Effect of fracture orientation on detection accuracy of vertical root fractures in non-endodontically treated teeth using cone beam computed tomography



This study aimed to investigate the effect of fracture orientation on the detection accuracy of vertical root fractures (VRFs) in non-endodontically treated teeth using four different cone beam computed tomography (CBCT) units.

Materials and methods

Thirty eight out of 148 extracted human permanent teeth were chosen randomly, and VRFs were artificially induced to result in 20 mesiodistally and 18 buccolingually oriented root fractures. The fracture width was subsequently measured. All the teeth were scanned with four CBCT units. CBCT images were evaluated independently by two observers. Area under the receiver operating characteristic curve (AUC), sensitivity, and specificity were calculated for each observer and fracture orientation. The AUC between the two fracture orientations was compared using Z test.


The mean fracture width was 140 μm (standard deviation 26.8 μm). A statistically significant difference was found between the mesiodistal and buccolingual VRFs for the AUC from the CBCT unit 3D Accuitomo 170 (p = 0.02). There were no statistically significant differences between the mesiodistal and buccolingual VRFs for AUCs from the CBCT units NewTom VGi (p = 0.21), ProMax 3D Mid (p = 0.23), and i-CAT FLX (p = 0.21).


Fracture orientations of teeth with VRFs in non-endodontically treated teeth may play a role in the detection accuracy of CBCT images, but this effect seems to be dependent on the CBCT unit used.

Clinical relevance

Although for most of the CBCT units tested, the fracture orientation of VRF in non-endodontically treated teeth seems not to play a role for the diagnosis, clinical data is needed to further assess the impact of different devices on VRF detection.

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  1. 1.

    American Association of Endodontists (2008) Endodontics: colleagues for excellence—cracking the cracked tooth code: detection and treatment of various longitudinal tooth fractures. Available at: https://www.aae.org/specialty/newsletter/cracking-cracked-tooth-code. Accessed 14 Nov 2018

  2. 2.

    Chan C, Lin C, Tseng S, Jeng J (1999) Vertical root fracture in endodontically versus nonendodontically treated teeth: a survey of 315 cases in Chinese patients. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 87:504–507. https://doi.org/10.1016/S1079-2104(99)70252-0

    Article  PubMed  Google Scholar 

  3. 3.

    Wang P, Yan X, Lui D, Zhang W, Zhang Y, Ma X (2011) Detection of dental root fractures by using cone-beam computed tomography. Dentomaxillofac Radiol 40:290–298. https://doi.org/10.1259/dmfr/84907460

    Article  PubMed  PubMed Central  Google Scholar 

  4. 4.

    Haueisen H, Gärtner K, Kaiser L, Trohorsch D, Heidemann D (2013) Vertical root fracture: prevalence, etiology, and diagnosis. Quintessence Int 44:467–474. https://doi.org/10.3290/j.qi.a29715

    Article  PubMed  Google Scholar 

  5. 5.

    Liao WC, Tsai YL, Wang CY, Chang MC, Huang WL, Lin HJ, Liu HC, Chan CP, Chang SH, Jeng JH (2017) Clinical and radiographic characteristics of vertical root fractures in endodontically and nonendodontically treated teeth. J Endod 43:687–693. https://doi.org/10.1016/j.joen.2016.12.009

    Article  PubMed  Google Scholar 

  6. 6.

    Walton RE, Michelich RJ, Smith GN (1984) The histopathogenesis of vertical root fractures. J Endod 10:48–56. https://doi.org/10.1016/S0099-2399(84)80037-0

    Article  PubMed  Google Scholar 

  7. 7.

    Pitts DL, Natkin E (1983) Diagnosis and treatment of vertical root fractures. J Endod 9:338–346. https://doi.org/10.1016/S0099-2399(83)80150-2

    Article  PubMed  Google Scholar 

  8. 8.

    Tsesis I, Beitlitum I, Rosen E (2015) Treatment alternatives for the preservation of vertically root fractured teeth. In: Tamse A, Tsesis I, Rosen E (eds) Vertical root fractures in dentistry. Springer, Heidelberg, pp 97–107

    Google Scholar 

  9. 9.

    Walton RE (2017) Vertical root fracture: Factors related to identification. J Am Dent Assoc 148:100–105. https://doi.org/10.1016/j.adaj.2016.11.014

    Article  PubMed  Google Scholar 

  10. 10.

