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J Gandhara Med Dent Sci
October - December 2026
ORIGINAL ARTICLE
How to cite this article
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COMPARISON OF TOOTH LENGTH MEASURED WITH CONVENTIONAL PERIAPICAL VERSUS
CONE-BEAM COMPUTED TOMOGRAPHY
Ijaz Ul Haq
1
, Alia Ahmad
2
, Perkha Ali
1
, Arooba Nazami
1
, Toqir Ahmad
3
Haq IU, Ahmad A, Nazami A,
Ahmad T. Comparison of Tooth
Length Measured with Conventional
Periapical V ersus Cone-Beam
Computed Tomography. J Gandhara
Med Dent Sci. 2026;13(4): 9-13.
Date of Submission: 16-04-2026
Date Revised: 19-09-2026
Date Acceptance: 19-09-2026
2
Professor,
Department of
Operative
Dentistry &
Endodontics, Riphah Islamic
International Dental Hospital, Islamabad
3
Post Graduate
Resident,
Department of
Operative Dentistry &
Endodontics,
Riphah Islamic International Dental
Hospital, Islamabad
Correspondence
1
Ijaz Ul Haq, Resident,
Department
of
Operative Dentistry &
Endodontics, Riphah Islamic
International Dental Hospital, Islamabad
+92-300-5849041
drijazkhan93@gmail.com
ABSTRACT
OBJECTIVES
To compare tooth length measurements obtained using intraoral periapical
radiographs (IOPA) and CBCT in extracted single-rooted premolars.
METHODOLOGY
This cross-sectional comparative study was conducted at the Operative
Dentistry Department, Riphah International Dental Hospital, Islamabad.
Forty extracted single-rooted premolars from Pakistani patients aged 12-50
years were included. Teeth with incomplete root development, structural
defects, metallic restorations, or severe attrition were excluded. After
extraction, teeth were cleaned, disinfected, and mounted in a dry human
mandible with modelling wax to simulate soft tissue. Tooth lengths were
measured using IOPA with the paralleling technique and CBCT in the
sagittal plane. Measurements were compared using paired t-tests, with
stratication by age and gender.
RESULTS
The mean tooth length measured on IOPA was 19.78 mm (SD 1.44), while
CBCT measurements were shorter at 18.18 mm (SD 1.37) (p < 0.001). This
dierence was consistent across all age and gender groups. Females had
CBCT lengths of 17.98 mm versus 19.64 mm on IOPA, and males had
18.44 mm versus 19.96 mm. Participants aged 13–30 years had CBCT lengths
of 17.91 mm versus 19.94 mm on IOPA, and those aged 31–50 years had
18.37 mm versus 19.66 mm.
CONCLUSION
CBCT consistently produced shorter tooth length measurements than IOPA,
suggesting that periapical radiographs may overestimate tooth length. Its
three-dimensional imaging allows precise localisation of the root apex,
making it a reliable modality for endodontic measurement and treatment
planning.
KEYWORDS: Tooth Length, Cone Beam Computed Tomography,
Intraoral Periapical Radiograph, Endodontic Measurement, Root
Apex Localization
INTRODUCTION
Accurate determination of tooth length plays a central
role in the success of root canal treatment. One of the
most common causes of endodontic failure is inaccurate
working length estimation, which can result in
underfilling or overlling.
1,2
Both conditions may leave
behind infection or cause damage to the periapical
tissues, ultimately compromising the healing process
and long-term prognosis of the treated tooth.
3
Establishing the correct working length is essential
during both the preparation and obturation phases of
root canal therapy.
4,5
Effective cleaning and shaping
must reach the full extent of the root canal system to
remove necrotic tissue and bacteria. Similarly,
obturation should completely seal the canal to prevent
reinfection. An error in length determination at any
stage can reduce the eectiveness of treatment and
increase the risk of future complications.
6
Over the
years, several techniques have been developed to
estimate root canal length, ranging from traditional
methods like tactile feedback and paper point use to
more advanced tools such as electronic apex locators
and radiographic imaging.
7
Of these modalities,
conventional periapical radiographs have traditionally
been the diagnostic modality of choice due to their high
levels of availability, cost-eciency, and operational
simplicity.
