What is the best radiographic imaging modality for evaluating a suspected mandible fracture?

Best Imaging for Suspected Mandible Fracture

CT maxillofacial with multiplanar reformations is the best imaging modality for evaluating suspected mandibular fractures, offering nearly 100% sensitivity and superior detection of subtle nondisplaced fractures compared to conventional radiography. 1, 2

Why CT Maxillofacial is Superior

CT maxillofacial should be your first-line imaging choice because it provides:

• Nearly 100% sensitivity with improved interobserver agreement compared to panoramic radiography 1, 2
• Superior detection of posterior mandibular fractures, particularly ramus and condyle fractures where displacement can be subtle 1
• Better identification of comminution and displacement, which are critical findings that change surgical management 1
• Multiplanar and 3-D reconstructions that allow better characterization of complex fractures and are essential for preoperative surgical planning 1
• Faster acquisition time and less reliance on patient positioning than radiography 1

When Panoramic Radiography May Be Considered

Orthopantomogram (OPG) can be appropriate only in patients with low clinical suspicion of injury, with sensitivity of 86-92% for simple mandibular fractures 2. However, be aware of critical limitations:

• Misses nondisplaced and minimally displaced anterior fractures due to overlap with cervical spine 2
• Poor visualization of condyle and subcondylar fractures with anterior displacement 2
• CT identifies more fractures even when OPG appears normal 1

Research confirms that helical CT has surpassed panoramic radiography as the gold standard, with enhanced imaging quality and decreased interpretation error 3.

Critical Clinical Pitfalls to Avoid

Always search for a second fracture after identifying the first—67% of mandibular fractures occur in pairs due to the U-shaped ring configuration 1, 4, 2, 5. Common patterns include:

• Mandibular angle or subcondylar fracture with contralateral parasymphyseal fracture 1, 4, 2, 5
• "Flail mandible": bilateral subcondylar fractures with symphyseal fracture 1, 4, 2, 5

Screen for associated injuries because mandibular fractures rarely occur in isolation:

• Intracranial injuries occur in 39% of patients with mandibular fractures 1, 4, 2, 5
• Cervical spine injuries occur in approximately 11% of patients 4, 2, 5
• 20-40% have additional injuries beyond the mandible 1, 4, 2, 5

Imaging Algorithm

1. Order CT maxillofacial with multiplanar reformations for any suspected mandibular fracture 1, 2
2. Systematically examine the entire mandible for a second fracture after identifying the first 1, 5
3. Consider head CT based on mechanism of injury, as 39% have intracranial injuries 1, 4, 2
4. Evaluate cervical spine clinically and with imaging if indicated, as 11% have cervical spine injuries 4, 2, 5

What NOT to Use

• Head CT is not useful as the initial imaging modality to identify mandibular injury 1
• MRI has no role in the initial imaging evaluation of suspected mandibular injury 1
• Plain radiographs of the mandible are inferior to CT and should not be relied upon 1