Reinforcement of Simulated Immature Permanent Teeth after Mineral Trioxide Aggregate Apexification

Objectives

The objectives of this study were to compare the fracture resistance of simulated human immature teeth that have undergone mineral trioxide aggregate (MTA) apexification and have been root-filled with fiber post, composite resin, MTA, or gutta-percha.

An Assessment of the Effects of Orthodontic Treatment after Apexification of Traumatized Immature Permanent Teeth: A Retrospective Study

IntroductionRoot resorption may occur in traumatized necrotic teeth that have undergone apexification after orthodontic treatment. This study examined the effects of orthodontic treatment on the outcome of apexification.MethodsThis retrospective study included 36 children presenting with anterior permanent traumatized teeth with immature roots who were treated by apexification and root canal treatment. The orthodontic group consisted of 17 children with 24 teeth that were subjected to orthodontic treatment after apexification. The control group consisted of 19 children with 21 teeth that underwent only apexification without orthodontic treatment. Almost half of the teeth in both groups underwent apexification with calcium hydroxide, whereas the other half were treated with mineral trioxide aggregate. The effects of sex, stage of root development, and apexification material on the outcomes of apexification were analyzed and compared between the 2 groups.ResultsApexification was successful in 88% of cases after at least 5 years of follow-up. Neither apexification technique nor sex had a significant effect on treatment outcome. The stage of root development had a positive effect on outcome, although it was not statistically significant. Some root resorption (average = 0.3 mm) was observed after orthodontic treatment, whereas teeth that underwent apexification without orthodontic treatment exhibited some root elongation (average = 0.1 mm). This difference was highly significant.ConclusionsMinor root resorption was observed in the orthodontic group compared with a minor increase in root length in the control group. Orthodontic movement of immature traumatized teeth after apexification appears to be safe.     

The effect of mineral trioxide aggregate on the apexification and periapical healing of teeth with incomplete root formation

Aim To evaluate the influence of mineral trioxide aggregate (MTA) on apexification and periapical healing of teeth in dogs with incomplete root formation and previously contaminated canals and to verify the necessity of employing calcium hydroxide paste before using MTA. Methodology Twenty premolars from two 6‐month old dogs were used. After access to the root canals and complete removal of the pulp, the canal systems remained exposed to the oral environment for 2 weeks. Canal preparation was then carried out using Hedström files, under irrigation with 1% sodium hypochlorite, 1 mm short of the radiographic apex. After drying, the canals of two premolars in each dog were left empty (control group). The other eight teeth in each animal were divided into two experimental groups. The apical thirds of the canals of group 1 were filled with MTA. In the teeth of group 2, the canals were dressed with a calcium hydroxide–propylene glycol paste. After 1 week, the paste was removed and the apical third was filled with MTA. All teeth were restored with reinforced zinc oxide cement (IRM) and amalgam. The animals were killed 5 months later, and blocks of the teeth and surrounding tissues were submitted to histological processing. The sections were studied to evaluate seven parameters: formation of an apical calcified tissue barrier, level of barrier formation, inflammatory reaction, bone and root resorption, MTA extrusion, and microorganisms. Results of experimental groups were analysed by Wilcoxon's nonparametric tests and by the test of proportions. The critical value of statistical significance was 5%. Results Significant differences (P < 0.05) were found in relation to the position of barrier formation and MTA extrusion. The barrier was formed in the interior of the canal in 69.2% of roots from MTA group only. In group 2, it was formed beyond the limits of the canal walls in 75% of the roots. MTA extrusion occurred mainly in roots from group 2. There was similarity between the groups for the other parameters. Conclusions Mineral trioxide aggregate used after root canal preparation favoured the occurrence of the apexification and periapical healing. The initial use of calcium hydroxide paste was not necessary for apexification to occur, and has shown to be strongly related to the extrusion of MTA and formation of barriers beyond the limits of the root canal walls.     

