Limitations of Panoramic Radiograph-Based Fractal Dimension Analysis in Detecting Mandibular Trabecular Changes in Type 2 Diabetes Mellitus

Background: Fractal dimension (FD) analysis has been widely applied to medical and dental images to quantify trabecular bone complexity. Panoramic radiographs are routinely used in dental practice; however, the capability of two-dimensional panoramic imaging combined with FD analysis to detect subtle mandibular trabecular alterations associated with systemic diseases such as type 2 diabetes mellitus (T2DM) remains uncertain. Methodology: This retrospective cross-sectional study included 106 individuals, comprising 53 patients diagnosed with T2DM and 53 non-diabetic controls. Fractal dimension values were calculated using a standardized box-counting algorithm from four anatomically defined mandibular regions of interest (anterior, premolar, molar, and condylar) on panoramic radiographs. Intergroup comparisons of FD values were performed to evaluate the sensitivity of panoramic radiograph-based FD analysis in detecting diabetes-related trabecular differences. Results: No statistically significant differences in fractal dimension values were observed between the T2DM and control groups across all evaluated mandibular regions (p > 0.05). These findings highlight methodological limitations related to image dimensionality, projection geometry, and regional trabecular heterogeneity. Conclusions: Fractal analysis remains a valuable quantitative tool; however, its application to panoramic radiographs should be interpreted cautiously when used to assess systemic bone alterations.