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| Title |
Cone-beam Computed Tomography (CBCT) Demonstrates Higher Diagnostic Accuracy than 2-D Periapical Radiographs in Identifying Vertical Root Fractures in Patients with Suspected Fractures |
| Clinical Question |
In patients with suspected vertical root fractures, does cone-beam computed tomography (CBCT) more consistently and accurately identify the presence of a fracture than 2-D periapical radiographs? |
| Clinical Bottom Line |
For suspected vertical root fractures (VRFs), CBCT has shown greater accuracy and consistency than periapical radiographs. However, it is not recommended as a first-line imaging tool in clinical practice. CBCT has several limitations: fracture detectability can be affected by variations in fracture size, direction, and completeness, and diagnostic accuracy is reduced in teeth with endodontic materials or metal posts due to artifacts. CBCT also exposes patients to higher radiation and cost. The recommended standard remains a comprehensive clinical exam supported by periapical radiographs and fracture exploration as initial steps. |
| Best Evidence |
(you may view more info by clicking on the PubMed ID link) |
| PubMed ID |
Author / Year |
Patient Group |
Study type
(level of evidence) |
| #1) 40726824 | de Lima Dias-Junior, 2025 | Systematic review of 100 in-vitro studies assessing the diagnostic accuracy of VRF with CBCT scans | Systematic review of non-randomized trials | | Key results | CBCT shows higher sensitivity for detecting complete vertical root fractures than incomplete ones. Both sensitivity and specificity decrease in the presence of metal posts. Diagnostic accuracy differed significantly by fracture type (p = 0.0015): complete fractures (SSe = 0.749; 95% CI: 0.675–0.811) vs incomplete fractures (SSe = 0.522; 95% CI: 0.424–0.618). Specificity differences were not statistically significant (p = 0.2189). | | #2) 39438817 | Shokri, 2024 | Systematic review of 23 articles and 16 articles for meta-analysis | Systematic review of randomized trials | | Key results | CBCT showed higher sensitivity than periapical radiographs for detecting vertical root fractures, while specificity was similar between the two.
Sensitivity
•CBCT: 0.708 (95% CI: 0.608–0.792)
•PA: 0.518 (95% CI: 0.408–0.626)
Though there is an overlap of the CI’s, a statistical significance was determined (p < 0.05), indicating CBCT is more likely to correctly identify fractures.
Specificity
•CBCT: 0.841 (95% CI: 0.756–0.9)
•PA: 0.876 (95% CI: 0.803–0.925)
The difference was not significant (p = 0.46).
About 27% of fractures were not detected, likely due to artifacts from metal posts or gutta-percha. Periapical radiographs detected 51% of fractures but are limited by factors like beam angulation.
| | #3) 38795077 | Mareque-Bueno, 2024 | 98 patients | Gold standard-controlled diagnostic study | | Key results | Trial included 98 patients diagnosed with longitudinal tooth fracture (cracked tooth, split tooth and VRF) through direct visualization after extraction with comprehensive clinical and radiographic records. CBCT detected bone loss patterns associated with longitudinal root fractures significantly more often than periapical radiographs (71% vs 42%, p < 0.05). Visualization of fracture lines was also higher with CBCT (65%) than PA radiographs (45%), with overall significance (p < 0.001). Detection varied with factors like prior root canal treatment, deep probing depths, and having more than eight teeth extracted. | | #4) 40726824 | PradeepKumar, 2021 | Meta-analysis of 8 studies with >450 patients presenting with suspected VRFs | Meta-Analysis | | Key results | CBCT showed a sensitivity of 0.78 (95% CI: 0.64–0.88) and specificity of 0.80 (95% CI: 0.63–0.91) for diagnosing vertical root fractures in root-filled teeth. The positive likelihood ratio was 4, and the negative likelihood ratio was 0.2—both below thresholds considered strong for confirming or excluding disease. | |
| Evidence Search |
((vertical root fracture detection and CBCT or periapical film) |
Comments on
The Evidence |
The systematic reviews (de Lima Dias-Junior 2025; PradeepKumar 2021) provided statistically significant evidence supporting CBCT’s diagnostic accuracy in VRFs. Overlap was noted in the CI’s (sensitivity) but yielded a statistically significant p-value. The retrospective and in vitro diagnostic accuracy studies (Mareque-Bueno 2024, Shokri 2024) support the systematic reviews but have small sample sizes. Across studies, sensitivity and specificity consistently favor CBCT. In these studies, the presence of full-coverage restorations and previous history of root canal therapy and or metal post placement were discussed as worsening the diagnostic ability of a CBCT. However, the significance is weak, and all reported the need for more RCTs or retrospective/prospective studies to be performed. |
| Applicability |
The patient populations studied (older adult patients with suspected VRFs) are generalizable to most clinical dental settings. CBCT is becoming increasingly accessible, though financial cost, radiation exposure, and equipment specifications may limit use in most practices. Periapical radiographs remain the first-line diagnostic tool due to cost and accessibility, but evidence supports CBCT as the superior diagnostic modality in equivocal or high-suspicion cases. In practice, it should still be suggested to perform a comprehensive clinical exam and use periapical radiographs. |
| Specialty/Discipline |
(Oral Medicine/Pathology/Radiology) |
| Keywords |
Vertical root fracture, VRF
Cone beam computed tomography, CBCT
Periapical radiograph, periapical, PA
|
| ID# |
3589 |
| Date of submission: |
10/15/2025 |
| E-mail |
fortuno@livemail.uthscsa.edu |
| Author |
Mason Fortuno |
| Co-author(s) |
Christopher Young |
| Co-author(s) e-mail |
youngc4@livemail.uthscsa.edu |
| Faculty mentor/Co-author |
Dr. Hassem Geha |
| Faculty mentor/Co-author e-mail |
Geha@uthscsa.edu |
Basic Science Rationale
(Mechanisms that may account for and/or explain the clinical question, i.e. is the answer to the clinical question consistent with basic biological, physical and/or behavioral science principles, laws and research?) |
post a rationale |
| None available | |
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Comments and Evidence-Based Updates on the CAT
(FOR PRACTICING DENTISTS', FACULTY, RESIDENTS and/or STUDENTS COMMENTS ON PUBLISHED CATs) |
post a comment |
| None available | |
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