
==== Front
Oral Radiol
Oral Radiol
Oral Radiology
0911-6028
1613-9674
Springer Nature Singapore Singapore

38976094
766
10.1007/s11282-024-00766-2
Review Article
Developing evidence-based clinical imaging guidelines for the diagnosis of vertically fractured teeth
Kim Ki-Hong 1
http://orcid.org/0000-0003-0218-5304
Kim Jo-Eun noel1st@snu.ac.kr

1
http://orcid.org/0000-0001-7223-9262
Lee Sam-Sun 1
http://orcid.org/0000-0002-8943-4192
Lee Chena 2
http://orcid.org/0000-0002-2424-9965
Choi Miyoung 3
http://orcid.org/0000-0003-0247-8932
Yong Hwan Seok 4
http://orcid.org/0000-0003-0674-5444
Jung Seung Eun 5
http://orcid.org/0000-0003-3406-0645
Heo Min-Suk 1
http://orcid.org/0000-0002-8771-0392
Huh Kyung-Hoe 1
1 https://ror.org/04h9pn542 grid.31501.36 0000 0004 0470 5905 Department of Oral and Maxillofacial Radiology, School of Dentistry and Dental Research Institute, Seoul National University, Seoul, Korea
2 https://ror.org/00tfaab58 0000 0004 0647 4215 Department of Oral & Maxillofacial Radiology, Yonsei University College of Dentistry, Seoul, Korea
3 https://ror.org/04f097438 grid.453731.7 0000 0004 4691 449X Division for Healthcare Technology Assessment Research, National Evidence-Based Healthcare Collaborating Agency, Seoul, Korea
4 https://ror.org/047dqcg40 grid.222754.4 0000 0001 0840 2678 Department of Radiology, Korea University Guro Hospital, Seoul, Korea
5 https://ror.org/01fpnj063 grid.411947.e 0000 0004 0470 4224 Department of Radiology, College of Medicine, Eunpyeong St. Mary’s Hospital, The Catholic University of Korea, Seoul, Korea
8 7 2024
8 7 2024
2024
40 4 471483
1 4 2024
30 6 2024
© The Author(s) 2024
2024
https://creativecommons.org/licenses/by/4.0/ Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.
Objectives

This study aimed to develop an evidence-based clinical imaging guideline for teeth suspected with vertical root fractures.

Methods

An adaptation methodology based on the Korean Clinical Imaging Guidelines (K-CIG) was used in the guideline development process. After searching for guidelines using major databases such as Ovid-Medline, Elsevier-Embase, National Guideline Clearinghouse, and Guideline International Network, as well as domestic databases such as KoreaMed, KMbase, and KoMGI, two reviewers analyzed the retrieved articles. The retrieved articles were included in this review using well-established inclusion criteria.

Results

Twenty articles were identified through an online search, of which three were selected for guideline development. Based on these three guidelines, this study developed specific recommendations concerning the optimal imaging modality for diagnosing teeth suspected of vertical root fractures.

Conclusions

Periapical radiography is the preferred method for assessing teeth with mastication-related pain and suspected vertical root fractures. However, if intraoral radiographs do not provide sufficient information about root fractures, a small FOV CBCT may be considered. However, the use of CBCT in endodontically treated teeth is significantly constrained by the presence of artificial shading.

Keywords

Imaging guideline
Vertical root fracture
Periapical radiography
Cone beam computed tomography
Systematic review
http://dx.doi.org/10.13039/501100003669 Korea Centers for Disease Control and Prevention 2018E380500 issue-copyright-statement© Japanese Society for Oral and Maxillofacial Radiology 2024
==== Body
pmcIntroduction

The clinical signs of vertical root fractures (VRF) are similar to those of root canal treatment failure or periodontal disease, making diagnosis difficult [1]. However, after conclusive diagnosis, the prognosis of teeth with VRFs is notably poor [2]. Urgent decision-making is required to prevent further bone loss, which can complicate subsequent reconstructive interventions, often necessitating extraction, root amputation, or implantation [1, 3]. Thus, accurate diagnosis is crucial to avoid unnecessary extraction of treatable teeth [4].

Periapical radiography (PA) is widely used to observe trauma sites with minimal radiation exposure. However, fractures may elude detection if the X-ray beam fails to traverse the fracture line [3]. Further, PA radiography does not provide three-dimensional information about the tooth and surrounding structures, with potential overlap obscuring the VRF detection sensitivity [5].

Given the limitations of conventional imaging modalities in visualizing VRFs, alternative imaging systems, such as cone-beam computed tomography (CBCT), are urgently needed [6]. CBCT imaging enables the precise visualization and evaluation of teeth with VRFs [5, 7]. However, VRF often manifests in endodontically treated teeth, with a reported prevalence ranging from 3.7 to 30.8% [8–11]. The presence of radiopaque materials within the root canal, such as gutta-percha or metallic posts, can reduce the diagnostic validity due to beam hardening and streak artifacts mimicking fracture lines [7]. Despite its advantages, CBCT usage is constrained by its high radiation dose, high cost, and limited availability [3].

Given the intricate nature and importance of VRF, selecting an appropriate imaging modality is paramount for diagnosis. Radiological examinations require stringent justification, ensuring that benefits outweigh risks associated with radiation exposure [12, 13]. To regulate the appropriateness of radiological examinations and procedures, clinical guidelines have been developed to support clinical referrals and decisions [14]. In addition to clinical exams, clinicians made diagnosis through imaging such as periapical, panoramic, and even CBCT, and surgical findings. The use of CBCT is increasingly being used to diagnose VRF, although it has not been precisely studied which imaging modalities are used and to what extent. However, there are no clinical imaging guidelines for VRF (Vertical Root Fracture) in South Korea. This study aimed to develop evidence-based Korean clinical imaging guidelines (K-CIG) for teeth with suspected VRFs.

Materials and methods

Guidelines were developed through collaboration between the Korean Academy of Oral and Maxillofacial Radiology, Korean Society of Radiology, and National Evidence-Based Healthcare Collaborating Agency. The methodology proposed by Choi et al. [15], and applied by Kim et al. [16] was used to develop evidence-based guidelines. For this purpose, a development committee, working group, and consensus group were established.

Committee composition

The working group handled the development process by selecting key questions. Members recommended by the professional society were chosen for their comprehensive understanding of clinical practice guideline development and proactive engagement in the developmental stages. The working group was formed by assembling the recommended members.

The development committee, comprising experts in oral and maxillofacial radiology, research methodology, and clinical guideline development, assumed a comprehensive planning role, providing support for the study methodology.

Finally, the consensus group comprised six potential end users of the clinical guidelines nominated by five relevant societies who actively participated in an expert panel survey (utilizing the Delphi method) to review key questions and agree on draft recommendations.

Definition of a key question

The working group formulated key questions for review by the development committee and consensus group. Each question was meticulously crafted to articulate clear and concise sentences encompassing all components of PICO: patient, intervention, comparator, and outcomes.

Following a thorough review, the final version of the key questions was as follows:

Search for guidelines

Core databases (Ovid-Medline, Elsevier-Embase, Guideline International Network, and National Guideline Clearinghouse) were searched to identify relevant guidelines. Three domestic academic databases (KoreaMed, KMbase, and KoMGI) were searched for domestic guidelines. The search was limited to the period from 2000 to September, 2023.

An extensive database search was conducted using the following keywords: “tooth fracture”, “radiography”, “crack”, “guideline”, “recommendation” and “cone-beam computed tomography”. The domestic academic databases were searched for domestic guidelines. The working group reviewed the search strategy and results, supplemented by a manual search to ensure that no important guidelines were missed.

Selection of searched guidelines

Two members of the working group independently reviewed the retrieved literature based on the selection criteria. To ensure objectivity, both primary and secondary screening were performed. Primary screening comprised review of the title and abstract of the study/guidelines, while secondary selection, comprised full text reviews. In cases of disagreement between reviewers, clinical guidelines were selected by consensus. After this selection process, the working group selected the relevant literature and recorded the reasons for exclusion [15, 16].

Inclusion criteria [15, 16]: (1) Clinical guidelines that included PICOs aligned with the key question, (2) Clinical guidelines published in Korean or English, and (3) clinical guidelines published since 2000 were selected.

Exclusion criteria [15, 16]: (1) guidelines do not target patients related to the key question, (2) guidelines not including the relevant imaging modality, (3) guidelines not reporting appropriate outcomes (diagnostic accuracy/efficacy/safety/prognostic impact/patient assessment), (4) non-clinical guidelines, (5) guidelines not presenting recommendations, (6) guidelines not created with evidence-based methods, (7) guidelines reported in languages other than English/Korean, (8) duplicate articles, and (9) full-text not available.

Search for recent studies

Recent randomized controlled trials or observational studies were searched to ensure that the recommendations were current and reliable. The search period was limited to after the publication date of the most recent guidelines among those selected.