Effects of Apical Barriers and Root Filling Materials on Stress Distribution in Immature Teeth: Finite Element Analysis Study

PurposeA finite element analysis (FEA) study was performed to determine whether the material of apical barrier used for root apexification and/or the use of canal reinforcement affect the stress distribution in an endodontically treated immature permanent tooth in order to infer in which clinical scenarios a fracture is more likely to occur based on the ultimate tensile strength threshold of dentin.Methods and MaterialsAn extracted human immature mandibular premolar was selected as the reference model and scanned by micro-computed tomography (micro-CT). The digital model was segmented and converted to STL (Standard Tessellation Language) using Simpleware Scan-IP and exported in IGES (Initial Graphics Exchange Specification) to Ansys 19. Six experimental models were designed with different combinations of composite, mineral trioxide aggregate (MTA), and Biodentine (BIO). Using FEA, a static 300 N load at a 135 angle with respect to the axis of the tooth was applied to each model and von Mises stress values (MPa) were measured at the sagittal, apical 8-mm, 5-mm, 2-mm, and 1-mm levels.ResultsIn all regions examined, the control (NT model) had lower stress in the root compared WITH experimental models. At the mid-root level, models with composite, MTA, and BIO reinforcement exhibited lower stresses in the root dentin than those with pulp or gutta-percha. BIO models had equal or greater average von Mises stress values than those of MTA models in all regions. Both, MTA and BIO, caused increases in stress of surrounding root dentin, with BIO causing a greater increase than MTA.ConclusionsStress distribution in immature permanent teeth treated by apexification is affected by the types of materials used. Root dentin's stress was lower when the mid-root canal was reinforced by composite, MTA, or BIO, which provided similar stress reduction to the root dentin. MTA is a more favorable apical barrier material from a mechanical standpoint because it induces less stress on apical root dentin than BIO.     

Fracture Resistance of Teeth with Simulated Perforating Internal Resorption Cavities Repaired with Different Calcium Silicate–based Cements and Backfilling Materials

Introduction

This study assessed the fracture resistance (FR) of teeth with simulated perforating internal resorption cavities repaired with different calcium silicate–based cements (CSCs) and backfilling materials.

Weakened anterior roots--intraradicular rehabilitation

This paper highlights the fact that many anterior teeth requiring restoration are severely weakened having wide, flared canal spaces, and thin dentinal walls that are prone to fracture. Traditionally these teeth have been restored using metal posts and are often unsuccessful because of lack of retention or root fracture. This paper describes how mineral trioxide aggregate (MTA) can be used to form an immediate apical seal rather than waiting months for apexification. Weakened roots can be reinforced using dentine bonding agents and composite resin and if insufficient coronal tooth structure is present a quartz-fibre post can be placed to retain a composite core.     

Fracture resistance of simulated immature roots using Biodentine and fiber post compared with different canal-filling materials under aging conditions

Objective

The aim of this study was to evaluate the fracture resistance of simulated immature roots using Biodentine (BD) and fiber post (FP) compared with different root canal-filling materials under aging conditions.

Materials and methods

One hundred and forty maxillary central anterior teeth were randomly divided into seven groups (n = 20/group). Negative control received no treatment. In the other groups, the root canals were prepared to simulate immature teeth. The root canals were filled with a 4-mm apical plug of BD and restored intraradicular with BD, BD + FP, composite resin (CR), CR + FP, and gutta-percha (GP). Positive controls were instrumented but without restoration. Teeth were subjected to thermocycling and received cyclic loading before fracture resistance test. Fracture resistance was conducted using a universal testing machine with a crosshead speed of 0.5 mm/min until fracture. Load to fracture was recorded in newtons (N). Data were statistically analyzed using one-way analysis of variance and Tukey’s test at P < 0.05.

Results

Root canals restored intraradicular with BD + FP and CR + FP showed the highest fracture resistance compared with the other experimental groups (P < 0.001). There was no significant difference in the fracture resistance between CR and BD groups (P = 0.998). GP and positive control groups were significantly lower resistance to fracture than the other groups (P < 0.001).

Conclusions

Intraradicular reinforcement with BD + FP and CR + FP enhanced the fracture resistance of simulated immature teeth than the other experimental groups.

Clinical relevance

Biodentine or composite resin combined with fiber post could be used to reinforce immature teeth with an apical Biodentine plug.

     

Mineral trioxide aggregate as an alternative treatment for intruded permanent teeth with root resorption and incomplete apex formation

Abstract – A case of extensive crown fracture associated with intrusion of the permanent maxillary central incisors in an 8‐year‐old boy is reported. The treatment of both injured teeth included attempts of apexification and arrest of root resorption with calcium hydroxide. After 8 months of the trauma, there was no calcified barrier formation in the apex. Mineral trioxide aggregate (MTA) was then used as a filling material. At 15‐month follow up, the teeth were asymptomatic and correctly sealed, the external inflammatory root resorption had stopped, and the radiolucent image had disappeared, which meant the initial healing of the periapical lesion. MTA may be considered as an alternative option for the treatment of traumatized and immature permanent teeth.     

