Radiographic Imaging for Mandible Fractures

Standard Views (Plain Radiography)

The mandible is a U-shaped bone and fractures frequently occur at two sites simultaneously - one at the point of impact and a contralateral fracture (commonly the condylar neck). For this reason, at least two views at right angles are mandatory.

1. Orthopantomogram (OPT) / Panorex - First-line study

The dental panoramic radiograph (OPT/Panorex) is the single most useful initial view. It captures the entire mandible in one image and has a sensitivity of ~92% for mandible fractures (vs. 66% for other plain radiographic series).

Demonstrates fractures of the body, angle, parasymphysis, and ramus
Good for detecting condylar and subcondylar fractures
The standard first investigation when clinical suspicion is moderate-to-low

$Panoramic (Panorex) view - unfavorable mandibular angle fracture with obvious misalignment (arrow)$

Panoramic view demonstrating an unfavorable mandibular fracture with obvious misalignment (arrow) due to distracting forces of the masseter muscle. From Tintinalli's Emergency Medicine.

2. Posteroanterior (PA) Mandible Radiograph - Paired with OPT

Always obtained alongside the OPT. It is particularly good for:

Confirming and clarifying condylar fractures that may be subtle on the OPT
Demonstrating displacement in the coronal plane

$OPT (a) showing right mandibular body and left condylar fracture; PA mandible (b) showing the condylar fracture more clearly$

Fig. 31.5(b): PA mandible radiograph clearly showing the left condylar fracture, which may not be obvious on OPT to an inexperienced clinician. From Bailey and Love's Surgery.

3. Additional Plain Views

View	Indication
Intraoral (periapical)	Parasymphyseal fractures; suspected dental/alveolar fractures
Right & Left oblique lateral mandibular views	Alternative to OPT if patient cannot cooperate (e.g., dementia, agitation)
Chest radiograph	Unconscious patient with missing teeth - exclude aspiration

CT Scan - When Indicated

CT (axial + coronal sections) is ordered in:

Positive plain radiograph with suspected condylar fracture
Complex or comminuted fractures
Multiple facial fractures
High-energy mechanism (MVA)
Air-fluid level seen in any sinus

CT provides gold-standard bony detail and allows 3D reconstruction, which is invaluable for surgical planning and reconstructive procedures.

Fracture Sites to Look For

Common sites (from most to least frequent per Tintinalli's):

Angle - 36%
Body - 21%
Parasymphyseal - 17%
Condyle/subcondylar, symphysis, coronoid, ramus

Key rule: A mandibular fracture should be considered bilateral until proven otherwise because the U-shaped ring tends to break in two places.

What to Look For on the Radiograph

Radiolucent fracture line (break in cortex)
Step deformity at the inferior border - can mimic a missing tooth in the parasymphyseal region
Tooth displacement or loss
Malocclusion / malalignment of dental arches
Condylar displacement or telescoping
Subcondylar fractures (slender neck - easily missed on OPT alone)

Sources:

Grainger & Allison's Diagnostic Radiology, Fractures of the Mandible section
Bailey and Love's Short Practice of Surgery (28th Ed.), pp. 429-430
Tintinalli's Emergency Medicine, Chapter 259 (Mandible Fractures)
Cummings Otolaryngology Head and Neck Surgery (Panorex sensitivity 92% vs. 66%)

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