Quality assessment

The final selected guidelines underwent a rigorous quality appraisal following the Korean Appraisal of Guidelines for Research and Evaluation II (K-AGREE II) [17]. Two reviewers from the development committee assessed the selected literature, with each category scored on a scale of 1–7. To ensure reproducibility and clarity, the reasons for assigning scores were recorded. If the difference in scores between the reviewers was more than four points, the literature was re-examined.

Guidelines that scored ≥ 50 in the “Rigor of Development” domain were considered candidates for K-CIG development [15, 16]. Exceptionally, even documents scoring below 50 points were selected as guidelines for summarizing recommendations and evidence if they were notably scarce or domestically developed clinical guidelines [15].

Grading the evidence level and drafting the recommendation document

Upon completion of the guideline assessment, recommendations and their supporting evidence were organized using key questions, after which the recommendations were drafted. The table for comparison of guidelines outline the details of the recommendations. In addition, it also assessed whether the guidelines can be accepted and applied in our society.

An evidence table comprising the primary studies included in the selected guidelines was created for each key question. Data from the primary studies were extracted according to a predefined format. The quality of the studies was assessed at the individual study level, and the results were recorded in the evidence table. This process was conducted independently by the two authors, following an agreement process. The evidence levels from individual articles were aggregated to produce an overall evidence level for each recommendation, categorized as high (I), moderate (II), low (III), or very low (IV) [15, 16].

Draft recommendations comprised a recommendation for a key question and a summary of the evidence, considerations, and references, each including a recommendation grade and an overall evidence level. First, the contents of the recommendations related to each key question and the unique recommendation grades were summarized. The recommendation grades were categorized as A (recommendation to implement), B (recommendation to implement under certain conditions), C (recommendation not to implement), and I (no recommendation). The recommendation grade indicates the direction of the recommendation and the evidence level indicates the strength of the recommendation. A comprehensive evaluation was conducted to ensure that the recommendations were updated, acceptable, and applicable, gauging their practicality in the domestic context.

Agreement of the recommendation grade

The Development Committee reviewed the recommendation grade and evidence level of the draft version of the recommendations created by the working group. The agreed-upon results of the working group and development committee facilitated the definitive assessment of the validity of the recommendation document.

Finalizing the recommendation document

The consensus group used the Delphi method of anonymity to achieve formal agreement. The first questionnaire included key questions, draft recommendations, recommendation grades, and evidence levels, enabling quick and comprehensive assessment. The agreement level for each recommendation, recommendation grade, and evidence level were assessed and rated on a scale of 1 (strongly disagree) to 9 (strongly agree).

After the first survey, a second questionnaire assessing the level of agreement and opinion was constructed, and a survey was conducted. In the second survey, the distribution of all the respondents in the first survey and each reviewer’s assessment results were provided item-by-item. The reviewer was then asked to decide whether to change or retain the results of the first assessment. An agreement was reached through these iterative rounds.

Results

PICO

The PICO guidelines were developed based on key questions generated by the working group. The PICO framework for the key questions is shown in Table 1. Table 1 PICO of the key question

Population	Intervention	Comparators	Outcome	
Patients with pain when chewing and suspected VRFs	CBCT	Periapical radiographs	Diagnostic Possibility of vertical root fracture	

Search for guidelines

Tables 2, 3, 4 show the results from international academic databases. Table 5 presents the domestic database results. The KGC and KoMGI yielded no results. All searches were limited to the period from 2000 to September 2023; however, due to NGC being taken off-line in July 2018, searches for NGC were limited to the period up to June 2018. Table 2 Search results from international databases: Ovid-Medline

Searching Date: 2023.9	
N	Search Term	Search Result	
P (Population)			
 1	exp Tooth Fractures/	6609	
 2	((teeth or tooth or root) and (fracture$ or crack$ or injur$)).mp	40,104	
 3	1 OR 2	40,104	
C (Comparators)			
 4	exp Cone-Beam Computed Tomography/ OR CBCT.mp	19,685	
 5	(intraoral radiography OR tube-shift OR SLOB).tw	403	
 6	(imaging or radiolog$ or radiograp$).tw	1,452,156	
 7	OR/4–6	1,463,161	
P & C			
 8	3 AND 7	4,865	
Guideline filter			
 9	(guideline$ or recommendation$).ti. or (practice guideline or guideline).pt	159,155	
Generalization			
 10	8 AND 9	11	

Table 3 Search results from international databases: Elsevier Embase

Searching Date: 2023.9	
N	Search Term	Search Result	
P (Population)			
 1	‘tooth fracture’/exp	7826	
 2	((teeth or tooth or root) and (fracture* or crack* or injur*)):ab,ti	32,702	
 3	1 OR 2	35,865	
C (Comparators)			
 4	‘cone beam computed tomography’/exp OR CBCT:ab,ti	33,894	
 5	(‘intraoral radiography’ OR ‘tube-shift’ OR SLOB):ab,ti	420	
 6	(imaging or radiolog* or radiograp*):ab,ti	2,016,336	
 7	OR/4–6	2,035,568	
P & C			
 8	3 AND 7	4714	
Guideline filter			
 9	guideline*:ti OR recommendation*:ti	186,154	
Generalization			
 10	8 AND 9	8	

Table 4 Search results from international databases: GIN, NGC

Searching date: 2023.9 (GIN), 2018.6 (NGC)	
Database	N	Search Term	Search Result	
1.GIN	1	Tooth Fractures	1	
2.NGC	1	Tooth AND Fractures	4	

Table 5 Search Results from Domestic Databases

Searching Date: 2023.9	
Database	N	Search Term	Search Result	
1.KoreaMed	1	“Tooth Fractures”[ALL] AND Guideline[ALL]	0	
2	teeth[ALL] and fracture*[ALL] and Guideline[ALL]	2	
3	tooth[ALL] and crack[ALL] and Guideline[ALL]	0	
4	Sum	2	
5	After omitting overlapped literatures	2	
2.KMBASE	1	([ALL = vertical root fracture] AND[ALL = recommendation])	0	
2	([ALL = tooth] AND[ALL = fractures] AND[ALL = recommendation])	0	
3	Sum	0	
4	After omitting overlapped literatures	0	

Selection of searched guidelines

A total of 20 guidelines were retrieved. In the first screening based on titles and abstracts, 17 guidelines were excluded. Secondary selection based on full texts resulted in the exclusion of one additional guideline. However, the manual search identified one more guideline. Consequently, three guidelines were included (Fig. 1). Table 6 presents the list of retrieved guidelines, indicating the selection status and the reasons for exclusion, if applicable.Fig. 1 Selection process of searched guidelines

Table 6 Screening result of the searched guidelines

No	Author	Title	Exclusion criteria	
1st
Screening	2nd
Selection	
1	P. S. Owtad et al. 2015 [18]	Management Guidelines for Traumatically Injured Teeth during Orthodontic Treatment	1	–	
2	L. A. S. Kullman 2012 [19]	Guidelines for dental radiography immediately after a dento-alveolar trauma, a systematic literature review	Selected	Selected	
3	S. L. Farook et al. 2013 [20]	Guideline for management of hypochlorite injury in endodontics	1	–	
4	V. A. Petrosyan, P. 2013 [21]	Third molar surgery: changes in patient demographics over 18 years and the effect of the nice guidelines	1	–	
5	M. L. Konishi et al. 2012 [22]	Important technical parameters are not presented in reports of intraoral digital radiography in endodontic treatment: Recommendations for future studies	Selected	1	
6	Y. F. Zadik et al. 2008 [23]	Dentists' knowledge and implementation of the 2007 American Heart Association guidelines for prevention of infective endocarditis	1	–	
7	A. M. Subbiya et al. 2017 [24]	Radix distolingualis: a case report, review and endodontic treatment guidelines dentistry section	1	–	
8	Soares P.B.F. 2020 [25]	Lateral Luxation of Incisor—A Case Report of Using a New Cone-Beam Computed Tomography Software and Reposition Guideline	1	–	
9	Lee A.H.C. 2021 [26]	Cemental tear: literature review, proposed classification and recommendations for treatment	1	–	
10	Mehrabi F. 2021 [27]	International Association for Dental Traumatology guideline updates	1	–	
11	Krastl G. 2022 [28]	Traumatized teeth: clinical practice guideline for the interim management of teeth with various poor prognosis scenarios in growing patients	1	–	
12	Hirschhaut M 2023 [29]	Clinical Guidelines for the Surgical/Orthodontic Management of Impacted Maxillary Central Incisors Based on a Decision Tree	1	–	
13	Parsons MS 2022 [30]	ACR Appropriateness Criteria R Imaging of Facial Trauma Following Primary Survey	1	–	
14	C. National Guideline 2013 [31]	HealthPartners Dental Group and Clinics third molar guideline	1	–	
15	C. National Guideline 2017 [32]	Use of adjuvant bisphosphonates and other bone-modifying agents in breast cancer: a Cancer Care Ontario and American Society of Clinical Oncology clinical practice guideline	1	–	
16	C. National Guideline 2014 [33]	Perioperative protocol. Health care protocol	1	–	
17	C. National Guideline 2013 [34]	ACR Appropriateness Criteria&reg; headache	1	–	
18	J.W. KIM et al. 2005 [35]	lifetime and fracture patterns of NITI rotary files in molars	1	–	
19	B.S.Kang et al. 2002 [36]	tooth injuries in the emergency department	1	–	
20	K. HORNER et al. 2012 [37]	Radiation No 172 Cone beam CT for dental and maxillofacial radiology (Evidence-based guidelines)	Selected	Selected	
21	S.M. Mallya 2015 [38]	Evidence and Professional Guidelines for Appropriate Use of Cone Beam Computed Tomography	–	Selected