The use of mineral trioxide aggregate to achieve root end closure: three case reports

Abstract – The use of mineral trioxide aggregate (MTA) to achieve root end closure has many advantages over the traditional calcium hydroxide (Ca(OH)₂) technique including the reduced number of visits and the reduced mechanical damage to dentine. Limited studies have reported the outcome of using MTA as an apexification material and a one‐stage obturation technique in non‐vital immature teeth. This article illustrates three successful clinical cases where MTA was used as an apexification material. In case study one: Type 1 Dens Invaginatus tooth with incomplete root formation, case study two: an immature tooth that suffered pulp necrosis following an enamel and dentine fracture trauma and case study three: a non‐vital tooth following an apical root fracture.     

Release of Transforming Growth Factor Beta 1 from Human Tooth Dentin after Application of Either ProRoot MTA or Biodentine as a Coronal Barrier

IntroductionVarious factors may influence intracanal calcification in teeth treated with regenerative endodontic procedures. Bioactive materials, including ProRoot MTA (MTA; Dentsply Tulsa Dental Specialties, Memphis, TN) and Biodentine (BD; Septodont, Saint-Maur-des-Fossés, France), have been widely used as a coronal barrier in the final step of regenerative endodontic procedures. The purposes of this study were to evaluate the effect of either MTA or BD after application as a coronal barrier on transforming growth factor beta 1 (TGF-β1) release from root canal dentin and to observe the impact of these materials on human apical papilla cell (APC) mineralization.MethodsEither MTA or BD was applied in enlarged root canals of human root segments. After storing for 14 days in phosphate-buffered saline, TGF-β1 release was evaluated using an enzyme-linked immunosorbent assay. To investigate the effect of the materials on APC mineralization, APCs were grown in the presence of either the materials alone or material-filled root segments. Cell mineralization was quantified after 14 and 21 days using alizarin red S staining. Calcium deposits were quantitatively analyzed. Statistical analysis was performed using the Kruskal-Wallis and Mann-Whitney U tests with the significance level at .05.ResultsThe greatest amount of TGF-β1 release was observed in the root segments treated with BD. BD, used either alone or as a coronal barrier, promoted greater APC mineralization than did MTA on both days 14 and 21. Interestingly, when BD was applied as a coronal barrier, the mineralization effect was significantly reduced compared with the use of the materials alone (P < .05).ConclusionsWhen used as a coronal barrier, BD promoted the release of TGF-β1 from the root canal dentin. A higher mineralization effect was observed with BD than with MTA.     

Influence of Preoperative Pulp Inflammation in the Outcome of Full Pulpotomy Using a Dog Model

IntroductionThis study aimed to evaluate the impact of preoperative pulp inflammation on the histologic outcome of full pulpotomy performed in mature permanent posterior teeth using 4 different biomaterials.MethodsFive beagle dogs (providing a total of 120 roots) were selected. Dentin exposure was performed in teeth from the second and third quadrants. One week later, full pulpotomy procedures were performed using 4 different bioactive materials (ProRoot MTA [MTA], TotalFill BC Putty [BC], Biodentine [BIO], and an experimental cement [ie, pulp capping material]). The hemostasis time was registered. After 14 weeks, the animals were killed. Pulp-dentin tissues were histologically and radiographically assessed. The significance level was set at .05.ResultsTeeth with previously exposed dentin revealed a statistically significant increase in the time required to achieve hemostasis (P < .001), therefore confirming the pulp inflammation status induced by 1-week exposure of occlusal dentin before performing full pulpotomy. There was no radiographic evidence of root resorption, periapical radiolucency, or lamina dura alterations. No statistically significant differences were observed between normal and inflamed pulp regardless of the evaluated histologic parameters. Moreover, histologic data concerning calcified barrier formation and the pulp tissue response show better results for BIO without statistical differences compared with MTA or BC (P > .05). The pulp capping material presented a lower performance, with statistically significant differences being detected in regard to the remaining 3 tested materials (P < .001).ConclusionsRadiographic and histologic outcomes of full pulpotomy are not jeopardized by short-term preoperative pulp inflammation. Moreover, BIO, MTA, and BC cements present suitable alternatives to be used as pulp capping agents.     

