Chronic kidney disease (CKD) can compromise bone quality during growth, yet noninvasive assessment in pediatric patients difficult. This study examined mandibular bone in pediatric CKD using fractal dimension (FD) and radiomorphometric indices (RI) on panoramic radiographs.

27 pediatric CKD patients and 27 age- and sex-matched controls were evaluated retrospectively. FD was calculated from 3 regions of interest (ROIs) using ImageJ/FracLac. Mandibular cortical width (MCW), panoramic mandibular index (PMI), and superior foraminal distance (SL) were measured. FD was compared with t tests (Welch’s t -test where appropriate) and RI with the Mann-Whitney U test.

Intraobserver and interobserver reliability were good to excellent (intraclass correlation coefficient 0.86–0.95). FD was significantly lower in the CKD group across all 3 ROIs (P = .003, .004, and < .001), with the largest effect in the gonial region (Cohen d = −1.39). MCW (P = .209), PMI (P = .457), and SL (P = .545) did not differ between groups.

Lower FD values indicated reduced mandibular trabecular complexity in pediatric CKD, whereas mandibular RIs remained unchanged. These findings suggest that trabecular bone alterations may be detected earlier than cortical changes on panoramic radiographs. Further studies incorporating biochemical markers and longitudinal follow-up are needed to establish the clinical utility of FD as a complementary panoramic imaging parameter.