturation system when used as root canal filling materials and hence OrthoMTA is more appropriate material for sealing the root canals. However, Ghorbanzadeh A, indicated that there was no difference between the marginal adaptation of ProRootMTA, OrthoMTA, and RetroMTA as root-end filling materials after exposure to phosphate buffer saline for either 1 week or 2 months.
The setting time for sealers are extremely important and it is desirable that the setting time should be neither too fast nor too slow. Che JL observed that the setting time of RetroMTA and EndoCem MTA was shorter than ProRootMTA. Pornamazeh T also showed that RetroMTA has relatively short period of setting time in comparison to Calcium-Enriched Mixture (CEM) and Angelus MTA.
Along with having an ideal setting time and good sealing ability, the other important physical properties any endodontic material should possess is radiopacity and less discoloration. de Souza LC established that RetroMTA meets the radiopacity requirements standardized by ANSI/ADA number 572. Both Kang SH and Shim S showed that less discoloration was observed in RetroMTA in comparison with ProRootMTA and MTA Angelus. A study performed by Shokouhinejad N showed that in the absence of blood, Biodentine and ERRM putty exhibited less discoloration compared with OrthoMTA [Table 2].
Mechanical properties include properties like stress, strain, modulus of elasticity of endodontic materials. Che JL showed that the compressive strength of RetroMTA was significantly higher than that of OrthoMTA. Also, the shear bond strength of RetroMTA along with Biodentine and Theracal were very low at 60 min; however, it significantly increased at 24 hours and was found to be higher than Theracal and Dycal by Jantarat J. On the other hand, Ustun Y proved that ProRootMTA and RetroMTA exhibited superior bond strength values in comparison to the other biomaterials. Lee J performed a study to check the effect of Root Canal Cleaning Agents on the micro and flexural strength of RetroMTA and found that the micro and flexural strength of RetroMTA decreases with use of cleansing agents such as EDTA, MA and QMixTM [Table 3].
Chemical properties of the endodontic materials include pH, solubility, mineralization and bonding characteristics. Both Che JL and de Souza LC showed that the pH of RetroMTA, OrthoMTA and ProRootMTA were similar and found to be higher than EndoCem MTA. Solubility of OrthoMTA was the highest followed by ProRootMTA and EndoCem MTA and RetroMTA showed least solubility in the study conducted by Che JL. The mineralization gene expression was found to be upregulated with the use of OrthoMTA in the study conducted by Kum. On the other hand, Ashofteh Yazdi showed that blood or acidic pH exposure resulted in reduction in Ca (OH) 2 in RetroMTA. The caries affected dentin layer is highly demineralized and physiologically unremineralizable; however, Meraji N showed that good bonding characteristics with the caries affected dentine [Table 4].
Biological properties of OrthoMTA and RetroMTA discussed in this review include biocompatibility, cytotoxicity, cell viability, bio activity, and anti-bacterial properties. Kum KY performed a study to evaluate the biocompatibility of OrthoMTA and ProRoot and found that both the MTAs had favorable invitro biocompatibility. Chung CJ showed that RetroMTA has similar biocompatibility and angiogenic effects on human pulp cells, and therefore can potentially be as effective in pulp capping as ProRootMTA. Similar results were also concluded by Dezfouli NK in which comparable biocompatibility was observed in RetroMTA and MTA plus in comparison with ProRootMTA. On the same lines, Pornamazeh T also showed that RetroMTA has favorable biocompatibility compared to CEM cement and Angelus MTA. This was again restated by de Souza LC and Lee J.
