CLINICAL RESEARCH
Ibrahim Alaugaily, BDS,*† and
Adham A. Azim, BDS*†‡
SIGNIFICANCE
The presence of an angular
bony defect on a preoperative
CBCT scan on the mesial or
distal aspect of the tooth is
suggestive of the presence of a
crack limited to the crown on
the same side of the bony
defect.
From the *Division of Endodontics,
University at Buffalo, School of Dental
Medicine, Buffalo, New York;
†
Department of Restorative Dental
Sciences, College of Dentistry, King Saud
University, Riyadh, Saudi Arabia; and
‡
Department of Endodontics, University of
the Pacific, Arthur A. Dugoni School of
Dentistry, San Francisco, California
Address requests for reprints to Dr Adham
A. Azim, Chair of the Department of
Endodontics, University of the Pacific,
Arthur A. Dugoni School of Dentistry, San
Francisco, CA.
E-mail address: aazim@pacific.edu
0099-2399/$ - see front matter
Copyright © 2022 American Association
of Endodontists.
https://doi.org/10.1016/
j.joen.2022.06.004
1100 Alaugaily and Azim
CBCT Patterns of Bone Loss
and Clinical Predictors for the
Diagnosis of Cracked Teeth
and Teeth with Vertical Root
Fracture
ABSTRACT
Introduction: This study aimed to identify clinical and radiographic characteristics of teeth
with longitudinal fractures to assist in the diagnosis and differentiation between cracked teeth
and teeth with vertical root fracture (VRF). Methods: Ninety-five patients (95 teeth) diagnosed
with a longitudinal fracture (only cracked teeth or VRF) through clinical visualization of the
fracture line were included in this study. Clinical and radiographic data were collected from the
patients’ records to identify the characteristics associated with each condition. Fifty-four
patients (54 teeth) had full radiographic (periapical [PA] radiography and a cone-beam
computed tomographic [CBCT] scan) and clinical findings (probing depths and clinical images
of the fracture line). PA and CBCT images were evaluated by 2 independent examiners to
identify the different patterns of bone loss associated with these teeth (no defect, an angular
defect, a J-shaped defect, or a combined defect). Cohen kappa analysis was used to
compare the results between the 2 examiners and between the findings of the PA and CBCT
images. Pearson chi-square analysis, the Fisher exact test, and adjusted Bonferroni post hoc
testing were used to establish an association between the type and extension of the longi-
tudinal fracture with the probing depth, the CBCT pattern of bony defects, and the presence/
absence of the buccal plate and also to compare the clinical and radiographic characteristics
of cracked teeth and teeth with VRF (P , .05). Results: CBCT images had 4.4 times the odds
of detecting bony defects suggestive of longitudinal fractures compared with PA radiographs.
Teeth with VRF were more associated with indirect restorations, deep probing (.6 mm),
absence of the cortical plate, and a J-shaped defect on the CBCT image (P , .05). On the
other hand, cracked teeth were associated with direct restorations, shallow probing (,6 mm),
an intact cortical plate, and the presence of an angular defect on the CBCT image (P , .001).
There was a significant correlation between a radicular extension of the fracture line and deep
probing as well as J-shaped defects (P , .05). Conclusions: Patterns of bone loss on CBCT
imaging can likely differentiate between cracked teeth and teeth with VRF. The presence of an
angular defect may suggest the presence of a crack in the tooth before intervention. J-shaped
defects, deep probing (.6 mm), and loss of the cortical plate are likely suggestive of
VRF. (J Endod 2022;48:1100–1106.)
KEY WORDS
Angular defects; cracked tooth; cone-beam computed tomography; J-shaped lesions;
vertical root fracture
The clinical management and the prognosis of longitudinal fractures vary significantly and are based
primarily on proper diagnosis1. The American Association of Endodontists classified teeth with
longitudinal fractures into 5 different types: craze lines, fractured cusp, cracked tooth, split tooth, and
vertical root fracture (VRF)1. Craze lines are limited to enamel only, the patients are often asymptomatic,
and the condition may not represent a clinical concern1. Fractured cusps and split teeth are easier to
clinically diagnose because of the partial or complete mobility/absence of the fractured pieces. The
JOE  Volume 48, Number 9, September 2022
management of fractured cusps depends on
the remaining tooth structure, whereas split
teeth are considered hopeless and should be
extracted1. On the other hand, a cracked tooth
and a tooth with VRF may often present with
similar clinical and radiographic findings, which
can also mimic lesions of endodontic origin,
making diagnosis and treatment planning a
concern to the treating dentist and the patient.
