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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.
[({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.

Search 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)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Johnston CC and 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
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
Chayra GA et al 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
Markowitz BL 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)

Comment(s)

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.

Clinical 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

1. Johnston CC, Doris PE. Clinical trial of pantomography for the evaluation of mandibular trauma. Ann Emerg Med 1980;9(8):415-8.
2. Moilanen A. Primary radiographic diagnosis of fractures in the mandible. Int J Oral Surg 1982;11(5):299-303.
3. Chayra GA, Meador LR, Laskin DM. Comparison of panoramic and standard radiographs for the diagnosis of mandibular fractures. J Oral Maxillofac Surg 1986;44(9):677-9.
4. 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. Ann Plastic Surg 1999;42(2):163-9.