An endodontically treated tooth with a vertical root fracture (VRF) has a poor prognosis. Because there are no reliable methods for treatment, it is usually extracted.

A longitudinally-oriented fracture plane confined to the root, a VRF can only be seen if the primary imaging beam is within 4 degrees of the fracture plane. Superimposition of surrounding anatomic structures further impedes VRF visualization, which means detection occurs on periapical radiographs in only about one-third of cases.

To avoid unnecessary extraction of an otherwise treatable tooth, making a reliable diagnosis of VRF is the rationale behind using high-resolution cone-beam computed tomography (CBCT) imaging to detect VRF. However, the presence of imaging artifacts that may obscure the fracture plane calls into question the ability of CBCT to detect VRFs, scientists at the University of Toronto reported. Investigating CBCT’s diagnostic ability to detect VFRs in endodontically treated teeth, they searched the literature for studies published through August 2015 regarding patients with at least one endodontically treated permanent tooth suspected of having VRF on the basis of clinical signs and symptoms. They published their findings in the February 2016 issue of Journal of Endodontics.

Of 2,360 records initially identified, scientists analyzed four studies that met the inclusion criteria for this systematic review. Because of the small number of studies and marked clinical heterogeneity among them, the team opted not to perform a meta-analysis.

Results demonstrated a significant imprecision in the reported ranges of diagnostic ability owing to limited sample sizes, great variability in how studies were conducted, different CBCT models and imaging parameters, different types of reference testing and different populations under study. Examples included the subjective nature of radiologic interpretation and multiple sources of bias.

Definitive conclusions about diagnostic ability couldn’t be drawn, scientists said about the research. Instead, they asserted that the most clinically relevant question, “How accurate is CBCT in detecting VRFs in endodontically treated teeth?” remained unanswered. The findings were in agreement with two recent systematic reviews highlighted in discussion.

Scientists noted that CBCT is increasingly used in the clinical practice of dentistry, particularly within the specialty of endodontics, for the diagnosis of pathosis and preoperative assessment. “Because of the increased uptake of CBCT, the possibility of indiscriminant prescription and unjustified reliance on a test of unclear diagnostic ability is concerning,” they said. “To maximize the chances of detecting a VRF by using CBCT, the clinician’s best tools still consist of what is done before the CBCT (i.e. a thorough clinical examination and recognizing the signs and symptoms that are suggestive of a VRF).”

Among conclusions, they advised, “Until more evidence is presented to suggest that CBCT is both diagnostically accurate and efficacious, the prudent clinician should carefully consider its potential risks and harms before its prescription.”

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