The endodontic materials used should not only be biocompatible, but it should also be non- cytotoxic and allow cell viability and differentiation. Kim SY showed that OrthoMTA was significantly more cytotoxic than ProRoot and EndoCem MTA (P < 0.05) in pre osteoblast like cell line MC3T3-E1. On the other hand, Yun J noticed that the cytotoxicity of RetroMTA was found to be least followed by EndoCem Zr and EZ-SealTM on stem cells from human exfoliated deciduous teeth in his study. Lee H performed a study to determine the in vitro cell viability and differentiation potentials of human deciduous dental pulp cells (DPCs) on ProRootMTA, RetroMTA and EndoCem Zr and concluded that, ProRootMTA, RetroMTA, and EndoCem Zr were all associated with low cell viability and were unable to enhance the proliferation of human dental pulp cells. However, Lee H evaluated the effect of osteogenic differentiation of RetroMTA and ProRootMTA and concluded that RetroMTA improves osteoblastic differentiation and represents a desirable alternative to ProRootMTA as a root-end filling material. Similarly, Wongwatanasanti N found that Biodentine, ProRootMTA, and RetroMTA can induce proliferation of stem cells from the apical papilla. Dammaschke T showed that regular dentin was not regenerated when RetroMTA was placed over an exposed site and the newly formed calcified hard tissue was also not the product of genuine odontoblast differentiation.
Both Khedmat S and Donyavi Z studied the antibacterial property of RetroMTA and OrthoMTA. Khedmat S checked the antibacterial activities of OrthoMTA, RetroMTA, and ProRootMTA against Fusobacterium nucleatum (Fn), Porphyromonas gingivalis , and Prevotella intermedia Pi) and found that ProRootMTA, OrthoMTA, and RetroMTA had similar antibacterial activities against the three evaluated anaerobic endodontic bacteria, except RetroMTA against Pg. Donyavi Z carried out a study to evaluate antibacterial activity ofMTA, NEC, OrthoMTA and RetroMTA against common endodontic pathogens and proved that RetroMTA and OrthoMTA had acceptable antimicrobial activity against common endodontic pathogens [Table 5].
Indication/Uses of OrthoMTA and RetroMTA
Possessing such a wide range of properties, OrthoMTA and RetroMTA both can find applications in many endodontic procedures. Kang CM checked the clinical applicability of ProRootMTA, OrthoMTA and RetroMTA as partial pulpotomy materials in permanent teeth and found favorable results which did not significantly differ among the three groups even after 1 year. Both Kim SH and Kang CM tested the clinical applicability of ProRootMTA, OrthoMTA and RetroMTA as pulpotomy materials in primary teeth and found similar success rate for all the three materials. Song M performed an interesting study to evaluate the effect of human blood on the microhardness of OrthoMTA and RetroMTA and found that although blood contamination detrimentally affected the surface microhardness of all materials, RetroMTA might be a more suitable choice in situations in which blood contamination is unavoidable. Bakhtiar H compared the clinical efficacy of RetroMTA and ProRootMTA for partial pulpotomy and concluded that RetroMTA showed pulp disorganization, lack of inflammation, and discontinuous mineralization, which may signify a potential drawback for usage of RetroMTA for partial pulpotomy. On similar lines, Chang SW also indicated that ProRootMTA, Micro Mega MTA and calcium silicate-based cements may be recommended over RetroMTA for pulp capping. In contrast, Ustun Y showed that ProRootMTA and RetroMTA seem to be more suitable for use as a reparative material in case of furcal perforations [Table 6].
| Discussion|| |
This systematic review discusses the various properties, constituents and indications of RetroMTA and OrthoMTA. Although the composition of both MTAs were similar, it was found that RetroMTA contains calcium zirconia complex and OrthoMTA has bismuth oxide, which is unique to it. Zirconium oxide has a low cytotoxicity, is bio inert and does not cause tooth discoloration in presence of endodontic materials, on the other hand, Bismuth oxide is considered to be chemically inert and imparts radiopacity to the material. This difference in composition in both MTAs is responsible for different properties in RetroMTA and OrthoMTA.
OrthoMTA was found to have higher porosity, high pore volume and higher particle size in comparison with ProRootMTA. This larger mean particle size can be a contributing factor to the relative fragility of the material as stated by Kent and Wilson. 1971 The porosity of endodontic materials which is a characteristic of its composition, can produce centers of structural weakness and tensile strength of the material leading to microcracks.