HAND SEARCH

	
Exclusion criteria: (1) guidelines do not target patients related to the key question, (2) guidelines not including the relevant imaging modality, (3) guidelines not reporting appropriate outcomes (diagnostic accuracy/efficacy/safety/prognostic impact/patient assessment), (4) non-clinical guidelines, (5) guidelines not presenting recommendations, (6) guidelines not created with evidence-based methods, (7) guidelines reported in languages other than English/Korean, (8) duplicate articles, and (9) full-text not available

Search for recent studies

Considering the publication years of the selected recommendations (2011, 2012, and 2015), we searched for studies published between 2015 and September 2023, enrolling those containing evidence current and relevant to the key question or which contributed new insights warranting an update to the content of the evidence table. Studies with designs at the top of the evidence pyramid (meta-analyses > systematic review > cohort studies > case-controlled studies) were primarily selected [39]. Finally, 22 studies were included.

Quality assessment

Table 7 presents the results of the quality assessment of the three guidelines included in this review using the AGREE II tool [17]. Notably, only one of the three guidelines achieved a score > 50 in the “Rigor of development” domain. However, even lower-scoring guidelines were deemed acceptable in the acceptability/applicability assessment. Because of the limited number of guidelines available to address the key question, these guidelines were included based on the criteria adopted by Choi et al. [15]. Tables 8 present the recommendation matrix and acceptability and applicability assessments of the three guidelines. Table 7 Results of the Quality Assessment of the Guidelines using AGREE II Tool

Title of Guidelines	AGREE Score	Committee Opinion	
Guidelines for dental radiography immediately after a dento-alveolar trauma, a systematic literature review	33	Not recommended	
Radiation No 172 Cone beam CT for dental and maxillofacial radiology (Evidence-based guidelines)	90	Recommended	
Evidence and Professional Guidelines for Appropriate Use of Cone Beam Computed Tomography	31	Not recommended	
Not recommended: AGREE II < 50	

Table 8 Summary of recommendations selected from the existing guidelines and used to development

	Guideline A	Guideline B	Guideline C	
Recommendation	A suspicion of a vertical root fracture establishes a need for different horizontal angulations to be used during exposure and a transverse fracture needs different vertical angulations. CBCT could be an acceptable option in special cases, where there is a problem to find a clinically suspicious root fracture (minimally displaced root fractures)	Limited volume, high resolution CBCT is indicated in the assessment of dental trauma (suspected root fracture) in selected cases, where conventional intraoral radiographs provide inadequate information for treatment planning	CBCT imaging should be used only when the diagnostic information is not provided by conventional intraoral radiography and when the additional information from CBCT is likely to aid diagnosis and treatment planning

Second, as with all other imaging, the decision to pre-scribe a CBCT scan must be based on the patient’s history and clinical examination and justified on an individual basis. CBCT imaging can be used to augment clinical examination and conventional radiography in complex endodontic conditions

	
Grading of recommendation	Not Available	B	Not Available	
Aceeptability	
 Similarity of population	uncertain	uncertain	uncertain	
 Similarity of value and preference	Yes	Yes	Yes	
 Similarity of benefit by recommendation	Yes	Yes	Yes	
 Generally, acceptable	Yes	Yes	Yes	
Applicability	
 Applicability of intervention/instrument	Yes	Yes	Yes	
 Applicability of essential technique	Yes	Yes	Yes	
 No legal and institutional barriers	Yes	Yes	Yes	
 Generally, applicable	Yes	Yes	Yes	
Guideline A: Guidelines for dental radiography immediately after a dento-alveolar trauma, a systematic literature review [19]

Guideline B: Radiation No 172 Cone beam CT for dental and maxillofacial radiology (Evidence-based guidelines) [37]

Guideline C: Evidence and Professional Guidelines for Appropriate Use of Cone Beam Computed Tomography [38]

Grading the evidence level and drafting the recommendation document

Recommendations were proposed based on the three reviewed guidelines. Subsequently, an evidence table was prepared by summarizing the individual articles relevant to the key question and assigning an evidence level (Table 9). The proposed recommendations, recommendation grades, and evidence levels are as follows: Table 9 Evidence Table

Author, Year	Title	Type of Study	Patients (n)	Study Quality (KCIG)	
Wenzel et al. 2005 [40]	High resolution charge-coupled device sensor vs. medium resolution photostimulable phosphor plate digital receptors for detection of root fractures in vitro	Experimental	47 teeth	1	
Kamburoglu et al. 2009 [41]	Effectiveness of limited cone-beam computed tomography in the detection of horizontal root fracture	Experimental	36 teeth	2	
Bernardes et al. 2009 [42]	Use of cone beam volumetric tomography in the diagnosis of root fractures	Experimental	20	1	
Hassan et al. 2009 [7]	Detection of vertical root fractures in endodontically treated teeth by a cone beam computed tomography scan	Experimental	80 teeth	2	
Őzer et al. 2010 [3]	Detection of vertical root fractures of different thicknesses in endodontically enlarged teeth by cone beam computed tomography versus digital radiography	Experimental	80 teeth	2	
Varshosaz et al. 2010 [43]	Comparison of conventional radiography with cone beam computed tomography for detection of vertical root fractures: an in vitro study	Experimental	100 teeth	2	
Kamburoğlu et al. 2010 [44]	Detection of vertical root fracture using cone-beam computerized tomography: an in vitro assessment	Experimental	60 teeth	2	
Hassan et al. 2010 [45]	Comparison of five cone beam computed tomography systems for the detection of vertical root fractures	Experimental	80 teeth	2	
Edlund et al. 2011 [46]	Detection of vertical root fractures by using cone beam computed tomography: a clinical study	Observational	32 teeth	2	
Wanderley et al. 2018 [47]	Influence of Tooth Orientation on the Detection of

Vertical Root Fracture in Cone-beam Computed Tomography

	Experimental	30	2	
Ezzodini et al. 2015 [48]	Diagnostic value of cone-beam computed tomography

and periapical radiography in detection of vertical root fracture

	Experimental	80 teeth	3	
Salineiro et al. 2017 [49]	Radiographic diagnosis of root fractures: a systematic review, meta-analyses and sources of heterogeneity	Review	47 studies	2	
Amintavakoli et al. 2017 [50]	Reliability of CBCT diagnosing root fractures remains uncertain	Review	12 studies	3	
Kobayashi et al. 2017 [51]	Diagnosis of alveolar and root fractures: an in vitro study comparing CBCT imaging with periapical radiographs	Experimental	75 teeth	3	
Talwar et al. 2016 [52]	Role of Cone-beam Computed Tomography in Diagnosis of Vertical Root Fractures: A Systematic Review and Meta-analysis	Review	11 review 4 meta	1	
Chang et al. 2016 [4]	Cone-beam Computed Tomography for Detecting Vertical Root Fractures in Endodontically treated Teeth: A Systematic Review	Review	4 studies with a total of 130 patients	2	
Ma et al. 2016 [53]	RH, Ge ZP, Li G. Detection accuracy of root fractures in cone-beam computed tomography images: a systematic review and meta-analysis	Review	13 studies	1	
Habibzadeh et al. 2023 [54]	Diagnostic efficacy of cone-beam computed tomography for detection of vertical root fractures in endodontically treated teeth: a systematic review	Review	20 studies	2	
de Lima et al. 2023 [55]	Influence of the technical parameters of CBCT image acquisition on vertical root fracture diagnosis: a systematic review and meta-analysis	Review	60 studies

60 reports

	2	
PradeepKumar et al. 2021 [56]	Diagnosis of Vertical Root Fractures by Cone-beam Computed Tomography in Root-filled Teeth with Confirmation by Direct Visualization: A Systematic Review and Meta-Analysis	Review	8 studies	2	
Al Hadi et al. 2020 [57]	Detection of Vertical Root Fractures Using Three Different Imaging Modalities: An In Vitro Study	Experimental	60 teeth	2	
Hekmatian et al. 2018 [58]	Detection of Vertical Root Fractures Using Cone-Beam Computed Tomography in the Presence and Absence of Gutta-Percha	Experimental	50 teeth	2	

Finalizing the recommendation document

The Delphi method was used to ensure data anonymity. The recommendation document was finalized after two rounds of evaluation by six experts from relevant clinical fields. The level of agreement was quantified, yielding means of 8.0 (SD 1.2) and 7.6 (SD1.6) for Recommendations 1&2 (Table 10). Table 10 Result of Delphi method

Recommendation No	Recommendation grade	Evidence Level	Average	MIN	Q1	Median	Q2	MAX	SD	CV	Number of respondents	
1	A	II	8.0	6	7.5	8.0	9.0	9	1.2	0.1	6	
2	B	II	7.6	5	6.5	8.0	9.0	9	1.6	0.2	6	
MIN minimum, Q Quartile, MAX maximum, SD standard deviation, CV coefficient of variation

Discussion

Herein, we formulated imaging guidelines for diagnosing VRF based on three guidelines and 22 evidence-based studies. The literature suggests the primary use of two-dimensional radiographs, reserving CBCT for cases difficult to diagnose using PA radiography. As with other radiologic modalities, CBCT should only be used when the benefits outweigh the risks [12, 13]. Therefore, the dentists should ensure that the information obtained from CBCT imaging can enhance patient care, patient safety, and ultimately enable more predictable and optimal treatment [59].