Resistance to fracture of simulated external cervical resorption cavities repaired with different materials

The aim of the study was to evaluate the fracture resistance (FR) of teeth with simulated external cervical resorption (ECR) cavities repaired with different materials. Following the shaping of the 80 human permanent maxillary central incisors, standard ECR cavities were prepared and restored with a nanohybrid composite resin; a high viscosity GIC Equia Forte Fill; Biodentine; Biodentine + nanohybrid composite resin; MTA BIOREP; MTA BIOREP + nanohybrid composite resin. Then, the root canals were obturated with AH Plus and gutta-percha. The roots were embedded acrylic resin blocks and fracture strength test was applied. The highest FR was observed in the Biodentine group, while the lowest was in Equia group (p < 0.05). No significant results were observed among composite, Biodentine + composite, MTA BIOREP + composite and MTA BIOREP (p > 0.05). Biodentine may be a preferable material for repairing ECR cavities. Adding a composite layer on MTA BIOREP and Biodentine did not improve the FR of these materials.     

Treatment Outcomes of Regenerative Endodontic Procedures in Traumatized Immature Permanent Necrotic Teeth: A Retrospective Study

IntroductionThis retrospective study aimed to evaluate the clinical and radiographic outcomes of regenerative endodontic procedures (REPs) for traumatic immature permanent teeth. Meanwhile, predictors influencing treatment outcomes were also analyzed to provide evidence for the management of immature teeth after different traumatic scenarios.MethodsTraumatized immature permanent teeth diagnosed with pulp necrosis treated by REPs using blood clot or concentrated growth factor scaffolds with at least 6 months of follow-up were included from 2012 to 2021. Treatment outcomes were categorized as a success or failure and survival. Further root development was assessed in terms of the percentage changes in the apical diameter, root length, and radiographic root area. Among different injury types, the clinical and radiographic outcomes of REPs were evaluated by the Fisher exact test and the Kruskal-Wallis test, respectively. Survival analysis and Cox regression analysis were performed to identify significant predictors affecting outcomes.ResultsSixty-two teeth with a mean of 22.3 months of follow-up satisfied the criteria, and 80.6% of the teeth had a successful outcome. A significant change was observed in a decrease of the apical diameter (69.3%) and an increase of the radiographic root area (22.6%) after REPs. Among different injury types, the success rates of REPs were as follows: fracture, 84.6%; luxation, 83.3%; combined injuries, 78.6%; and avulsion, 33.3% (P > .05). Fractured teeth had a significantly greater decrease of the apical diameter than combined injuries (P < .05). Avulsion was more prone to developing root resorption than fracture (P < .05). Scaffold was a significant predictor for success; a blood clot had a significantly reduced risk for failure than concentrated growth factor (hazard ratio = 16; 95% confidence interval, 2.1–125.2; P < .001).ConclusionsREPs provided satisfactory outcomes in traumatized immature permanent necrotic teeth. However, severe injuries, especially avulsion, should be determined carefully to perform REPs when resorption is expected. Scaffold selection may be an important consideration.     

Success of Direct Pulp Capping Using Mineral Trioxide Aggregate and Calcium Hydroxide in Mature Permanent Molars with Pulps Exposed during Carious Tissue Removal: 1-year Follow-up

IntroductionThis randomized clinical trial aimed to compare the success rate and postoperative pain of direct pulp capping (DPC) using calcium hydroxide (CH) and mineral trioxide aggregate (MTA) in teeth with carious pulp exposures and reversible pulpitis.MethodsSixty-four permanent teeth were randomly divided after caries excavation into 2 groups: CH and MTA (n = 32 in each group). Exposed pulps were capped using standardized protocols. The treated teeth were restored with glass ionomer cement and composite restoration. The primary outcome was success rate at the 12-month follow-up, and the secondary outcome was postoperative pain after 7 days. Clinical and radiographic evaluations were performed at 3, 6, and 12 months. Pain was recorded using the visual analog scale every 24 hours for 7 days after intervention.ResultsFifty-six patients were analyzed at the 12-month follow-up, 29 treated with CH and 27 with ProRoot MTA (Dentsply Tulsa Dental, Tulsa, OK). The success rate was 69% for CH and 93% for ProRoot MTA (P < .05). The kappa value of interrater agreement was 0.773.No significant difference in pain incidence was found between the 2 groups (P > .05) although a significant pain reduction was found 6 hours after the procedure in both the groups. Significantly lower pain scores were reported in the MTA group (6.3 ± 9.5) compared with the CH group (18.5 ± 20.8) after 18 hours.ConclusionsTeeth with carious pulp exposures and reversible pulpitis can be treated successfully with DPC. MTA proved better than CH in terms of both success rate and pain intensity.     

