Mandibular X-ray View Recommendation
CT maxillofacial without IV contrast with multiplanar reformations is the most appropriate initial imaging modality for evaluating the mandible, offering nearly 100% sensitivity for detecting mandibular pathology compared to only 86-92% sensitivity for conventional radiography. 1, 2
Primary Imaging Recommendation
Order CT maxillofacial without IV contrast as your first-line imaging study for mandibular evaluation. 1
Why CT is Superior
CT maxillofacial provides nearly 100% sensitivity for detecting subtle mandibular fractures, early osteomyelitis, and nondisplaced lesions that conventional radiography will miss 3, 2, 4
CT offers superior delineation of both osseous and soft-tissue structures with high image resolution, allowing comprehensive evaluation of bone destruction, soft tissue involvement, and periosteal reaction 3, 2
Multiplanar and 3-D reconstructions better characterize the extent of pathology and are essential for surgical planning, particularly for assessing comminution and displacement 3, 2, 5
CT has faster acquisition time than MRI and is less dependent on patient positioning than panoramic radiography 3
When Panoramic Radiography May Be Considered
Panoramic radiography (orthopantomogram/OPG) is appropriate only in low clinical suspicion cases where you are screening for dental pathology as the source 3, 2
Critical Limitations of Panoramic Radiography
Sensitivity is only 86-92% for mandibular pathology, meaning you will miss 8-14% of fractures and early infections 3, 2
Misses nondisplaced and minimally displaced anterior fractures due to overlap with the cervical spine that obscures anterior regions 3, 2
Poor visualization of the posterior mandible, mandibular condyle, and subcondylar fractures with anterior displacement 3, 2
Will miss early osteomyelitis and underestimate disease extent in infectious processes 3
Clinical Context for Imaging Selection
For Suspected Mandibular Trauma
Order CT maxillofacial when the patient presents with:
- Trismus 1
- Malocclusion 1, 6
- Gingival or mucosal hemorrhage 1
- Loose, fractured, or displaced teeth 1, 6
- Step deformity 6
- Pain with mouth closed 6
For Suspected Mandibular Infection
Order CT maxillofacial when the patient presents with:
Additional Imaging Considerations
When to Add CT Head
Obtain CT head in addition to CT maxillofacial when evaluating mandibular trauma, as 39% of patients with mandibular fractures have coexisting intracranial injuries 5
When to Consider MRI
Reserve MRI for specific scenarios where soft tissue characterization is critical:
- Evaluating abscess formation or nerve involvement in infectious processes 3
- Detecting inferior alveolar nerve damage when fractures extend through the mandibular canal 3, 5
MRI should supplement, not replace, CT imaging 3
Chest Radiography Consideration
Order a chest radiograph to exclude tooth aspiration if there is a tooth that is absent following trauma, as an avulsed tooth in the airway carries risk of developing obstructive pneumonia 1
Critical Pitfalls to Avoid
Never rely on panoramic radiography alone for diagnosing mandibular fractures or infections, as you will miss early pathology and underestimate disease extent 3, 2, 5
Always search for a second fracture after identifying the first one, as 67% of mandibular fractures occur in pairs due to the U-shaped configuration of the mandible 2, 5
Do not overlook associated cervical spine injuries, which occur in approximately 11% of patients with mandibular fractures 2, 5
Cortication of the mandibular canal on panoramic radiographs does not predict the proximity of the canal to the cortices of the mandible; CT is required for accurate buccolingual localization 7, 8