8
However, due to the two-dimensional
nature of the images produced, such radiographs may
negatively impact the accuracy of measurements due to
image distortions and overlay of other anatomical
structures. Cone-beam computed tomography (CBCT)
is a newer technological development that oers
volumetric images and is potentially able to increase the
accuracy of length measurements, especially those of
anatomically complex or multi-rooted dentition.
9
A
previous study conducted in India reported that mean
tooth length was 21.21.7mm with CBCT and
http://doi.org/10.37762/jgmds.13-4.899
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J Gandhara Med Dent Sci
October - December 2026
22.31.8mm with periapical radiograph.
10
Though
CBCT has shown promising results due to its lack of
magnication error, questions remain regarding its
routine use, particularly given the higher cost and
radiation dose compared to traditional methods. So
there is a need to compare conventional periapical
radiographs and CBCT in determining tooth length.
This will help guide the ecacy of periapical
radiographs in determining tooth length. The objective
of the current investigation was to compare tooth length
measured with conventional periapical radiographs
versus cone beam computed tomography.
METHODOLOGY
This cross-sectional comparative study was conducted
at Operative Dentistry, Riphah Islamic International
Dental Hospital, Islamabad, from October 28, 2025, to
March 15, 2026, (
Ref No. IIDC/IRC/2025/007/001,
Dated: 01-07-2025) using a non-probability,
consecutive sampling technique. The sample size was
calculated in OpenEpi and was 80 (40 per group)
extracted single-rooted premolar teeth, calculated at
80% power and a 95% condence interval, using a
mean tooth length of 21.2 1.7 mm with CBCT and
22.3 1.8 mm with periapical radiograph, based on a
previous study.
10
Since the same set of teeth was
assessed using two dierent methods, the nal sam ple
size will be 40. The study included Pakistani nationals
of both genders aged 12-50 years. Only teeth with
complete root development and those that were
structurally intact without any root damage were
included in the study. Teeth containing metallic
restorations were excluded. In addition, teeth with
incomplete root apex formation, evident signs of root
resorption, or marked occlusal surface wear due to
attrition were also excluded from the study. Patients
fulfilling the inclusion criteria who were referred from
the Orthodontics Department to the Oral Surgery
Department for extraction were selected. Written
informed consent was obtained from all participants
after a detailed explanation of the study. The age and
gender of the participants were recorded. This study
involved extracted single-rooted premolar teeth
collected from patients undergoing orthodontic
treatment. Only teeth with complete root development
and no structural defects were included. After
extraction, the teeth were thoroughly cleaned using
ultrasonic scalers to remove any remaining soft tissue,
calculus, or bone fragments. The cleaned specimens
were then stored in 5% sodium hypochlorite solution in
accordance with CDC disinfection guidelines. Below
are the operational denitions used in the study. The
length of the tooth was measured as the straight
distance between the coronal reference point, which
was the tip of the cusp, and the apical end of the root
canal. The measurement was recorded in millimetres.
The traditional periapical radiograph (IOPA) refers to
the periapical imaging assessment of tooth length using
images produced with the paralleling technique. Tooth
length was measured from the cusp tip to the apex of
the root. Cone beam computed tomography (CBCT)
was dened as a three-dimensional imaging method
that provides volumetric images of the maxillofacial
region using a cone-shaped X-ray beam. In this study,
tooth length was measured on the sagittal plane using
the digital ruler tool available in the CBCT software.
The coronal reference point was the most occlusal point
of the cusp tip, while the most distal point of the root
was used as the apical reference point and served as the
endpoint of the tooth-length measurement. The
extracted teeth were placed in a dry human mandible in
the alveolar sockets in order to simulate clinical
situations, which involved ten specimens at a time. A
buccal and lingual bilateral 15-mm-thick layer of
modelling wax was applied and used to approximate the
density of soft tissue. A wooden platform was made to
hold the mandible to provide stability and impose a
uniform orientation when taking imaging shots.
Radiographic assessment was done using standardised
imaging guidelines. The radiographs of every tooth
were taken separately in the paralleling technique.