Effects of intracanal mineral trioxide aggregate and calcium hydroxide during four weeks on pH changes in simulated root surface resorption defects: an in vitro study using matched pairs of human teeth

Introduction

Diffusion of hydroxyl ions from intracanal calcium hydroxide (CH) through dentin is used to arrest external inflammatory root resorption. However, long-term and short-term CH placement has been associated with an increased risk of root fracture. Intracanal mineral trioxide aggregate (MTA) might provide an alternative to CH as a source of hydroxyl ions. This in vitro study compared the effects of intracanal MTA and CH on hydroxyl ion diffusion through dentin by measuring pH changes over time in simulated root surface resorption defects prepared in matched pairs of teeth; the null hypothesis tested was that there is no difference.

Methods

Root surface cavities were prepared 5 mm from the apex in extracted human permanent anterior teeth (21 matched pairs) and 7 additional teeth (controls). Root canals were instrumented to size 50/.04 and filled with either tooth-colored MTA (ProRoot) or CH (UltraCal XS); control teeth were filled with saline. The pH in root surface cavities was measured at 3 hours, 24 hours, 1 week, 2 weeks, 3 weeks, and 4 weeks.

Results

In controls, pH readings did not differ significantly during the 4 weeks (P > .05, repeated-measures analysis of variance [ANOVA]). For the experimental intragroup effects, significant pH changes occurred over time in the MTA group (P = .005, repeated-measures ANOVA) and the CH group (P < .0001). For the experimental intergroup effects, the overall mean pH was higher in the MTA group (8.66; standard error [SE], 0.07) compared with the CH group (8.46; SE, 0.07) (P = .014, paired t test). At 4 weeks pH was higher in the MTA group (8.30; SE, 0.16) compared with the CH group (7.90; SE, 0.11) (P = .011); at all other time points intergroup differences were insignificant. The null hypothesis was rejected.

Conclusions

Intracanal MTA and CH groups differed in their overall effect on pH measured in simulated root surface resorption defects. At 4 weeks intracanal placement of MTA compared with CH resulted in a small but significantly higher pH.     

The Effect of Different Cavity Designs and Temporary Filling Materials on the Fracture Resistance of Upper Premolars

IntroductionThe aim of this study was to compare the fracture resistance of upper premolars undergoing root canal treatment that had been temporarily restored with 4 different temporary filling materials.MethodsThis study was based on 120 extracted upper premolars. Eight teeth were left intact and served as the negative control group. Mesio-occluso-distal cavities with 2 different designs were prepared for the rest of the teeth (for group 1 a width of one third of the intercuspal distance and for group 2 a width of two thirds of the intercuspal distance). Then, the endodontic access cavities were prepared, and the root canals instrumented with Revo-S rotary files (MicroMega, Besancon, France). Thereafter, a total of 16 teeth consisting of 8 each from group 1 and group 2 served as the positive control group and did not have any temporary filling material. The teeth were randomly divided into 4 subgroups (n = 12) according to the temporary filling material: Cavit G (3M ESPE, St Paul, MN), Coltosol F (Coltène/Whaledent AG, Altstätten, Switzerland), Intermediate Restorative Material (Dentsply Sirona, Konstanz, Germany), or DiaTemp (DiaDent Europe BV, Almere, Netherlands). Each specimen was then subjected to a fracture resistance test using a universal testing machine until the fracture occurred. The force required to fracture each specimen was recorded, and the data were statistically analyzed.ResultsThe negative control group showed the highest fracture resistance values compared with the other groups, whereas the positive control groups showed the lowest fracture resistance values. There were no statistically significant differences in the fracture resistance of upper premolar teeth undergoing root canal treatment among Cavit G, Intermediate Restorative Material, Coltosol F, and DiaTemp, regardless of the cavity width (P > .05).ConclusionsThe cavity design was found to be an effective factor on the fracture resistance of upper premolar teeth undergoing root canal treatment. The temporary filling materials tested did not affect the fracture resistance.     