    Moule AJ, Kahler B (1999) Diagnosis and management of teeth with vertical root fractures. Aust Dent J 44:75–87. https://doi.org/10.1111/j.1834-7819.1999.tb00205.x

    Article  PubMed  Google Scholar 

  11. 11.

    Hassan B, Metska ME, Ozok AR, van der Stelt P, Wesselink PR (2009) Detection of vertical root fractures in endodontically treated teeth by a cone beam computed tomography scan. J Endod 35:719–722. https://doi.org/10.1016/j.joen.2009.01.022

    Article  PubMed  Google Scholar 

  12. 12.

    Kambungton J, Janhom A, Prapayasatok S, Pongsiriwet S (2012) Assessment of vertical root fractures using three imaging modalities: cone beam CT, intraoral digital radiography and film. Dentomaxillofac Radiol 41:91–95. https://doi.org/10.1259/dmfr/49798768

    Article  PubMed  PubMed Central  Google Scholar 

  13. 13.

    Jakobson SJ, Westphalen VP, Silva Neto UX, Fariniuk LF, Schroeder AG, Carneiro E (2014) The influence of metallic posts in the detection of vertical root fractures using different imaging examinations. Dentomaxillofac Radiol 43:20130287. https://doi.org/10.1259/dmfr.20130287

    Article  PubMed  Google Scholar 

  14. 14.

    De Martin ESD, Campos CN, Pires Carvalho AC, Devito KL (2018) Diagnosis of mesiodistal vertical root fractures in teeth with metal posts: influence of applying filters in cone-beam computed tomography images at different resolutions. J Endod 44:470–474. https://doi.org/10.1016/j.joen.2017.08.030

    Article  Google Scholar 

  15. 15.

    Youssefzadeh S, Gahleitner A, Dorffner R, Bernhart T, Kainberger FM (1999) Dental vertical root fractures: value of CT in detection. Radiology 210:545–549. https://doi.org/10.1148/radiology.210.2.r99ja20545

    Article  PubMed  Google Scholar 

  16. 16.

    Tsesis I, Kamburoglu K, Katz A, Tamse A, Kaffe I, Kfir A (2008) Comparison of digital with conventional radiography in detection of vertical root fractures in endodontically treated maxillary premolars: an ex vivo study. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 106:124–128. https://doi.org/10.1016/j.tripleo.2007.09.007

    Article  PubMed  Google Scholar 

  17. 17.

    Khedmat S, Rouhi N, Drage N, Shokouhinejad N, Nekoofar MH (2012) Evaluation of three imaging techniques for the detection of vertical root fractures in the absence and presence of gutta-percha root fillings. Int Endod J 45:1004–1009. https://doi.org/10.1111/j.1365-2591.2012.02062.x

    Article  PubMed  Google Scholar 

  18. 18.

    Kondylidou-Sidira A, Fardi A, Giannopoulou M, Parisis N (2013) Detection of experimentally induced root fractures on digital and conventional radiographs: an in vitro study. Odontology 101:89–95. https://doi.org/10.1007/s10266-012-0059-0

    Article  PubMed  Google Scholar 

  19. 19.

    Rud J, Omnell KA (1970) Root fractures due to corrosion. Diagnostic aspects. Scand J Dent Res 78:397–403. https://doi.org/10.1111/j.1600-0722.1970.tb02088.x

    Article  PubMed  Google Scholar 

  20. 20.

    Corbella S, Del Fabbro M, Tamse A, Rosen E, Tsesis I, Taschieri S (2014) Cone beam computed tomography for the diagnosis of vertical root fractures: a systematic review of the literature and meta-analysis. Oral Surg Oral Med Oral Pathol Oral Radiol 118:593–602. https://doi.org/10.1016/j.oooo.2014.07.014

    Article  PubMed  Google Scholar 

  21. 21.

    Talwar S, Utneja S, Nawal RR, Kaushik A, Srivastava D, Oberoy SS (2016) Role of cone-beam computed tomography in diagnosis of vertical root fractures: a systematic review and meta-analysis. J Endod 42:12–24. https://doi.org/10.1016/j.joen.2015.09.012

    Article  PubMed  Google Scholar 

  22. 22.