Exposure was done using a Kodak Insight lm, through
a Satelac unit using a 0.40-second exposure time. The
film was mounted perpendicular to the length of the
tooth, and the X- ray beam was set perpendicularly to
the lm and the specimen. A lm holder of XCP was
fixed using modelling wax to maintain the same
positioning. The radiographs that were obtained were
scanned and reviewed by dental imaging software to
measure the dimensions of the teeth, crowns and roots.
Acquisition of the prepared mandible was done using
cone-beam computed tomography (CBCT) at an
accelerating voltage of 90 kV, a voxel size of 0.2 mm
and a eld of view of 5 x 8 cm to ensure that it was in
the right position. Afterwards, individual teeth were
pointed out in the multiplanar reformatted images, and
linear measures were taken in the sagittal plane using
the special software. To assess interobserver reliability,
two observers independently measured the tooth length
on all IOPA and CBCT images using the predened
coronal and apical reference points. The observers were
trained and calibrated using the same measurement
protocol before the formal assessment. The observers
were blinded to each other's measurements and to the
results obtained from the alternative imaging modality.
Each observer recorded measurements independently in
millimetres. Pearson's correlation coecient was used
to assess the correlation between measurements
obtained by the two observers. The interobserver
Comparison of Tooth Length Measured with Conventional Periapical Versus
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J Gandhara Med Dent Sci
October - December 2026
correlation was high (r = 0.91), indicating strong
consistency between the observers. The statistical tests
were done in R 4.3.1. Continuous variables were tested
for normality using the Shapiro-Wilk test. In cases like
age and length of teeth, which were obtained using both
intra-oral periapical radiography (IOPA) and CBCT,
the arithmetic mean and standard deviation were
calculated. Categorical variables, especially gender,
were summarised in terms of counts and percentages.
Paired-samples t -test was used in comparisons of tooth
length in the two imaging modalities. Paired-samples t-
test was also used to conduct subgroup analysis by
gender and age in order to examine the possible
modification eects. The p-value of less than 0.05 was
taken to be statistically signicant (two-sided).
RESULTS
All of our continuous variables were normally
distributed, so parametric tests were run. (Table 1). The
mean age of participants was 33.2 years (SD 10.15).
The mean tooth length was 19.78 mm (SD 1.44) on
intraoral periapical radiographs and 18.18 mm (SD
1.37) on cone beam computed tomography. Females
accounted for 57.5% (23/40) and males 42.5% (17/40).
Participants aged 3150 years comprised 57.5%, while
42.5% were aged 1330 years. (T able 2) Tooth length
measured on cone beam computed tomography (mean
18.18 mm, SD 1.37) was signicantly shorter than that
measured on intraoral periapical radiographs (mean
19.78 mm, SD 1.44) (p<0.001). (Table 3) Tooth length
measured on cone beam computed tomography (CBCT)
was signicantly shorter than on intraoral periapical
radiographs (IOPA) across all gender and age groups.
For females, the mean CBCT length was 17.98 mm
versus 19.64 mm on IOPA (p<0.001), and for males,
18.44 mm versus 19.96 mm (p<0.001) (Student's t-test).