Cracked teeth are challenging to diagnose
because of the difficulty in identifying the
location, direction, and extension of the crack
line before and during the clinical treatment2.
Similarly, the diagnosis of teeth with VRF is
uncertain because the fracture line is infrabony
and not clinically visible during endodontic
examination3. Although cracked teeth can be
saved through endodontic treatment with high
success and survival rates2,4–7, teeth with VRF
have poor prognosis and can only be treated
through extraction or amputation of the
fractured root1.
Teeth with longitudinal fractures can
present with different radiographic
presentations on periapical (PA) radiography8,
including wide enlargement of the periodontal
ligament along the root length, the presence of
a J-shaped or “halo” appearance, the
presence of an angular periodontal defect
extending apically from the crestal bone and
terminating at the level of the fracture line, or
complete separation of the root fragments.
However, these radiographic presentations
can only be observed in 30–50% of vertical
fracture cases8,9 and, to date, have not been
correlated to cracked teeth.
Cone-beam computed tomographic
(CBCT) imaging is a widely used imaging tool
among endodontists10. It has been
recommended by the American Association of
Endodontists and the American Association of
Oral and Maxillofacial Radiologists as the
imaging modality of choice for cases with
inconclusive diagnosis, teeth with complicated
anatomy, and surgical and nonsurgical
endodontic retreatments11. Several studies
have shown higher sensitivity and specificity of
CBCT imaging in detecting VRF compared
with 2-dimensional radiographs12–14.
However, smaller fracture lines and cracks are
too small to be detected on the scan,
especially with beam hardening, scattering,
and streak artifacts that can compromise the
quality of the produced image15, making
CBCT imaging an unpredictable tool in the
detection of root fractures16. Longitudinal
fractures (cracked teeth and VRF) are often
associated with early bony changes in the
periradicular area, which can be
radiographically visualized using 3-dimensional
(3D) imaging. Identifying the type of longitudinal
JOE  Volume 48, Number 9, September 2022
fracture before initiating treatment using
radiographic parameters can assist clinicians
in better diagnosing and treatment planning of
teeth requiring root canal treatment.
To our knowledge, the different patterns
of bone loss associated with these longitudinal
fractures have not been previously investigated
using 3D imaging and have not been
correlated to cracked teeth. Therefore, the aim
of this study was to correlate and compare the
location and position of longitudinal fractures
associated with cracked teeth and teeth with
VRF to the preoperative clinical and
radiographic findings using CBCT imaging.
MATERIALS AND METHODS
Study Design and Patient
Population
This study was approved by the institutional
review board (institutional review board no.
MODCR 00004324). The study was
composed of 95 patients referred to the
endodontic postgraduate program and faculty
practice for endodontic evaluation and
treatment from 2016 through January 2021. All
patients were diagnosed with a longitudinal
fracture either during clinical examination or
intervention, and either nonsurgical (initial
treatment or retreatment) or surgical treatment
(apicoectomy, root amputation, or extraction)
was planned accordingly. The treatment
options were explained to the patients in detail,
and the most appropriate treatment option
was performed. The patient population was
limited to patients who were clinically
diagnosed with either a cracked tooth or a
tooth with VRF. Patients with craze lines,
fractured cusps, or split teeth were not
included in this study. All identified clinical
cases were entered into the program’s
database (Endolit LLC, Orinda, CA), and
information related to patients’ age, sex, tooth
type (anterior, premolar, or molar) and position
(maxillary or mandibular), pulp and PA status,
presence/absence of sinus tracts, and type of
restoration was recorded.
Clinical and Radiographic
Assessment of Teeth with
Longitudinal Fractures
This evaluation was performed on a subset of
the patients diagnosed with cracked teeth or
VRF for whom full clinical and radiographic
data were present. Clinical assessment of the
teeth included the probing depth (6 mm or
,6 mm) and information regarding the
longitudinal fracture that was listed in the
clinical notes and confirmed with intraoperative
clinical photographs. For a case to be
included, a clinical photograph had to illustrate
Diagnosis of Cracked Teeth and Teeth with VRF
the position, direction, and extension of the
longitudinal fracture and whether it was limited
to the crown or extending to the root. All clinical
pictures were acquired using a digital-single
lens reflex camera mounted on surgical
operating microscopes (OPMI pico; Carl Zeiss
Meditec, Inc, Dublin, CA).
The radiographic assessment of teeth
included PA radiographs and CBCT images.