RetroMTA was found to have a higher mean gap area and faster bacterial leakage and lower sealing ability in comparison to ProRootMTA whereas OrthoMTA showed lower microleakage in comparison to RealSeal SE, showing that it is more appropriate material for sealing the root canals. The setting time for RetroMTA was found to be shorter than other biomaterials, which was in line with the claim given by BioMTA (Seoul, Korea) that the setting time for RetroMTA is 180 sec and 360 min for initial and final setting. Hence, this material can be recommended for single-visit procedures where other properties are not a major concern. This systematic review indicated that RetroMTA shows lesser discoloration in comparison to other bioceramics, however, OrthoMTA showed more discoloration in comparison to Biodentine and other endodontic materials. This may be due to the compositional variation. Kang CM et al., 2015, showed that the bismuth oxide disc showed a clear color with curing time, whereas, the zirconium oxide powder did not display any discoloration. This is because of dissociation of bismuth oxide to metallic bismuth and oxygen as proven by Vallés M et al., 2013.
RetroMTA was found to be more mechanically strong as it showed higher compressive strength than OrthoMTA, higher shear bond strength with time and higher push-out bond strength than other biomaterials. In general, the mechanical properties of any substance are determined by the physical properties of the materials such as particle size, porosity, pore volume, etc. Since OrthoMTA has a higher particle size and higher pore volume, this may be a reason for the lower mechanical strength in comparison to RetroMTA.
The solubility of OrthoMTA was found to be much more than RetroMTA. Generally, any root canal filler should have a low solubility as a highly soluble root canal sealer would perpetually lead the formation of gaps in the material and the root dentin, thereby leading to leakage from the oral cavity and periapical tissues as stated by Al-Haddad HA et al., 2016. OrthoMTA was found to be more cytotoxic than ProRootMTA and on the other hand, RetroMTA less cytotoxic. All the endodontic materials used in dentistry, should be biocompatible and have low cytotoxicity as mentioned by Osorio RM et al., 1998. This review showed that RetroMTA improves osteoblastic differentiation, induces proliferation of stem cell from apical papilla and did not help in the regeneration of dentin.
Both OrthoMTA and RetroMTA can be used for partial pulpotomy in permanent teeth and as pulpotomy material in primary molars. However, Chang SW et al., 2015 showed that other biomaterials are more suitable as pulp capping agent. RetroMTA can be used for reparative processes and in case of blood contamination, RetroMTA is recommended over other biomaterials. However, Bakhtiar et al., 2018 showed that RetroMTA showed pulp disorganization, absence of inflammation, and discontinuous mineralization, which may represent a potential drawback.
The present systematic review is touted as the first of its kind describing the composition, properties and indications of both RetroMTA and OrthoMTA. It includes all the original articles on OrthoMTA and RetroMTA, however, this review has few limitations. The number of articles on OrthoMTA and RetroMTA were very limited. Secondly, articles in particular areas of interest of OrthoMTA were missing, hence it was difficult to establish a comparison between OrthoMTA and RetroMTA.
| Conclusion|| |
The present review confirmed that RetroMTA exhibits an excellent property, namely, short setting time, less tooth discoloration, high compressive strength, higher shear bond strength with time, higher push-out bond strength, low solubility, low cytotoxicity, biocompatibility, antibacterial property, and can be used in reparative processes in case of blood contamination. However, OrthoMTA shows less microleakage, is biocompatible and possess antibacterial properties. Further studies on OrthoMTA in particular areas of interest have to be established to determine the comparison between OrthoMTA and RetroMTA.
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Conflicts of interest
There are no conflicts of interest.
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Dr. Viral Maru
Department of Pediatric and Preventive Dentistry, D Y Patil School of Dentistry, Navi Mumbai, Maharashtra
Source of Support: None, Conflict of Interest: None
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]