To detect vertical and horizontal root fractures, Wenzel et al. emphasized the necessity of obtaining PA radiographs at two and three vertical and horizontal angles, respectively. Specifically, a minimum of three PA radiographs were required, each differing by 15°, vertically and horizontally [40]. Other studies suggest aligning the X-ray in 2D radiography parallel to the fracture line (± 4°) for optimal diagnostic accuracy [60]. In addition, the visibility of the fracture line is influenced by the degree of displacement or separation of the fragments [61]. The radiologic features of VRF are as follows: a visible fracture line, separation of root fragments, space between the root filling and the canal wall, vertical bone loss, and characteristic diffused or halo/J-type radiolucency around the root [48].

A previous study showed that conventional radiographs have low sensitivity for detecting minimally displaced root fractures [61]. Although CBCT offers improved sensitivity, it is expensive and inappropriate for routine use due to the high radiation dose [41]. When diagnosing VRF, an inexpensive method that minimizes radiation exposure and is readily clinically applicable, such as PA radiography, is required. In untreated teeth, when both clinical and digital radiological data are insufficient, CBCT may be appropriate to identify VRF [57].

CBCT allows precise visualization and evaluation of teeth with VRFs, with a higher sensitivity, specificity, and accuracy than PA radiography [5, 7]. One in vitro study found significantly elevated sensitivity in CBCT imaging compared to PA (0.752 vs 0.242) when using a 0.2-mm voxel size to detect VRFs in unfilled teeth [52]. Another study used nine differently angled images of each tooth and reported a low sensitivity (28%) and specificity (33%) for conventional 2D images, while CBCT imaging showed a higher sensitivity (55%) and specificity (82%) [6]. The heightened sensitivity of CBCT compared to PA radiography stems from its capacity to provide multi-planar views at various angles and orientations, utilizing extremely thin slices and high contrast [52].

Given that VRFs are predominantly associated with endodontically treated teeth, evaluating the potential impact of root canal filling on fracture line visibility is crucial [7]. The diagnostic odds ratio (DOR) serves as a metric of the effectiveness of a diagnostic test. In one study, CBCT demonstrated superior performance in unfilled teeth (DOR = 94.26) compared to PA radiography (DOR = 14.42) [52]. However, in filled teeth, no significant difference was observed between the collective DOR, with PA radiography slightly outperforming CBCT [52]. The mean (SD) sensitivity (%) of CBCT for detecting VRFs in the presence of gutta-percha and metal posts was 72.76 (18.73), ranging from 30 to 92%, while the mean specificity (%) was 75.44 (18.26), ranging from 45 to 100% [54].

The lower sensitivity of CBCT in root-filled teeth may be attributed to unique challenges, such as beam hardening and artifact generation [52]. Given the prevalence of VRFs in root-filled teeth [58], these artifacts may resemble root fractures or overlapping root fracture lines, leading to incorrect diagnoses [62].

However, recent studies have reported conflicting results. Al Hadi et al. [57] reported that root canal filling material did not significantly affect the specificity of VRF detection on CBCT images (100% in both groups). Similar outcomes were observed in three other recent studies [63–65]. These results can be attributed to the enhanced image resolution generated by the CBCT systems used [57]. The researchers concluded that image quality was directly affected by voxel size in CBCT examinations, recommending a 0.2–0.3-mm voxel resolution scan to diagnose VRF [64]. On the other hand, other recent studies still question the usefulness of CBCT in diagnosing VRF in obturated teeth. Patel et al. [66] and Chang et al. [4] each concluded in their in vitro and systematic reviews that using CBCT to detect VRF in root-filled teeth is inaccurate.

The disparate outcomes presented in recent studies may be due to variations in the image quality and performance of the CBCT systems. Elsaltani et al. [63] reported that the accuracy of VRF diagnosis in endodontically treated teeth varied based on the CBCT system used, with the smallest voxel size of 0.125 mm (i-CAT) exhibiting superior accuracy. However, voxel size alone is insufficient for diagnostic accuracy, as different systems with the same 0.2-mm voxel size (Planmeca ProMax 3D, J Morita, and Galileos 3D) demonstrated varying accuracies [63]. Another factor affecting diagnostic accuracy is the type of detector used. Instruments with high diagnostic capabilities use flat panel detectors, whereas those using image intensifier tubes or charge-coupled devices have relatively low diagnostic capabilities [63].

Nonetheless, the appropriate imaging modality for VRF may vary depending on the location of the tooth (maxillary/mandibular, anterior/posterior) or the number of roots. This guideline is based on existing guidelines and research papers, necessitating foundational research. However, due to a lack of supporting literature, these factors have not been included in this guideline. As the guideline will be updated periodically, if research results reflecting these aspects are accumulated, it is likely that more specific guidelines can be established in the next update.

When developing and applying the proposed guidelines, cost considerations must also be taken into account. The costs of imaging tests and the extent of health insurance coverage can vary by country. In South Korea, PA and CBCT are often covered by insurance. These factors were considered in the assessment of acceptability and applicability. However, even if the cost of CBCT is not prohibitively expensive and it can be performed without difficulty, the periapical view, which can diagnose with lower radiation exposure and cost, should be the first choice.

Compared to traditional radiography, CBCT slightly increases the patient’s radiation exposure to yield more comprehensive information. Therefore, in most cases, an increased radiation dose is justifiable. However, the unwarranted use of CBCT raises concerns as conventional plain films can fulfill many diagnostic requirements with a lower radiation dose [43]. The radiation dose in CBCT remains higher than that in traditional panoramic imaging systems. According to the 2007 International Commission on Radiological Protection guidelines, the effective radiation doses calculated for i-CAT with 6- and 13-inch FOVs are 75.3 and 110.5 mSv, respectively, which are 5.8–8.5 times higher than panoramic imaging (13 mSv) [67]. Generally, methods with higher sensitivity are preferred. However, given the high radiation dose and cost associated with CBCT, and the high specificity of PA radiography (low false-positive rate), CBCT confirmation is deemed unnecessary if VRF are observed on PA radiography. Nevertheless, CBCT is recommended when VRF are suspected and PA radiography fails to detect them [48].

Recent studies have focused on developing techniques to reduce the exposure dose of CBCT while maintaining image quality. Loubele et al. investigated the correlation between the radiation dose and image quality of four CBCT scanners, concluding that high-resolution i-CAT exhibited the most favorable image quality to radiation dose ratio [68]. Another proposed method, by Mora et al. [69], involved reducing the number of basis projections. Following a previous study investigating the accuracy of limited cone-beam computed tomography for vertical fracture detection [5], a subsequent study [69] revealed that a significant reduction in radiation exposure could be achieved by decreasing the number of images from 180 to 60 without a difference in root fracture diagnosis. As CBCT continues to gain popularity, further studies are required in this emerging field [43].

This guideline was created through a systematic review, end-user review, and consensus. The selective use of PA and CBCT will serve as a valuable resource for clinicians deciding on appropriate imaging modalities VRF diagnosis.

Conclusion

This study developed evidence-based clinical imaging guidelines for the diagnosis of VRFs. The applicability of these guidelines should be consistently monitored and evaluated to ensure the best possible patient outcomes in a clinical setting.

Acknowledgements

This study was also performed with the assistance of the National Evidence-based Collaborating Agency and the Korean Society of Radiology.

Author contributions

K. Kim, J. Kim and S. Lee were involved in the writing of the manuscript and in the interpretation of the results. M. Choi, H. Yong and S. Jung establish the foundation of Korean Clinical imaging guidelines process and check each step. C. Lee, M. Heo and K. Huh were involved in the data collection process and analyzed the data. All authors read and approved the final manuscript.

Funding

This work was conducted as part of the Research Program supported by the Korea Centers for Disease Control and Prevention (fund code: 2018E380500). The funding body provided the basis for research design and helped collect data.

Data availability

The data analyzed during the current study will be available from the corresponding author upon reasonable request.

Declarations

Conflict of interest

The authors declare that they have no competing interests.

Ethical approval

Not applicable.

Informed consent

Not applicable.

Human or animal subjects

This article does not contain any studies with human or animal subjects performed by the any of the authors.