By age group, participants aged 1330 years had mean
lengths of 17.91 mm (CBCT) versus 19.94 mm (IOPA,
p<0.001), and those aged 3150 years had 18.37 mm
versus 19.66 mm (p=0.01) (Student's t-test). (Tables 4
& 5)
*
Shapiro-Wilk test
Table 2: Descriptive Statistics of Demographics and Tooth
Length on Periapical Radiograph and CBCT
Variable N=40*
Age, years
33.2 (10.15)
Tooth length (intraoral periapical radiograph)
19.78 (1.44)
Tooth length (cone beam computed
tomography)
18.18 (1.37)
Gender
Female 23 (57.5%)
Male 17 (42.5%)
Age group (years)
1330 17 (42.5%)
3150 23 (57.5%)
Table 1: Normality Distribution of Continuous Data
Variable W-Statistic
p-value
Age in years of the participants
Tooth length (intraoral periapical radiograph)
Tooth length(cone beam computed
0.956
0.975
0.970
0.121
0.511
0.349 tomograph)
Table 4: Comparison of Tooth Length Measured by Cone Beam
Computed Tomography and Intraoral Periapical Radiography
According to Gender
Gender
Parameter CBCT IOPA Mean dierence
(95% CI)
p-value
Female Tooth length,
Mean (SD)
17.98
(1.45)
19.64
(1.72)
<0.001
Male Tooth length,
Mean (SD)
18.44
(1.25)
19.96
(0.98)
-1.66 (-2.35 to
- 0.93)
-1.52 (-2.11 to
-0.93)
<0.001
*
Paired t-test
Table 5: Comparison of Tooth Length Measured by Cone Beam
Computed Tomography and Intraoral Periapical Radiography
According to Gender
Age
group
(years)
Variable Cone beam Com
puted Tomogra
phy (CBCT)
Intraoral Periap
ical Radiograph
y (IOPA)
p-value
1330 Tooth length,
Mean (SD)
17.91 (0.67)
19.94 (1.58)
<0.001
3150 Tooth length,
Mean (SD)
18.37 (1.70)
19.66 (1.36)
0.01
*
Student’s t-test
Table 3: Comparison of Tooth Length Measured by Cone Beam
Computed Tomography and Intraoral Periapical Radiography
*
Paired t-test
Variable
Statistic
Cone
computed
tomography
(CBCT)
Intraoral
periapical
radiography
(IOPA)
Mean
dierence
(95% CI)
p-value
length
(SD)
(1.37)
Tooth Mean 18.18 19.78
(1.44)
−1.60 (-2.0
5 to - 1.15)
<0.001
beam
DISCUSSION
The current study aimed to compare tooth length
measurements, obtained using conventional intra-oral
periapical radiographs (IOPA) and cone beam
computed tomography (CBCT) in extracted single-
rooted premolar samples. The ndings also revealed
Comparison of Tooth Length Measured with Conventional Periapical Versus
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J Gandhara Med Dent Sci
October - December 2026
that CBCT-related measurements were always shorter
in comparison with those of IOPA in all the participants
of the study, regardless of age and sex. Such a
dierence implies that there is no concordance between
the two imaging methods and that IOPA has a
systematic overestimation of the actual length of the
teeth anatomy. The observed dierence was statistically
significant and was observed in younger (13-30 years)
and older (31-50 years) cohorts, male and female
subjects, which supports the presence of an eect
associated with the imaging modality per se (and not
demographic characteristics). The dierences that have
been observed can be attributed to the inherent
technical and geometrical peculiarities of these two
imaging modalities. The cone-beam computed
tomography (CBCT) provides real three-dimensional
volumetric images, which allow us to view the root
apex directly, in various orthogonal views: sagittal,
coronal and axial.
11
The three-dimensional
representation minimises the superimposition of the
adjacent structure and also allows a more accurate
localisation of the apical terminus.
12
In comparison,
traditional periapical radiographs form two-dimensional
shadows of naturally three-dimensional anatomy; these
projections are prone to magnication, foreshortening,
and distortion, which are contingent on X-ray beam
angulation and/or positioning. The apical region can be
covered by superimposed structures, including adjacent
teeth or alveolar bone, which frequently causes the
apparent increase in the length of the tooth on
radiographs.
13
In addition, slight changes in X-ray beam
orientation or lm location can be of great concern on
intra-oral periapical (IOPA) images. However, CBCT
measurements are relatively immune to these errors as
they are volumetrically reconstructed and the position
of the linear measurement tools is more than simple to
use with specialised software. Such considerations are
probably the underlying factor in the shorter tooth
lengths always reported with CBCT in the current
study. Our ndings support the ndings of previous in
vitro studies. Sherrard et al.
14
observed that tooth and
root lengths measured using CBCT were similar to
those measured using digital callipers and that
periapical radiography signicantly overestimated tooth
length in particular premolars and incisors. Similarly,
Kumar et al.