Two independent examiners (a board-certified
endodontist and a senior endodontic resident)
analyzed the PA radiographs and CBCT Digital
Imaging and Communications in Medicine
(DICOM) files. The DICOM files were exported
on a 3D viewer software (Horos; Horos Project,
Geneva, Switzerland) on a 27-inch iMac
screen (Apple, Cupertino, CA). Each root/tooth
was examined to identify any unusual or
unique bone loss patterns suggestive of a
longitudinal fracture. The bony patterns were
categorized as follows (Fig. 1A–L):
1. No visible bone defects: radiographic
presentation does not show any unusual
bone loss patterns in the periradicular area
other than a PA radiolucency centered
around the apical third of the root
2. Angular defect: a triangular bony defect on
the mesial or distal aspect of the tooth with
a wide base from the crest of the alveolar
bone extending apically with the apex of the
triangle pointed toward the root8 (Fig. 1B)
3. J-shaped (halo) defect17: periradicular
radiolucency located on the lateral aspect
of the root and extending apically on the
side of the root (mesial, distal, or both on
the PA radiograph or mesial, distal, buccal,
or lingual/palatal aspect of the root on the
CBCT image) reaching the tooth apex
(Fig. 1F)
4. Combined/irregular bone defect: a bone
loss pattern that includes a combination of
the previously described bony patterns or a
haphazard bone loss pattern around the
tooth from the cementoenamel junction to
the apex of the root (Fig. 1J)
To minimize bias, both examiners
evaluated the PA radiographs first followed by
the CBCT DICOM files on all 3 planes (sagittal,
axial, and coronal) without any information
regarding the type of the longitudinal fracture
(crack or VRF), the probing depth associated
with the tooth, or the location and extension of
the crack/fracture line. If one of the previously
described bone loss patterns were identified,
each reviewer would accordingly predict which
root had the longitudinal fracture.
Radiographic disagreements between the
examiners were resolved through a discussion
until a consensus was achieved. After
radiographic examination, the examiners
1101
FIGURE 1 – Radiographic presentation of teeth with clinical evidence of longitudinal fractures. (A–D ) An angular defect associated with a cracked tooth. (A ) A PA radiograph of a
mandibular left first molar showing a shallow fill and no apparent periradicular pathology. (B ) A CBCT sagittal view of the same tooth showing an angular defect on the distal aspect of
the tooth. (C ) A clinical photograph showing a horizontal fracture line running on the roof of the pulp chamber. (D ) After completion of the root canal treatment, the crack line is running
on the distal wall extending to the distal canal orifice. (E–H ) A J-shaped lesion associated with VRF. (E ) A PA radiograph of a maxillary left first molar showing a short fill on the
mesiobuccal root and a PA radiolucency associated with the root. (F ) A CBCT sagittal view of the same tooth showing a J-shaped lesion associated with the mesiobuccal root. (G ) A
clinical photograph showing a fracture line running on the lingual aspect of the root. (H ) A clinical photograph after root amputation of the mesiobuccal root. (I–L ) A combined lesion
associated with a cracked tooth. (I ) A PA radiograph of a mandibular right first and second molar showing a shallow fill and no apparent periradicular pathology. (J ) A CBCT sagittal view
of the mandibular right second molar showing an angular defect on the mesial aspect of the root and a J-shaped lesion extending to the furcation area. (K ) A clinical photograph
showing a crack line running on the mesial marginal ridge and extending to the mesiolingual canal. (L ) The mandibular right second molar extracted and showing a crack line on the
mesial aspect of the tooth extending to the radicular part of the tooth.

observed the crack position and extension on and whether it matched the radiographic was also observed on the CBCT scan for every
the clinical photographs to record the type and prediction. The presence or absence of an case on the axial and coronal view. The cortical
location of the longitudinal fracture on the tooth intact cortical plate (buccal or lingual/palatal) plate was considered absent if there was no

FIGURE 2 – Loss of the buccal plate secondary to VRF. (A ) A PA radiograph of a maxillary left first molar showing PA radiolucency around the mesiobuccal root. (B ) A CBCT coronal
view showing loss of the buccal plate along the entire mesiobuccal root. (C ) A clinical photograph during an exploratory surgery showing VRF of the mesiobuccal root.