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
==== Refs
References

1. Meister F Jr Lommel TJ Gerstein H Diagnosis and possible causes of vertical root fractures Oral Surg Oral Med Oral Pathol 1980 49 3 243 253 10.1016/0030-4220(80)90056-0 6928310
Meister F Jr, Lommel TJ, Gerstein H. Diagnosis and possible causes of vertical root fractures. Oral Surg Oral Med Oral Pathol. 1980;49(3):243–53. 10.1016/0030-4220(80)90056-0.6928310 10.1016/0030-4220(80)90056-0
2. Tamse A Vertical root fractures in endodontically-treated teeth: diagnostic signs and clinical management Endod Top 2006 13 1 84 94 10.1111/j.1601-1546.2006.00200.x
Tamse A. Vertical root fractures in endodontically-treated teeth: diagnostic signs and clinical management. Endod Top. 2006;13(1):84–94. 10.1111/j.1601-1546.2006.00200.x.10.1111/j.1601-1546.2006.00200.x
3. Özer SY Detection of vertical root fractures of different thicknesses in endodontically enlarged teeth by cone beam computed tomography versus digital radiography J Endod 2010 36 7 1245 1249 10.1016/j.joen.2010.03.021 20630309
Özer SY. Detection of vertical root fractures of different thicknesses in endodontically enlarged teeth by cone beam computed tomography versus digital radiography. J Endod. 2010;36(7):1245–9. 10.1016/j.joen.2010.03.021.20630309 10.1016/j.joen.2010.03.021
4. Chang E Lam E Shah P Azarpazhooh A Cone-beam computed tomography for detecting vertical root fractures in endodontically-treated teeth: a systematic review J Endod 2016 42 2 177 185 10.1016/j.joen.2015.10.005 26631300
Chang E, Lam E, Shah P, Azarpazhooh A. Cone-beam computed tomography for detecting vertical root fractures in endodontically-treated teeth: a systematic review. J Endod. 2016;42(2):177–85. 10.1016/j.joen.2015.10.005.26631300 10.1016/j.joen.2015.10.005
5. Mora MA Mol A Tyndall DA Rivera EM In vitro assessment of local computed tomography for the detection of longitudinal tooth fractures Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2007 103 6 825 829 10.1016/j.tripleo.2006.09.009 17188531
Mora MA, Mol A, Tyndall DA, Rivera EM. In vitro assessment of local computed tomography for the detection of longitudinal tooth fractures. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2007;103(6):825–9. 10.1016/j.tripleo.2006.09.009.17188531 10.1016/j.tripleo.2006.09.009
6. Nair MK Uma Devi P Gröndahl H-G Webber RL Wallace JA Detection of artificially induced vertical radicular fractures using tuned aperture computed tomography Eur J Oral Sci 2001 109 6 375 379 10.1034/j.1600-0722.2001.00085.x 11767273
Nair MK, Uma Devi P, Gröndahl H-G, Webber RL, Wallace JA. Detection of artificially induced vertical radicular fractures using tuned aperture computed tomography. Eur J Oral Sci. 2001;109(6):375–9. 10.1034/j.1600-0722.2001.00085.x.11767273 10.1034/j.1600-0722.2001.00085.x
7. Hassan B Metska ME Ozok AR van der Stelt P Wesselink PR Detection of vertical root fractures in endodontically-treated teeth by a cone beam computed tomography scan J Endod 2009 35 5 719 722 10.1016/j.joen.2009.01.022 19410091
Hassan B, Metska ME, Ozok AR, van der Stelt P, Wesselink PR. Detection of vertical root fractures in endodontically-treated teeth by a cone beam computed tomography scan. J Endod. 2009;35(5):719–22. 10.1016/j.joen.2009.01.022.19410091 10.1016/j.joen.2009.01.022
8. Morfis A Vertical root fractures Oral Surg Oral Med Oral Pathol 1990 69 5 631 635 10.1016/0030-4220(90)90248-Q 2185453
Morfis A. Vertical root fractures. Oral Surg Oral Med Oral Pathol. 1990;69(5):631–5. 10.1016/0030-4220(90)90248-Q.2185453 10.1016/0030-4220(90)90248-Q
9. Sjögren U Hägglund B Sundqvist G Wing K Factors affecting the long-term results of endodontic treatment J Endod 1990 16 10 498 504 10.1016/S0099-2399(07)80180-4 2084204
Sjögren U, Hägglund B, Sundqvist G, Wing K. Factors affecting the long-term results of endodontic treatment. J Endod. 1990;16(10):498–504. 10.1016/S0099-2399(07)80180-4.2084204 10.1016/S0099-2399(07)80180-4
10. Vire DE Failure of endodontically-treated teeth: classification and evaluation J Endod 1991 17 7 338 342 10.1016/S0099-2399(06)81702-4 1779219
Vire DE. Failure of endodontically-treated teeth: classification and evaluation. J Endod. 1991;17(7):338–42. 10.1016/S0099-2399(06)81702-4.1779219 10.1016/S0099-2399(06)81702-4
11. Fuss Z Lustig J Tamse A Prevalence of vertical root fractures in extracted endodontically-treated teeth Int Endod J 1999 32 4 283 286 10.1046/j.1365-2591.1999.00208.x 10551119
Fuss Z, Lustig J, Tamse A. Prevalence of vertical root fractures in extracted endodontically-treated teeth. Int Endod J. 1999;32(4):283–6. 10.1046/j.1365-2591.1999.00208.x.10551119 10.1046/j.1365-2591.1999.00208.x
12. Hayashi T Arai Y Chikui T Hayashi-Sakai S Honda K Indo H Kawai T Kobayashi K Murakami S Nagasawa M Naitoh M Nakayama E Nikkuni Y Nishiyama H Shoji N Suenaga S Tanaka R A committee on clinical practice guidelines & Japanese society for oral and maxillofacial radiology. Clinical guidelines for dental cone-beam computed tomography Oral Radiol 2018 34 89 104 10.1007/s11282-018-0314-3 30484133
Hayashi T, Arai Y, Chikui T, Hayashi-Sakai S, Honda K, Indo H, Kawai T, Kobayashi K, Murakami S, Nagasawa M, Naitoh M, Nakayama E, Nikkuni Y, Nishiyama H, Shoji N, Suenaga S, Tanaka R. A committee on clinical practice guidelines & Japanese society for oral and maxillofacial radiology. Clinical guidelines for dental cone-beam computed tomography. Oral Radiol. 2018;34:89–104. 10.1007/s11282-018-0314-3.30484133 10.1007/s11282-018-0314-3
13. Malone J Guleria R Craven C Horton P Järvinen H Mayo J O’reilly G Picano E Remedios D Le Heron J Rehani M Holmberg O Czarwinski R Justification of diagnostic medical exposures: some practical issues. Report of an international atomic energy agency consultation Br J Radiol 2012 85 1013 523 538 10.1259/bjr/42893576 21343316
Malone J, Guleria R, Craven C, Horton P, Järvinen H, Mayo J, O’reilly G, Picano E, Remedios D, Le Heron J, Rehani M, Holmberg O, Czarwinski R. Justification of diagnostic medical exposures: some practical issues. Report of an international atomic energy agency consultation. Br J Radiol. 2012;85(1013):523–38. 10.1259/bjr/42893576.21343316 10.1259/bjr/42893576
14. Jeong WK Baek JH Jung SE Do KH Yong HS Kim MJ Choi M Lee M Choi SJ Jo AJ Choi JA Imaging guidelines for enhancing justifications for radiologic studies J Korean Med Sci 2016 31 Suppl 1 S38 44 10.3346/jkms.2016.31.S1.S38 26908986
Jeong WK, Baek JH, Jung SE, Do KH, Yong HS, Kim MJ, Choi M, Lee M, Choi SJ, Jo AJ, Choi JA. Imaging guidelines for enhancing justifications for radiologic studies. J Korean Med Sci. 2016;31(Suppl 1):S38-44. 10.3346/jkms.2016.31.S1.S38.26908986 10.3346/jkms.2016.31.S1.S38
15. Choi SJ Jeong WK Jo AJ Choi JA Kim MJ Lee M Jung SE Do KH Yong HS Sheen S Choi M Baek JH Methodology for developing evidence-based clinical imaging guidelines: joint recommendations by Korean society of radiology and national evidence-based healthcare collaborating agency Korean J Radiol 2017 18 1 208 216 10.3348/kjr.2017.18.1.208 28096730
Choi SJ, Jeong WK, Jo AJ, Choi JA, Kim MJ, Lee M, Jung SE, Do KH, Yong HS, Sheen S, Choi M, Baek JH. Methodology for developing evidence-based clinical imaging guidelines: joint recommendations by Korean society of radiology and national evidence-based healthcare collaborating agency. Korean J Radiol. 2017;18(1):208–16. 10.3348/kjr.2017.18.1.208.28096730 10.3348/kjr.2017.18.1.208
16. Kim MJ Choi M Yong HS Lee C Kim J-E Heo M-S Developing evidence-based clinical imaging guidelines of justification for radiographic examination after dental implant installation BMC Med Imaging 2020 20 1 102 10.1186/s12880-020-00501-3 32867728