    Melo SL, Bortoluzzi EA, Abreu M Jr, Correa LR, Correa M (2010) Diagnostic ability of a cone-beam computed tomography scan to assess longitudinal root fractures in prosthetically treated teeth. J Endod 36:1879–1882. https://doi.org/10.1016/j.joen.2010.08.025

    Article  PubMed  Google Scholar 

  23. 23.

    Özer SY (2011) Detection of vertical root fractures by using cone beam computed tomography with variable voxel sizes in an in vitro model. J Endod 37:75–79. https://doi.org/10.1016/j.joen.2010.04.021

    Article  PubMed  Google Scholar 

  24. 24.

    Melo SL, Haiter-Neto F, Correa LR, Scarfe WC, Farman AG (2013) Comparative diagnostic yield of cone beam CT reconstruction using various software programs on the detection of vertical root fractures. Dentomaxillofac Radiol 42:20120459. https://doi.org/10.1259/dmfr.20120459

    Article  PubMed  PubMed Central  Google Scholar 

  25. 25.

    Brady E, Mannocci F, Brown J, Wilson R, Patel S (2014) A comparison of cone beam computed tomography and periapical radiography for the detection of vertical root fractures in nonendodontically treated teeth. Int Endod J 47:735–746. https://doi.org/10.1111/iej.12209

    Article  PubMed  Google Scholar 

  26. 26.

    Ma RH, Ge ZP, Li G (2016) Detection accuracy of root fractures in cone-beam computed tomography images: a systematic review and meta-analysis. Int Endod J 49:646–654. https://doi.org/10.1111/iej.12490

    Article  PubMed  Google Scholar 

  27. 27.

    Zhang ZL, Cheng JG, Li G, Zhang JZ, Zhang ZY, Ma XC (2012) Measurement accuracy of temporomandibular joint space in Promax 3-dimensional cone-beam computerized tomography images. Oral Surg Oral Med Oral Pathol Oral Radiol 114:112–117. https://doi.org/10.1016/j.oooo.2011.11.020

    Article  PubMed  Google Scholar 

  28. 28.

    Hassan B, Metska ME, Ozok AR, van der Stelt P, Wesselink PR (2010) Comparison of five cone beam computed tomography systems for the detection of vertical root fractures. J Endod 36:126–129. https://doi.org/10.1016/j.joen.2009.09.013

    Article  PubMed  Google Scholar 

  29. 29.

    Guo XL, Li G, Zheng JQ, Ma RH, Liu FC, Yuan FS, Lyu PJ, Guo YJ, Yin S (2019) Accuracy of detecting vertical root fractures in non-root filled teeth using cone beam computed tomography: effect of voxel size and fracture width. Int Endod J. https://doi.org/10.1111/iej.13076

  30. 30.

    Donaldson K, O'Connor S, Heath N (2013) Dental cone beam CT image quality possibly reduced by patient movement. Dentomaxillofac Radiol 42:91866873. https://doi.org/10.1259/dmfr/91866873

    Article  PubMed  PubMed Central  Google Scholar 

  31. 31.

    Nardi C, Borri C, Regini F, Calistri L, Castellani A, Lorini C, Colagrande S (2015) Metal and motion artifacts by cone beam computed tomography (CBCT) in dental and maxillofacial study. Radiol Med 120:618–626. https://doi.org/10.1007/s11547-015-0496-2

    Article  PubMed  Google Scholar 

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The authors would like to express their sincere thanks to the statistician, Dr. Fang-Chao Liu, for his valuable suggestion on statistical analysis.


The study was supported by National Natural Science Foundation of China (Grant No. 81671034).

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Correspondence to Gang Li.

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All procedures performed in studies involving human participants were in accordance with the ethical standards of Institutional Review Board of Peking University School and Hospital of Stomatology (PKUSSIRB-201838111) and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

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Guo, X., Li, G., Yin, S. et al. Effect of fracture orientation on detection accuracy of vertical root fractures in non-endodontically treated teeth using cone beam computed tomography. Clin Oral Invest 23, 4433–4439 (2019). https://doi.org/10.1007/s00784-019-02905-0

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  • Vertical root fracture
  • Cone beam computed tomography
  • Fracture orientation
  • Non-endodontically treated tooth
  • Diagnosis