1102 Alaugaily and Azim JOE  Volume 48, Number 9, September 2022
TABLE 1 - Distribution and Characterization of Teeth with Longitudinal Fractures initially identified. The mean age of the patients
was 60.3 years 6 12 years with a median age
Recorded variables n (%) Cracks VRFs Chi-square P value of 61.5; 92.6% of the teeth were molars. There
Tooth type 1.750 .415 was a significant association between the
Anterior 0 0 0 presence of VRF and previously treated teeth,
Premolar 7 (7.4) 7 0 teeth with sinus tracts, and teeth with indirect
Molar 88 (92.6) 74 14 restorations (P , .05). On the other hand,
Tooth location 0.275 .599 cracked teeth were associated with direct
Maxillary 33 (34.8) 29 4 restorations (P , .001). Amalgam was the
Mandibular 62 (65.2) 52 10
most common restorative material found in
Root canal status 62.80 ,.001*
cracked teeth (52.5%) followed by direct
Initial treatment 78 (82.1) 77 1
Vital 13 (13.7) 13 0 composite filling (33.8%). The results are
Nonvital 65 (68.4) 64 1 displayed in Table 1. Fifty-four patients had full
Previously treated 17 (17.9) 4 13 clinical (probing depth and clinical information
Sinus tract 6.11 .013* regarding the crack location and extension)
Present 18 (18.9) 12 6 and radiographic records (PA and CBCT
Absent 77 (81.1) 69 8 records) and were included in the final
Type of restoration 30.21 ,.001* statistical analysis; 41 of the teeth were
Direct 72 (75.8) 69 3 cracked teeth (74.1%), and 13 were VRFs
Amalgam 44 (46.3) 42 2
(24.1%).
Composite 28 (29.4) 27 1
Indirect 23 (24.2) 11 12
Single crown 22 (23.1) 11 11
Bridge abutment 1 (1) 0 1 Interexaminer and
PA lesion 3.11 .077 Interradiographic Agreement
Present 70 (73.7) 57 13 When evaluating the patterns of bone loss, the
Absent 25 (26.3) 24 1 interexaminer agreement was “near perfect”
Status of adjacent teeth 3.27 .194 using PA radiographs (K 5 0.89, P , .001)
Both present 48 (50.5) 38 10 and “perfect” using CBCT scans (K 5 1.0,
Only 1 present 32 (33.7) 30 2 P , .01). However, there was only a slight
Both absent 15 (15.8) 13 2
agreement between the PA and CBCT findings
PA, periapical; VRFs, vertical root fractures. (K 5 0.14, P 5 .01). PA radiographs showed
Bold and * indicates significance. evidence of bone loss suggestive of a
longitudinal fracture in only 9 of 54 cases
bone covering at least two thirds of the root in radiographic pattern of bone loss identified (16.6%), whereas CBCT imaging showed the
a coronoapical direction (Fig. 2A–C). on the CBCT scan (angular defect, same findings in 40 of 54 cases (72%)
J-shaped defect, or combined defect) and (Table 2). Of 41 cracked teeth, angular defects
Statistical Analysis the clinical extension of the longitudinal were only observed in 4 teeth (9%) using PA
The Pearson chi-square test and the Fisher fracture. For this final analysis, teeth with no radiographs compared with 19 teeth (46%)
exact test were used to establish an radiographic evidence of bony defects on using CBCT scans. Same findings were also
association between the type of the the CBCT scans were excluded. All noted among teeth with VRF. Of 13 teeth with
longitudinal fracture (crack or VRF) and the statistical analyses were performed using VRF, J-shaped and combined defects were
clinical (probing depth) and radiographic SPSS software (SPSS Inc, Chicago, IL) with observed in 4 teeth using PA radiographs
(CBCT patterns of bone loss and status of a P value set at .05. (30%) compared with 12 teeth using CBCT
the cortical plate) findings and between the imaging (92%). CBCT imaging had 4.4 times
probing depth (,6 mm or 6 mm) and the the odds of detecting evidence of bony
clinical extension of the longitudinal fracture
RESULTS changes associated with cracks and VRF
(within the crown 1 radicular/radicular Distribution and Characteristics compared with PA radiographs (odds ratio 5
fracture line). Adjusted Bonferroni post hoc A total of 95 teeth with longitudinal fractures 14.3; 95% confidence interval, 36.5–5.58).