Kim MJ, Choi M, Yong HS, Lee C, Kim J-E, Heo M-S. Developing evidence-based clinical imaging guidelines of justification for radiographic examination after dental implant installation. BMC Med Imaging. 2020;20(1):102. 10.1186/s12880-020-00501-3.32867728 10.1186/s12880-020-00501-3
17. Brouwers MC Kho ME Browman GP Burgers JS Cluzeau F Feder G Fervers B Graham ID Grimshaw J Hanna SE Littlejohns P Makarski J Zitzelsberger L AGREE II: advancing guideline development, reporting and evaluation in health care CMAJ 2010 182 18 E839 E842 10.1503/cmaj.090449 20603348
Brouwers MC, Kho ME, Browman GP, Burgers JS, Cluzeau F, Feder G, Fervers B, Graham ID, Grimshaw J, Hanna SE, Littlejohns P, Makarski J, Zitzelsberger L. AGREE II: advancing guideline development, reporting and evaluation in health care. CMAJ. 2010;182(18):E839–42. 10.1503/cmaj.090449.20603348 10.1503/cmaj.090449
18. Owtad P Management guidelines for traumatically injured teeth during orthodontic treatment J Clin Pediatr Dent 2015 39 3 292 10.17796/1053-4628-39.3.292 26208077
Owtad P, et al. Management guidelines for traumatically injured teeth during orthodontic treatment. J Clin Pediatr Dent. 2015;39(3):292. 10.17796/1053-4628-39.3.292.26208077 10.17796/1053-4628-39.3.292
19. Kullman L Al SM Guidelines for dental radiography immediately after a dento-alveolar trauma, a systematic literature review Dent Traumatol 2012 28 3 193 199 10.1111/j.1600-9657.2011.01099.x 22151857
Kullman L, Al SM. Guidelines for dental radiography immediately after a dento-alveolar trauma, a systematic literature review. Dent Traumatol. 2012;28(3):193–9. 10.1111/j.1600-9657.2011.01099.x.22151857 10.1111/j.1600-9657.2011.01099.x
20. Farook S Guideline for management of hypochlorite injury in endodontics Int J Oral Maxillofac Surg 2013 42 10 1314 10.1016/j.ijom.2013.07.489
Farook S, et al. Guideline for management of hypochlorite injury in endodontics. Int J Oral Maxillofac Surg. 2013;42(10):1314. 10.1016/j.ijom.2013.07.489.10.1016/j.ijom.2013.07.489
21. Petrosyan V Ameerally P Third molar surgery: changes in patient demographics over 18 years and the effect of the nice guidelines Int J Oral Maxillofac Surg 2013 42 10 1241 10.1016/j.ijom.2013.07.243
Petrosyan V, Ameerally P. Third molar surgery: changes in patient demographics over 18 years and the effect of the nice guidelines. Int J Oral Maxillofac Surg. 2013;42(10):1241. 10.1016/j.ijom.2013.07.243.10.1016/j.ijom.2013.07.243
22. Konishi M Important technical parameters are not presented in reports of intraoral digital radiography in endodontic treatment: recommendations for future studies Oral Surg Oral Med Oral Pathol Oral Radiol 2012 114 2 251 258.e6 10.1016/j.oooo.2012.02.015 22769411
Konishi M, et al. Important technical parameters are not presented in reports of intraoral digital radiography in endodontic treatment: recommendations for future studies. Oral Surg Oral Med Oral Pathol Oral Radiol. 2012;114(2):251-258.e6. 10.1016/j.oooo.2012.02.015.22769411 10.1016/j.oooo.2012.02.015
23. Zadik Y Dentists’ knowledge and implementation of the 2007 American heart association guidelines for prevention of infective endocarditis Oral Surg Oral Med Oral Pathol Oral Radiol Endodontol 2008 106 6 e16 e19 10.1016/j.tripleo.2008.08.009
Zadik Y, et al. Dentists’ knowledge and implementation of the 2007 American heart association guidelines for prevention of infective endocarditis. Oral Surg Oral Med Oral Pathol Oral Radiol Endodontol. 2008;106(6):e16–9. 10.1016/j.tripleo.2008.08.009.10.1016/j.tripleo.2008.08.009
24. Subbiya A Radix distolingualis: a case report, review and endodontic treatment guidelines J Clin Diagn Res: JCDR. 2017 11 6 ZD10 10.7860/jcdr/2017/27480.10012 28764306
Subbiya A, et al. Radix distolingualis: a case report, review and endodontic treatment guidelines. J Clin Diagn Res: JCDR. 2017;11(6):ZD10. 10.7860/jcdr/2017/27480.10012.28764306 10.7860/jcdr/2017/27480.10012
25. Soares PBF Lateral luxation of incisor-a case report of using a new cone-beam computed tomography software and reposition guideline Braz Dent J 2020 31 337 343 10.1590/0103-6440202003069 32667512
Soares PBF, et al. Lateral luxation of incisor-a case report of using a new cone-beam computed tomography software and reposition guideline. Braz Dent J. 2020;31:337–43. 10.1590/0103-6440202003069.32667512 10.1590/0103-6440202003069
26. Lee AH Cemental tear: literature review, proposed classification and recommendations for treatment Int Endod J 2021 54 11 2044 2073 10.1111/iej.13611 34403513
Lee AH, et al. Cemental tear: literature review, proposed classification and recommendations for treatment. Int Endod J. 2021;54(11):2044–73. 10.1111/iej.13611.34403513 10.1111/iej.13611
27. Mehrabi F Djemal S International association for dental traumatology guideline updates Br Dent J 2021 230 10 671 675 10.1038/s41415-021-3019-7 34050302
Mehrabi F, Djemal S. International association for dental traumatology guideline updates. Br Dent J. 2021;230(10):671–5. 10.1038/s41415-021-3019-7.34050302 10.1038/s41415-021-3019-7
28. Krastl G Traumatized teeth: clinical practice guideline for the interim management of teeth with various poor prognosis scenarios in growing patients Quintessence Int 2022 53 8 722 731 35976739
Krastl G, et al. Traumatized teeth: clinical practice guideline for the interim management of teeth with various poor prognosis scenarios in growing patients. Quintessence Int. 2022;53(8):722–31.35976739
29. Hirschhaut M Clinical guidelines for the surgical/orthodontic management of impacted maxillary central incisors based on a decision tree Compend Contin Educ Dent (15488578) 2023 44 9 510 515
Hirschhaut M, et al. Clinical guidelines for the surgical/orthodontic management of impacted maxillary central incisors based on a decision tree. Compend Contin Educ Dent (15488578). 2023;44(9):510–5.
30. Parsons MS ACR appropriateness criteria® imaging of facial trauma following primary survey J Am Coll Radiol 2022 19 5 S67 S86 10.1016/j.jacr.2022.02.013 35550806
Parsons MS, et al. ACR appropriateness criteria® imaging of facial trauma following primary survey. J Am Coll Radiol. 2022;19(5):S67–86. 10.1016/j.jacr.2022.02.013.35550806 10.1016/j.jacr.2022.02.013
31. HealthPartners. Dental Group and Clinics third molar guideline. National Guideline Clearinghouse. 2013 May
32. Dhesy-Thind S Use of adjuvant bisphosphonates and other bone-modifying agents in breast cancer: a cancer care Ontario and American society of clinical oncology clinical practice guideline J Clin Oncol 2017 35 18 2062 2081 10.1200/jco.2016.70.7257 28618241
Dhesy-Thind S, et al. Use of adjuvant bisphosphonates and other bone-modifying agents in breast cancer: a cancer care Ontario and American society of clinical oncology clinical practice guideline. J Clin Oncol. 2017;35(18):2062–81. 10.1200/jco.2016.70.7257.28618241 10.1200/jco.2016.70.7257
33. Card, R., et al. Perioperative protocol. Inst Clin Syst Improv. 2014.
34. Whitehead MT ACR appropriateness criteria® headache J Am Coll Radiol 2019 16 11 S364 S377 10.1016/j.jacr.2019.05.030 31685104
Whitehead MT, et al. ACR appropriateness criteria® headache. J Am Coll Radiol. 2019;16(11):S364–77.31685104 10.1016/j.jacr.2019.05.030
35. Kim J-W Lifetime and fracture patterns of NiTi rotary files in molars Restor Dent Endod 2005 30 3 184 192 10.5395/jkacd.2005.30.3.184
Kim J-W, et al. Lifetime and fracture patterns of NiTi rotary files in molars. Restor Dent Endod. 2005;30(3):184–92. 10.5395/jkacd.2005.30.3.184.10.5395/jkacd.2005.30.3.184
36. Kang BS Tooth injuries in the emergency department J Korean Soc Emerg Med 2002 13 3 250 255
Kang BS, et al. Tooth injuries in the emergency department. J Korean Soc Emerg Med. 2002;13(3):250–5.