Apexification with mineral trioxide aggregate: an overview of the material and technique

Mineral Trioxide Aggregate (MTA) was introduced as an alternative to traditional materials for the repair of root perforations, pulp-capping and as a retrograde root filling due to its superior biocompatibilty and ability to seal the root canal system. Traditionally, calcium hydroxide has been the material of choice for the apexification of immature permanent teeth but MTA holds significant promise as an alternative to multiple treatments with calcium hydroxide. The paper discusses the use of calcium hydroxide as a traditional apexification material and provides an overview of the composition, properties and applications of Mineral Trioxide Aggregate with emphasis on its use in apexification of immature permanent teeth. A case report is presented to highlight its use.     

漏斗状根管治疗牙重塑后不同桩核系统修复的抗折性研究

目的比较漏斗状根管治疗牙在根管重塑前后不同桩核系统修复的抗折强度及牙折形式。方法采用两因素三水平的析因设计。选择45颗近期拔除的上颌中切牙,随机分为9组,每组5颗。分别按照根管重塑因素和桩核系统因素的三个水平交互组合进行处理。样本进行破坏性力学试验,记录瞬间力值及牙折形式。结果根管重塑因素对抗折强度具有显著性影响（P〈0.05）,桩核系统因素对抗折强度不产生明显影响（P〉0.05）,两种因素之间无交互作用（P〉0.05）。结论根管重塑可显著提高漏斗状根管治疗牙桩核系统修复后的抗折强度。重塑后的漏斗状根管治疗牙,不同桩核系统修复后的抗折强度无显著性差异。     

Emerging therapies for the management of traumatized immature permanent incisors

Early loss of immature permanent teeth due to pulpal necrosis secondary to trauma can have dire consequences for a child's growth and development. The treatment alternatives include surgical endodontics, traditional calcium hydroxide apexification, and mineral trioxide aggregate (MTA) apexification. These options pose potential complications, including: arrest of root development; weakened dentinal walls; and increased potential for fracture. Revascularization of the dentin-pulp complex is a new approach that involves disinfecting the root canal system followed by tissue repair and regeneration while allowing for continued root development and thickening of the lateral dentinal walls through deposition of new hard tissue. The purpose of this report was to present the revascularization of an immature permanent maxillary central incisor that had evidence of external root resorption. Six months later, internal bleaching was performed to remove cervical discoloration from the triple antibiotic paste. At 18 months, the tooth remained vital and had evidence of continued root development.     

Impact of Conservative Endodontic Cavities on Root Canal Preparation and Biomechanical Behavior of Upper Premolars Restored with Different Materials

IntroductionThe purpose of this study was to evaluate the impact of conservative endodontic cavities (CECs) on root canal preparation, restoration, and biomechanical behavior of teeth prepared using different shaping systems and restorative materials.MethodsNinety upper premolars with a bifurcated root were matched based on morphology and randomly assigned to a control group (n = 10) or 1 of the following experimental groups (n = 40): traditional endodontic cavity and CEC. Teeth were subdivided according to instrumentation (n = 10) as follows: ProTaper Universal (Dentsply Maillefer, Ballaigues, Switzerland), Reciproc (VDW GmbH, Munich, Germany), Reciproc Blue (VDW GmbH), and Hyflex EDM (Coltene/Whaledent, Altstätten, Switzerland). After canal obturation, teeth were restored using temporary material, conventional composite, regular bulk fill composite, or bulk fill flow combined with conventional composite. Before and after preparation and after obturation, the teeth were scanned using micro–computed tomographic imaging. Canal transportation (CT), the percentage of untouched canal surfaces (UCSs), voids in restoration (VRs), and residual filling material in the pulp chamber were evaluated. Finite element analysis, fracture resistance, and the failure pattern were recorded. The data were analyzed using analysis of variance and the Tukey and chi-square tests.ResultsCECs had greater CT, percentage of filling material, and VRs compared with traditional endodontic cavities (P < .0001). The highest CT and UCSs were observed in CEC with ProTaper Universal. Bulk fill flow combined with conventional composite showed a lower percentage of VRs compared with other restorative materials (P < .05). Finite element analysis, fracture resistance, and failure pattern revealed similar behaviors in all groups (P > .05) .ConclusionsCECs had a negative impact on root canal centralization, UCSs, cleaning of the pulp chamber, and percentage of VRs. Controlled memory instruments were the most adequate for the root canal preparation of CECs. The endodontic cavity did not influence the biomechanical behavior of restored teeth.