testing was used to correlate the from 95 patients (41 men and 54 women) were CBCT scans also showed 100% positive

TABLE 2 - Interradiographic Agreement between Periapical (PA) and Cone-beam Computed Tomographic (CBCT) Findings

CBCT imaging Total

No evidence Evidence
J-shaped Combined/irregular
Angular defect defect defect
PA radiography No evidence 13 16 10 6 45
Angular defect 1 3 0 0 4
J- shaped defect 0 0 2 1 3
Evidence Combined/irregular defect 0 0 1 1 2
Total 14 19 13 8 54

JOE  Volume 48, Number 9, September 2022 Diagnosis of Cracked Teeth and Teeth with VRF 1103
TABLE 3 - Clinical and Radiographic Predictors for the Type of Longitudinal Fractures
Crack VRF Chi-square P value
Probing depth 13.8 ,.001*
6 mm 9 10
,6 mm 32 3 because the bony defects observed in this
CBCT bone defect 22.70 ,.001*
No defect 13 1 extension of these longitudinal fractures. It
Angular defect* 19 0 has always been recommended that a
J-shaped defect* 5 8
Irregular bone defect 4 4
Buccal plate 19.89 ,.001*
Present 40 7 This is likely due to the limitation of imaging
Absent 1 6
CBCT, cone-beam computed tomographic; VRF, vertical root fracture.
Bold and * indicates significance.
prediction of the root with longitudinal fracture
DISCUSSION
in cases with a J-shaped defect or a
The present study highlights the diagnostic
combined/irregular bone loss pattern (21/21
capability of CBCT imaging in the early
teeth) and 84% in cases with angular defects
detection of bony changes associated with
(16/19 teeth).
longitudinal fractures. Determining the
presence of a longitudinal fracture, as well as
Clinical and Radiographic its type, location, and extension, before
Predictors for the Type of initiating treatment can assist clinicians in
Longitudinal Fracture treatment planning and better prediction of the
There was a significant association between treatment outcome and the long-term
the probing depth, the integrity of the cortical prognosis of the tooth. There are inherent
plate, and the pattern of bone loss identified on limitations to clinically studying teeth with
the CBCT scan with the type of longitudinal longitudinal fractures because adequate
fracture (crack or VRF) (P , .05). Cases with visualization of all the fracture lines and their
cracked teeth were associated with an intact extension on the tooth is not always feasible. In
cortical plate, a probing depth ,6 mm, and the our assessment, we relied on cases with
presence of an angular defect on the CBCT clinical photographs illustrating these
scan (P , .001), whereas cases with VRF were longitudinal fractures under high magnification
more associated with the absence of the to overcome the ambiguity associated with the
cortical plate, a probing depth of 6 mm, and written description of these fractures in the
a J-shaped defect on the CBCT scan chart notes. Although we were able to locate at
(P , .001). least 1 fracture line in each tooth evaluated in
Adjusted Bonferroni post hoc testing this study, it is possible that other smaller
showed a significant association between the fracture lines are running deeper or in a
type of bony defect identified on the CBCT different direction and were not clinically
scan and the extension of the longitudinal visualized. Thus, the study findings should be
fracture. Angular defects were significantly interpreted with care given the small patient
associated with longitudinal fractures limited to sample size and the novelty of the data. To our
the crown (P , .0001), whereas J-shaped knowledge, this is the first clinical study
defects were significantly associated with the illustrating different patterns of bone loss
radicular extension of the longitudinal fracture associated with cracked teeth using CBCT
(P 5 .0002). There was also a significant imaging and correlating clinical with
association between deep probing depth radiographic findings.
(6 mm) and radicular extension of the In this study, CBCT imaging had 4
longitudinal fracture (P 5 .028). The results are times the odds of detecting bony changes
displayed in Tables 3 through 5, respectively. associated with longitudinal fractures
TABLE 4 - Correlation between the Probing Depth and the Clinical Extension of the Longitudinal Fracture
Within the crown Radicular extension P values
Probing depth ,6 mm 22 13 ,.028*
Probing depth 6 mm 6 13
Bold and * indicates significance.
1104 Alaugaily and Azim
compared with PA radiographs (P , .001).
These odds were double those observed in
studies comparing both imaging techniques
in the detection of PA diseases18. This can
be attributed to the nature of the disease
study are limited only to the location and the
definitive diagnosis for VRF should be made
through visualization by raising a flap19–21.
techniques to adequately observe these
fracture lines or the bony defects associated
with it. It has been previously shown that PA
radiographs can identify angular defects and
J-shaped defects in 14% and 37% of
longitudinal fractures, respectively22,23.