15
also found that CBCT provided very
high reliability and accuracy in the measurements of
both root and crown length, but the intraoral periapical
radiographs were prone to very high deviations, which
could be mainly due to projection errors. Combined,
these studies highlight the fact that the three-
dimensional imaging that CBCT allows enables a more
accurate assessment of the dental anatomy, thus
reducing the tendency at overestimation that is inherent
to two-dimensional radiographic methods.
Nevertheless, clinical and in vivo studies have recorded
slightly dierent results in a number of cases. As an
example, Bhullar et al.
16
and de Morais et al.
17
found
that cone-beam computed tomography (CBCT) values
were more likely to be highly precise, but the
dierences to those of periapical radiographs were
often not statistically signicant. The heterogeneity of
this kind may be explained by several factors such as
the occurrence of periapical lesions, the anatomic
variability of people, and discrepancies in measuring
methodology. Periapical pathology may blur the apex
of roots on intraoral periapical (IOPA) images,
therefore changing the apparent root length. On the
other hand, CBCT allows visualisation of the apex and
surrounding bone structures and the surrounding bone
structure with precision. In addition, the voxel size,
software tools used in measurement, and calibration of
observers can alter results, particularly in the clinical
setting where patient movement and soft tissue
interference can produce small errors. All of these
considerations, in turn, suggest that, though the general
trend is toward greater accuracy of CBCT, the extent of
its superiority over IOPA might vary depending on
certain clinical and methodological factors. Unlike the
available literature on the study of obturation and
working length, such as that of Cheng et al., the study
established that CBCT could detect discrepancies in
radiographically adequate obturations, with about 30
per cent of the cases that were acceptable on IOPA
having an unacceptable length on CBCT.
18
This fact
highlights the clinical importance of CBCT in
endodontics, where accuracy in determining the
measurements of teeth and roots is crucial in cleaning
of the canal, shaping and obturation. This information is
expanded to extracted premolars by the current study,
which proves that CBCT values are closer to the actual
anatomical lengths and, thus, reduce the potential errors
related to the procedure when implementing endodontic
and restorative treatment.
LIMITATIONS
This study has several limitations. The relatively small
sample size (n=40) and inclusion of only extracted
single-rooted premolars may limit the generalizability
of the ndings to other tooth types and clinical
situations. The in vitro design and use of a dry human
mandible with modelling wax could not fully replicate
clinical conditions such as patient movement and soft-
tissue variation. In addition, no independent gold-
standard method, such as direct measurement with a
digital calliper, was used to determine the actual
anatomical tooth length. CBCT measurements were
also obtained only in the sagittal plane, which may have
introduced measurement variability. Therefore, larger
Comparison of Tooth Length Measured with Conventional Periapical Versus
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J Gandhara Med Dent Sci
October - December 2026
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in vivo studies involving dierent tooth types and direct
reference measurements are recommended.
CONCLUSIONS
Measurement of the tooth length by means of cone-
beam computed tomography (CBCT) always reported
shorter lengths in comparison with those of periapical
radiography in all age and sex groups, indicating that
intra-oral periapical radiographs (IOPA) could be
overestimating the tooth length. The CBCT volumetric
imaging allows more accurate localisation of the root
apex, and thus, it makes it a more reliable modality for
accurate endodontic measurements and treatment plans.
CONFLICT OF INTEREST: None
FUNDING SOURCES: None
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Ijaz
Ul Haq
-
Concept & Design; Data Acquisition; Drafting
Manuscript;
Supervision; Final Approval
Alia Ahmad
-
Concept & Design; Data Acquisition; Drafting
Manuscript; Final Approval
Perkha Ali
-
Concept & Design; Data Acquisition;
Data
Analysis/Interpretation; Drafting Manuscript;
Final Approval
Arooba Nazami
-
Concept & Design; Data Acquisition;
Drafting Manuscript; Final Approval
Toqir Ahmad
-
Concept & Design; Data Acquisition; Drafting
Manuscript;
Critical Revision;
Final Approval
AUTHORS CONTRIBUTION
The authors accept responsibility for all aspects of the work
and will ensure that any concerns regarding the accuracy or
integrity of any part are properly investigated and resolved.
Comparison of Tooth Length Measured with Conventional Periapical Versus
