Cone-beam Computed Tomography in Dentistry: Clinical Utility, Radiation Stewardship and Evidence Gaps-A Critical Narrative Review

Abstract

Cone-beam computed tomography (CBCT) has become an established source of three-dimensional information in dental and maxillofacial care, yet better depiction of anatomy does not necessarily produce better patient outcomes. This critical narrative review examines where CBCT adds defensible clinical value, how its diagnostic advantages interact with radiation exposure and image artefacts, and which applications remain insufficiently evaluated. Relevant clinical studies, evidence syntheses, professional recommendations and methodological publications were considered through 27 August 2026. The review applies a hierarchy distinguishing technical performance, diagnostic accuracy, changes in management and patient-centred benefit. Evidence supports selective CBCT use for anatomically complex endodontic problems, assessment of implant sites, localisation of impacted teeth, characterisation of selected periodontal defects and evaluation of temporomandibular osseous structures. The strength of this support differs considerably between indications. Endodontic studies frequently demonstrate altered diagnostic interpretation or treatment plans, but changes in decisions are not themselves proof of improved tooth survival. For mandibular third-molar surgery, randomised trials and their synthesis have not shown a routine reduction in inferior alveolar nerve injury from adding CBCT to panoramic imaging. Radiation doses and diagnostic image quality vary with device, field of view and acquisition protocol, making patient- and task-specific optimisation essential, particularly in younger patients. Incidental findings, inadequate interpretation of the full reconstructed volume, metal artefacts and insufficient external validation of artificial-intelligence tools present additional challenges. An integrated, indication-led framework is proposed in which CBCT is justified only when the unresolved clinical question is likely to affect management and when a suitable lower-dose alternative is inadequate. Future work should prioritise pragmatic comparisons with conventional imaging, validated diagnostic thresholds, patient-reported outcomes, long-term effectiveness and transparent implementation audits. CBCT is most defensible as a selectively prescribed diagnostic adjunct rather than a routine replacement for two-dimensional radiography.