These findings appeared consistent with our
data when PA radiography was used for
radiographic evaluation. However, when
CBCT imaging was used for radiographic
assessment, the sensitivity of detecting
angular defects increased to 46% in cracked
teeth, and the detection of J-shaped defects
and combined defects in teeth with VRF
increased to 92%. Longitudinal fractures are
colonized with bacteria regardless of their
size, shape, direction, or extension24. Once
they extend to the cervical area, they can
initiate an inflammatory reaction at the
periodontium and subsequent resorption of
the surrounding bone. Because of the size of
these longitudinal fractures, bone loss can be
very minimal and not observed on a PA
radiograph but can be detected on CBCT
imaging, as illustrated in our results (Table 2).
The results of this study showed that
longitudinal fractures are primarily affecting
molar teeth in older patient populations. Molar
teeth are subjected to the highest occlusal
load and masticatory forces in the oral cavity,
which can contribute to the initiation and
propagation of a longitudinal fracture25,26.
There was a significant difference in the
clinical and radiographic presentations of
cracked teeth and teeth with VRF. Cracked
teeth were not associated with deep probing
and had no unique pretreatment clinical
findings suggestive of their presence.
However, they were associated with the
presence of an angular bony defect on the
mesial or distal aspects of the tooth, which
corresponded to the clinical location of the
crack in 16 of 19 teeth (84%). The presence of
angular defects was unique to cracked teeth
and was not observed in any of the cases with
VRF (P , .001). On the other hand, teeth with
VRF were associated with a deep probing
depth (6 mm), the presence of a sinus tract,
and having an indirect restoration (P , .05).
These clinical presentations often have been
JOE  Volume 48, Number 9, September 2022
TABLE 5 - Correlation between the Cone-beam Computed Tomographic Pattern of Bone Loss and the Clinical
Extension of the Longitudinal Fracture Using Adjusted Bonferroni Post Hoc Testing (Adjusted P Value 5 .008)
Within the crown, n (%)
Angular defect 17 (89.5)
J-shaped lesion 0 (0)
Irregular bone defect 1 (11.2)
Bold and * indicates significance.
associated with teeth with VRF22,23. Teeth
with VRF were also associated with a
J-shaped defect and irregular bone defects
on CBCT imaging, which corresponded
accurately to the fractured root in all the cases
(P , .001). These results appear to be
consistent with previously published
data17,27. Furthermore, we observed the
absence of the cortical plate in almost 50% of
the teeth with VFR. Loss of the cortical plate is
a sequela of long-standing fractures that are
colonized with bacteria and constantly irritate
the surrounding periodontium along the entire
root length24.
In this study, there was a significant
correlation between the pattern of bone loss
and the probing depth with the internal
extension of the longitudinal fracture. Eighty-
nine percent of cracked teeth with angular
Radicular extension, n (%) P Values
2 (10.5) ,.0001*
12 (100) .0002*
8 (88.8) .021
defects had their cracks observed above the
canal orifices (within the crown) (P , .001).
Although these cracks were clinically visualized
on the internal aspect of the crown and were
not associated with deep probing (P 5 .028),
an extension to these cracks is likely present
on the external root surface and colonized with
bacteria, resulting in angular bony defects at
the cervical area, as illustrated in Figure 1A–D.
Further extension of these longitudinal
fractures into the radicular portion of the root
would result in further bone destruction and
changes in the pattern of bone loss from an
angular defect to a J-shaped defect (Fig. 1E–H)
or a combined defect (Fig. 1I–L) and,
subsequently, an increase in the probing
depth, as observed in our results (Tables 4
and 5). Although some cracked teeth did not
present with any radiographic evidence of
bone loss, they might be incipient cracks that
have not yet extended to the cervical area and/
or colonized with bacteria.
Within the limitations of this study, we
can conclude that CBCT imaging can assist in
the preclinical diagnosis of cracked teeth and
VRFs through careful observation of the
patterns of bone loss. The presence of an
angular defect on the preoperative CBCT scan
can be a pretreatment predictor for the
presence of a crack limited to the crown.
However, clinicians should attempt to confirm
these findings through visualization of these
crack lines under high magnification. The
presence of a sinus tract, a J-shaped defect,
and deep probing (6 mm) in a previously
treated tooth is suggestive of a radicular
extension of a longitudinal fracture and
possibly VRF. The absence of the buccal plate
will likely increase these odds. Further clinical
studies using CBCT imaging and correlating
clinical with radiographic findings should be
conducted to further confirm these results.
ACKNOWLEDGMENTS
The authors deny any conflicts of interest
related to this study.

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1106 Alaugaily and Azim JOE  Volume 48, Number 9, September 2022