Radiological diagnosis of mandibular fracture
Date First Published:
March 1, 2000
Last Updated:
May 15, 2001
Report by:
Piraya Begum, Medical Student (Manchester Royal Infirmary)
Search checked by:
Steve Jones, Manchester Royal Infirmary
Three-Part Question:
In [adult patients with mandibular trauma] are [panoramic radiographs better than the standard mandibular series] at [accurately diagnosing fractures]?
Clinical Scenario:
A 24 year old man presents to the Emergency Department on Saturday night with injuries to his lower jaw. He has been involved in a fight. On examination there is extensive bruising to the left side of the face and chin. The patient is unable to open his mouth or talk due to pain and trismus. You suspect a mandibular fracture and decide to x-ray the mandible. You wonder whether a standard mandibular series or a panoramic view is the best technique for accurately detecting any fracture.
Search Strategy:
Medline 1966-10/99 using the OVID interface.
Search Details:
[({exp fractures OR fracture$.mp} AND {exp mandible OR mandible$.mp or mandibular.mp}) OR exp mandibular fractures] AND {exp radiography OR x-ray$.mp OR roentgen$.mp} AND {exp radiography, panoramic OR orthopantomogram.mp OR OPG.mp} LIMIT to human AND english.
Outcome:
64 papers found of which 60 irrelevant or of insufficient quality for inclusion. The four remaining papers are shown in the table.
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| Clinical trial of pantomography for the evaluation of mandibular trauma. Johnston CC, Doris PE. 1980 USA | 17 patients with 24 mandibular fractures Standard series vs OPG |
Survey | X-ray diagnosis | 8(47%) fractures seen more easily on OPG | Patients with fractures only |
| Ease of interpretation | OPG more easily interpreted | ||||
| Primary radiographic diagnosis of fractures in the mandible. Moilanen A. 1982 Finland | 272 mandibular fractures Standard series vs OPG |
Retrospective diagnostic | X-ray diagnosis | 33% fractures seen more easily on OPG | Gold standard not stated Patients with fractures only |
| Accuracy of interpretation | Error rate 7% for OPG, 40% for standard series | ||||
| Comparison of panoramic and standard radiographs for the diagnosis of mandibular fractures. Chayra GA, Meador LR, Laskin DM. 1986 USA | 50 patients with 88 mandibular fractures Standard series vs OPG |
Retrospective diagnostic | X-ray diagnosis | 27% fractures seen more easily on OPG | Gold standard not stated Patients with fractures only |
| Accuracy of interpretation | Error rate 8% for OPG, 34% for standard series | ||||
| Prospective comparison of axial computed tomography and standard and panoramic radiographs in the diagnosis of mandibular fractures. Markowitz BL, Sinow JD, Kawamoto HK jr et al. 1999 USA | 21 patients with 33 fractures Standard series vs OPG vs CT scan |
Prospective diagnostic | X-ray diagnosis | Sensitivities 91% (standard series) vs 88% (OPG) | Gold standard not stated Patients with fractures only |
| Accuracy of interpretation | Accuracy 93% (standard series) vs 90% (OPG) |
Author Commentary:
None of the studies offer good evidence to answer the question. All are small, poorly designed and study only patients with fractures. All, except the last, suggest that there is some diagnostic advantage in using the OPG, but reinforce the view that the OPG alone is not sufficiently sensitive to be used as a SnOut. Further well designed diagnostic studies in the correct spectrum of patients are needed.
Bottom Line:
Adult patients with suspected mandibular fractures should have OPG as a screening radiograph. If no fracture is seen but clinical suspicion remains high then further views should be obtained.
References:
- Johnston CC, Doris PE.. Clinical trial of pantomography for the evaluation of mandibular trauma.
- Moilanen A.. Primary radiographic diagnosis of fractures in the mandible.
- Chayra GA, Meador LR, Laskin DM.. Comparison of panoramic and standard radiographs for the diagnosis of mandibular fractures.
- Markowitz BL, Sinow JD, Kawamoto HK jr et al.. Prospective comparison of axial computed tomography and standard and panoramic radiographs in the diagnosis of mandibular fractures.