37. Horner K. Cone beam CT for dental and maxillofacial radiology (evidence based guidelines). Luxembourg: European Commission, Directorate-General for Energy X11; 2012.
38. Mallya SM Evidence and professional guidelines for appropriate use of cone beam computed tomography J Calif Dent Assoc 2015 43 9 512 520 10.1080/19424396.2015.12222891 26820008
Mallya SM. Evidence and professional guidelines for appropriate use of cone beam computed tomography. J Calif Dent Assoc. 2015;43(9):512–20. 10.1080/19424396.2015.12222891.26820008 10.1080/19424396.2015.12222891
39. Martins RP Buschang PH What is the level of evidence of what you are reading? Dent Press J Orthod 2015 20 22 25 10.1590/2176-9451.20.4.022-025.ebo
Martins RP, Buschang PH. What is the level of evidence of what you are reading? Dent Press J Orthod. 2015;20:22–5. 10.1590/2176-9451.20.4.022-025.ebo.10.1590/2176-9451.20.4.022-025.ebo
40. Wenzel A Kirkevang L-L High resolution charge-coupled device sensor vs. medium resolution photostimulable phosphor plate digital receptors for detection of root fractures in vitro Dent Traumatol 2005 21 32 36 10.1111/j.1600-9657.2004.00258.x 15660754
Wenzel A, Kirkevang L-L. High resolution charge-coupled device sensor vs. medium resolution photostimulable phosphor plate digital receptors for detection of root fractures in vitro. Dent Traumatol. 2005;21:32–6. 10.1111/j.1600-9657.2004.00258.x.15660754 10.1111/j.1600-9657.2004.00258.x
41. Kamburoglu K Ilker Cebeci AR Grondahl HG Effectiveness of limited cone-beam computed tomography in the detection of horizontal root fracture Dent Traumatol 2009 25 3 256 261 10.1111/j.1600-9657.2009.00770.x 19583573
Kamburoglu K, Ilker Cebeci AR, Grondahl HG. Effectiveness of limited cone-beam computed tomography in the detection of horizontal root fracture. Dent Traumatol. 2009;25(3):256–61. 10.1111/j.1600-9657.2009.00770.x.19583573 10.1111/j.1600-9657.2009.00770.x
42. Bernardes RA Use of cone-beam volumetric tomography in the diagnosis of root fractures Oral Surg Oral Med Oral Pathol Oral Radiol Endodontol 2009 108 2 270 277 10.1016/j.tripleo.2009.01.017
Bernardes RA, et al. Use of cone-beam volumetric tomography in the diagnosis of root fractures. Oral Surg Oral Med Oral Pathol Oral Radiol Endodontol. 2009;108(2):270–7. 10.1016/j.tripleo.2009.01.017.10.1016/j.tripleo.2009.01.017
43. Varshosaz M Tavakoli MA Mostafavi M Baghban AA Comparison of conventional radiography with cone beam computed tomography for detection of vertical root fractures: an in vitro study J Oral Sci 2010 52 4 593 597 10.2334/josnusd.52.593 21206162
Varshosaz M, Tavakoli MA, Mostafavi M, Baghban AA. Comparison of conventional radiography with cone beam computed tomography for detection of vertical root fractures: an in vitro study. J Oral Sci. 2010;52(4):593–7. 10.2334/josnusd.52.593.21206162 10.2334/josnusd.52.593
44. Kamburoglu K Murat S Yüksel SP Cebeci ARI Horasan S Detection of vertical root fracture using cone-beam computerized tomography: an in vitro assessment Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2010 109 2 e74 81 10.1016/j.tripleo.2009.09.005 20031454
Kamburoglu K, Murat S, Yüksel SP, Cebeci ARI, Horasan S. Detection of vertical root fracture using cone-beam computerized tomography: an in vitro assessment. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2010;109(2):e74-81. 10.1016/j.tripleo.2009.09.005.20031454 10.1016/j.tripleo.2009.09.005
45. Hassan B Metska ME Ozok AR van der Stelt P Wesselink PR Comparison of five cone beam computed tomography systems for the detection of vertical root fractures J Endod 2010 36 1 126 129 10.1016/j.joen.2009.09.013 20003950
Hassan B, Metska ME, Ozok AR, van der Stelt P, Wesselink PR. Comparison of five cone beam computed tomography systems for the detection of vertical root fractures. J Endod. 2010;36(1):126–9. 10.1016/j.joen.2009.09.013.20003950 10.1016/j.joen.2009.09.013
46. Edlund M Nair MK Nair UP Detection of vertical root fractures by using cone-beam computed tomography: a clinical study J Endod 2011 37 6 768 772 10.1016/j.joen.2011.02.034 21787486
Edlund M, Nair MK, Nair UP. Detection of vertical root fractures by using cone-beam computed tomography: a clinical study. J Endod. 2011;37(6):768–72. 10.1016/j.joen.2011.02.034.21787486 10.1016/j.joen.2011.02.034
47. Wanderley VA Freitas DQ Haiter-Neto F Oliveira ML Influence of tooth orientation on the detection of vertical root fracture in cone-beam computed tomography J Endod 2018 44 7 1168 1172 10.1016/j.joen.2018.04.006 29866408
Wanderley VA, Freitas DQ, Haiter-Neto F, Oliveira ML. Influence of tooth orientation on the detection of vertical root fracture in cone-beam computed tomography. J Endod. 2018;44(7):1168–72. 10.1016/j.joen.2018.04.006.29866408 10.1016/j.joen.2018.04.006
48. Ardakani FE Razavi SH Tabrizizadeh M Diagnostic value of cone-beam computed tomography and periapical radiography in detection of vertical root fracture Iran Endod J 2015 10 2 122 25834597
Ardakani FE, Razavi SH, Tabrizizadeh M. Diagnostic value of cone-beam computed tomography and periapical radiography in detection of vertical root fracture. Iran Endod J. 2015;10(2):122.25834597
49. Salineiro FCS Kobayashi-Velasco S Braga MM Cavalcanti MGP Radiographic diagnosis of root fractures: a systematic review, meta-analyses and sources of heterogeneity Dentomaxillofac Radiol 2017 46 8 20170400 10.1259/dmfr.20170400 28749700
Salineiro FCS, Kobayashi-Velasco S, Braga MM, Cavalcanti MGP. Radiographic diagnosis of root fractures: a systematic review, meta-analyses and sources of heterogeneity. Dentomaxillofac Radiol. 2017;46(8):20170400. 10.1259/dmfr.20170400.28749700 10.1259/dmfr.20170400
50. Amintavakoli N Spivakovsky S Reliability of CBCT diagnosing root fractures remains uncertain Evid Based Dent 2017 18 1 23 10.1038/sj.ebd.6401223 28338032
Amintavakoli N, Spivakovsky S. Reliability of CBCT diagnosing root fractures remains uncertain. Evid Based Dent. 2017;18(1):23. 10.1038/sj.ebd.6401223.28338032 10.1038/sj.ebd.6401223
51. Kobayashi-Velasco S Salineiro FCS Gialain IO Cavalcanti MGP Diagnosis of alveolar and root fractures: an in vitro study comparing CBCT imaging with periapical radiographs J Appl Oral Sci 2017 25 2 227 233 10.1590/1678-77572016-0332 28403364
Kobayashi-Velasco S, Salineiro FCS, Gialain IO, Cavalcanti MGP. Diagnosis of alveolar and root fractures: an in vitro study comparing CBCT imaging with periapical radiographs. J Appl Oral Sci. 2017;25(2):227–33. 10.1590/1678-77572016-0332.28403364 10.1590/1678-77572016-0332
52. Talwar S Utneja S Nawal RR Kaushik A Srivastava D Oberoy SS Role of cone-beam computed tomography in diagnosis of vertical root fractures: a systematic review and meta-analysis J Endod 2016 42 1 12 24 10.1016/j.joen.2015.09.012 26699923
Talwar S, Utneja S, Nawal RR, Kaushik A, Srivastava D, Oberoy SS. Role of cone-beam computed tomography in diagnosis of vertical root fractures: a systematic review and meta-analysis. J Endod. 2016;42(1):12–24. 10.1016/j.joen.2015.09.012.26699923 10.1016/j.joen.2015.09.012
53. Ma RH Ge ZP Li G Detection accuracy of root fractures in cone-beam computed tomography images: a systematic review and meta-analysis Int Endod J 2016 49 7 646 654 10.1111/iej.12490 26102215
Ma RH, Ge ZP, Li G. Detection accuracy of root fractures in cone-beam computed tomography images: a systematic review and meta-analysis. Int Endod J. 2016;49(7):646–54. 10.1111/iej.12490.26102215 10.1111/iej.12490
54. Habibzadeh S Ghoncheh Z Kabiri P Mosaddad SA Diagnostic efficacy of cone-beam computed tomography for detection of vertical root fractures in endodontically-treated teeth: a systematic review BMC Med Imaging 2023 23 1 1 13 10.1186/s12880-023-01024-3 36600192
Habibzadeh S, Ghoncheh Z, Kabiri P, Mosaddad SA. Diagnostic efficacy of cone-beam computed tomography for detection of vertical root fractures in endodontically-treated teeth: a systematic review. BMC Med Imaging. 2023;23(1):1–13. 10.1186/s12880-023-01024-3.36600192 10.1186/s12880-023-01024-3
55. de Lima KL Silva LR de Paiva Prado TB Silva MAG de Freitas Silva BS Yamamoto-Silva FP Influence of the technical parameters of CBCT image acquisition on vertical root fracture diagnosis: a systematic review and meta-analysis Clin Oral Investig 2023 27 2 433 474 10.1007/s00784-022-04797-z 36700991
de Lima KL, Silva LR, de Paiva Prado TB, Silva MAG, de Freitas Silva BS, Yamamoto-Silva FP. Influence of the technical parameters of CBCT image acquisition on vertical root fracture diagnosis: a systematic review and meta-analysis. Clin Oral Investig. 2023;27(2):433–74. 10.1007/s00784-022-04797-z.36700991 10.1007/s00784-022-04797-z
56. PradeepKumar AR Shemesh H Nivedhitha MS Hashir MMJ Arockiam S Maheswari TNU Natanasabapathy V Diagnosis of vertical root fractures by cone-beam computed tomography in root-filled teeth with confirmation by direct visualization: a systematic review and meta-analysis J Endod 2021 47 8 1198 1214 10.1016/j.joen.2021.04.022 33984375
PradeepKumar AR, Shemesh H, Nivedhitha MS, Hashir MMJ, Arockiam S, Maheswari TNU, Natanasabapathy V. Diagnosis of vertical root fractures by cone-beam computed tomography in root-filled teeth with confirmation by direct visualization: a systematic review and meta-analysis. J Endod. 2021;47(8):1198–214. 10.1016/j.joen.2021.04.022.33984375 10.1016/j.joen.2021.04.022
57. Al Hadi D Parekh S Naeem W Luke AM Mathew S Detection of vertical root fractures using three different imaging modalities: an in vitro study J Contemp Dent Pract 2020 21 5 549 553 10.5005/jp-journals-10024-2839 32690838
Al Hadi D, Parekh S, Naeem W, Luke AM, Mathew S. Detection of vertical root fractures using three different imaging modalities: an in vitro study. J Contemp Dent Pract. 2020;21(5):549–53. 10.5005/jp-journals-10024-2839.32690838 10.5005/jp-journals-10024-2839
58. Hekmatian E Fathollahzade H Sheikhi M Detection of vertical root fractures using cone-beam computed tomography in the presence and absence of gutta-percha Sci World J 2018 2018 1920946 10.1155/2018/1920946
Hekmatian E, Fathollahzade H, Sheikhi M. Detection of vertical root fractures using cone-beam computed tomography in the presence and absence of gutta-percha. Sci World J. 2018;2018:1920946. 10.1155/2018/1920946.10.1155/2018/1920946
59. Rios HF Borgnakke WS Benavides E The use of cone-beam computed tomography in management of patients requiring dental implants: an American academy of periodontology best evidence review J Periodontol 2017 88 10 946 959 10.1902/jop.2017.160548 28967330
Rios HF, Borgnakke WS, Benavides E. The use of cone-beam computed tomography in management of patients requiring dental implants: an American academy of periodontology best evidence review. J Periodontol. 2017;88(10):946–59. 10.1902/jop.2017.160548.28967330 10.1902/jop.2017.160548
60. Hegde MN Hegde ND Haldar C Vertical root fractures: review and case report J Interdiscip Dentistry 2011 1 2 101 104 10.4103/2229-5194.85027
Hegde MN, Hegde ND, Haldar C. Vertical root fractures: review and case report. J Interdiscip Dentistry. 2011;1(2):101–4. 10.4103/2229-5194.85027.10.4103/2229-5194.85027
61. Cohenca N Simon JH Roges R Morag Y Malfaz JM Clinical indications for digital imaging in dento-alveolar trauma. Part 1: traumatic injuries Dent Traumatol 2007 23 2 95 104 10.1111/j.1600-9657.2006.00509.x 17367457
Cohenca N, Simon JH, Roges R, Morag Y, Malfaz JM. Clinical indications for digital imaging in dento-alveolar trauma. Part 1: traumatic injuries. Dent Traumatol. 2007;23(2):95–104. 10.1111/j.1600-9657.2006.00509.x.17367457 10.1111/j.1600-9657.2006.00509.x
62. Gulibire A Cao Y Gao A Wang C Wang T Xie X Liang J Li W Lin Z Assessment of true vertical root fracture line in endodontically-treated teeth using a new subtraction software-a micro-CT and CBCT study Aust Endod J 2021 47 2 290 297 10.1111/aej.12476 33314451
Gulibire A, Cao Y, Gao A, Wang C, Wang T, Xie X, Liang J, Li W, Lin Z. Assessment of true vertical root fracture line in endodontically-treated teeth using a new subtraction software-a micro-CT and CBCT study. Aust Endod J. 2021;47(2):290–7. 10.1111/aej.12476.33314451 10.1111/aej.12476
63. Elsaltani MH Farid MM Ashmawy MSE Detection of simulated vertical root fractures: which cone-beam computed tomographic system is the most accurate? J Endod 2016 42 6 972 977 10.1016/j.joen.2016.03.013 27130336
Elsaltani MH, Farid MM, Ashmawy MSE. Detection of simulated vertical root fractures: which cone-beam computed tomographic system is the most accurate? J Endod. 2016;42(6):972–7. 10.1016/j.joen.2016.03.013.27130336 10.1016/j.joen.2016.03.013
64. da Silveira PF Vizzotto MB Liedke GS da Silveira HLD Montagner F da Silveira HED Detection of vertical root fractures by conventional radiographic examination and cone beam computed tomography-an in vitro analysis Dent Traumatol 2013 29 1 41 46 10.1111/j.1600-9657.2012.01126.x 22413921
da Silveira PF, Vizzotto MB, Liedke GS, da Silveira HLD, Montagner F, da Silveira HED. Detection of vertical root fractures by conventional radiographic examination and cone beam computed tomography-an in vitro analysis. Dent Traumatol. 2013;29(1):41–6. 10.1111/j.1600-9657.2012.01126.x.22413921 10.1111/j.1600-9657.2012.01126.x
65. Fisekcioglu E Dolekoglu S Ilguy M Ersan N Ilguy D In vitro detection of dental root fractures with cone beam computed tomography (CBCT) Iran J Radiol 2014 11 1 11485 10.5812/iranjradiol.11485
Fisekcioglu E, Dolekoglu S, Ilguy M, Ersan N, Ilguy D. In vitro detection of dental root fractures with cone beam computed tomography (CBCT). Iran J Radiol. 2014;11(1):11485. 10.5812/iranjradiol.11485.10.5812/iranjradiol.11485
66. Patel S Brady E Wilson R Brown J Mannocci F The detection of vertical root fractures in root filled teeth with periapical radiographs and CBCT scans Int Endod J 2013 46 12 1140 1152 10.1111/iej.12109 23617242
Patel S, Brady E, Wilson R, Brown J, Mannocci F. The detection of vertical root fractures in root filled teeth with periapical radiographs and CBCT scans. Int Endod J. 2013;46(12):1140–52. 10.1111/iej.12109.23617242 10.1111/iej.12109
67. Roberts J Drage NA Davies J Thomas DW Effective dose from cone beam CT examinations in dentistry Br J Radiol 2009 82 973 35 40 10.1259/bjr/31419627 18852212
Roberts J, Drage NA, Davies J, Thomas DW. Effective dose from cone beam CT examinations in dentistry. Br J Radiol. 2009;82(973):35–40. 10.1259/bjr/31419627.18852212 10.1259/bjr/31419627
68. Loubele M Bogaerts R Van Dijck E Pauwels R Vanheusden S Suetens P Marchal G Sanderink G Jacobs R Comparison between effective radiation dose of CBCT and MSCT scanners for dentomaxillofacial applications Eur J Radiol 2009 71 3 461 468 10.1016/j.ejrad.2008.06.002 18639404
Loubele M, Bogaerts R, Van Dijck E, Pauwels R, Vanheusden S, Suetens P, Marchal G, Sanderink G, Jacobs R. Comparison between effective radiation dose of CBCT and MSCT scanners for dentomaxillofacial applications. Eur J Radiol. 2009;71(3):461–8. 10.1016/j.ejrad.2008.06.002.18639404 10.1016/j.ejrad.2008.06.002
69. Mora M Tyndall DA Rivera EM Effect of the number of basis images on the detection of longitudinal tooth fractures using local computed tomography Dentomaxillofac Radiol 2007 36 7 382 386 10.1259/dmfr/25073870 17881595
Mora M, Tyndall DA, Rivera EM. Effect of the number of basis images on the detection of longitudinal tooth fractures using local computed tomography. Dentomaxillofac Radiol. 2007;36(7):382–6. 10.1259/dmfr/25073870.17881595 10.1259/dmfr/25073870
