Ct of maxillofacial trauma
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Ct of maxillofacial trauma

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post graduate lecture

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Ct of maxillofacial trauma Ct of maxillofacial trauma Presentation Transcript

  • DR.ANILRAJ K.K, MD,DNB.DMRDPROFESSOR AND HODTDMCH,ALAPUZHA
  •  CRANIO FACIAL TRAUMA –COMMON CLINICAL INDICATION INTRODUCTION OF MD CT AND ADVANCES IN IMAGE POST PROCESSING PROVIDE CRITICAL ANATOMICAL DETAILS WITH REQUIRED EFFICIENCY CHALLENGES FOR RADIOLOGIST-DETECT INJURIES AND DEMONSTRATE THOSE INJURIES TO CLINICIAN / SURGEON
  • CRANIOFACIAL ANATOMY THREE DIMENSIONS  Recognize bony structures  Functional dimension in terms of struts and buttresses  General relationship between face and skull base
  • Osseous anatomy-supraorbital Continuation of frontal calvarium (orbital plate of frontal bone on both sides) Frontal sinuses –posterior table fracture significant NEO REGION-junctional point of frontal sinus and calverium meet nasal bridge anteriorly and in turn joining with cribriform plate and ethmoid labrynth posteriorly Union of upper facial skeleton with anterior skull base
  • ORBIT ROOF- orbital plate of frontal bone+cribriform plate + lesser wing of sphenoid posteriorly Supra orbital notch-trigeminal branch MEDIAL WALL-frontal proces of maxilla,lacrimal bone,orbital plate of ethmoid(LP),sphenoid LATERAL WALL- posteriorly by GWS,anteriorly by zygoma FLOOR- orbital surface of maxilla and zygoma infra orbital foramen 3 FISSURES/FORAMEN
  •  MID FACE-maxilla, nasal bones,nasal cavity ZYGOMA- frequently fractured, succesful surgery means reestablishment of normal dimension and contour of zygomatic arch Inferior margin –maxillary alveolar ridge + teeth along the periphery and hard palate in the centre MANDIBLE- synphysis,body,angle, ramus,anterior coronoid process and posterior condyle Vulnerable points- condyle neck,angle, mental foramen,sites of impacted tooth
  • STRUTS AND BUTTRESES First described by GENTRY IN 1983 Network of vertically and horizontally oriented –in all 3 planes 3HORIZONTAL- Superior-orbital roof-cribriform plate-orbital roof Middle-orbital floor-zygomatic arches Inferior-hard palate 5 VERTICAL- 1 midline-nasal septum 2 medial sagital –medial wall of orbits and maxillary sinus- pterygoid plates
  • Struts and buttresses-contd.  2 lateral sagital-lateral wall of orbits and zygomatic arches  2 CORONAL-  Anterior strut- anterior surface of facial skeleton at NEO region with frontal bone  Posterior strut- posterior walls of maxillary sinuses with pterygoid plates
  • Site of union between facialskeleton and skull base  Roof of orbits- frontal calverium  Midface- frontal process of zygoma- FZS  Temporal process of zygoma- ZTS  Most impotant and posterior- pterygoid plate of sphenoid with posterior wall of maxillary sinuses just above maxillary alveolar ridge and just below the pterygopalatine fossa
  • classification By integrating the strut and buttresses concept with understanding of the relationship of facial skeleton with skull base ,a system statifies most fractures into 3 main catogories- also serving a functional framework for the injuries+ fairly well correlating with the theraputic decision making SOLITARY-simple/single bony wall COPLEX STRUT #- relationship between F.S and SB partially severed unilaterally or bilaterally,needs open reduction to avoid cosmetic deformity TRANSFACIAL-
  • classification SOLITARY STRUT Isolated orbital floor,medial wall or rim Isolated zygomatic arch Isolated frontal or maxillary sinus wall Nasal arch COMPLEX STRUT Nasoethmoidal-orbital,nasomaxillary Zygomaticomaxillary-ZMC TRANSFACIAL-Lefort I,II,III AND SMASH# MANDIBLE
  • BLOW OUT FRACTURE Pure blowout- acute rise in the intra orbital pressue- protective mechanism to maintain integrity of globe Medial orbital floor,inferior medial wall or combination Impure- associated with other # -orbital rim ,zygoma,transfacial structures Clinical- infraorbital nerve injury- numbness of cheek, upper lip and anterior maxillary teeth Diplopia-entrapment of IR Herniation of fat which may be tetherd to fat
  • Blow out fracture-contd 3rd nerve branch injury affecting IO Trauma to IR-impairment of contractility MEDIAL BLOWOUT- Injury /entrapment of MR Associted opacification of ethmoid air cells LATERAL BLOWOUT-/BLOW IN FRACTURE OF ROOF- Less common –associted with # supra orbital region. Frontal sinuses and calverium CORONAL IMAGING
  • Blow out #-complications ENOPHTHALMOS- Displacement of orbitalsoft tissues into maxillary or ethmiod sinus Artophy of orbital fat and scarring within fat #fragments > 2cm squre area / that are displaced > 3cm- potential surgical indication
  • Solitary strut ISOLATED ZYGOMATIC ARCH-due to focussed trauma Non displaced /displaced inward or outward Surgery for cosmetic reasons Inward displacement can impinge coronoid procees-can limit mandibular motion ISOLATED FRONTAL/MAXILLARY SINUS WALL NASAL FRACTYRES- most common ,50% Comminuted or displaced
  • COMPLEX STRUT# NEO/NASOMAXILLARY 4 facial struts converge in this region-single medial and 2 medial paramedian + superior horizontal Always complex and comminuted Always involve 2 out of 4 struts Involvement of nasal bone +frontal process of maxilla-free movement 50% unilateral Fragments displaced posteriorly-cribrifom plate Displaced laterally- NLD,NFD,Ocular injuries
  • COMPLEX STRUT # ZYGOMATICOMAXILLARY COMPLEX-ZMC Zygoma-inferolateral margin of orbit Point of intersection of lateral paramedian ,middle horizontal and anterior coronal struts TRIPOD/TRIMALAR #-dysjunction of zygoma #lateral orbital rim in the vicinity of ZFS #inferior orbital rim+ orbital floor Lateral orbital wall –ZSS #zygomatic arch (ZTS) #anterior and posterior wall of maxillary sinus
  • ZMC FRACTURES-contd INCOMPLETE-one of osseous connection intact NON DISPLACED- incomplete fracturing- ZFS DISPLACED /ROTATED Inferiorly/laterally/posteriorly Exo/enophthalmos if orbital volume affected Displacement at ZFS- open reduction Inferior displacement- distortion of lateral canthus- cosmetic deformity Infra orbital nerve/IR injury less frequent Impingement of coronoid process
  • TRANSFACIAL # RENE LE FORT in early 1900 All are complex –involve multiple struts – need open reduction and fixation All have potential to result in facial deformity All represent some degree of disconnection between facial skeleton and skull base Single most charecteristic feature is involvement of pterygoid plates
  • Le Fort type I Horontally oriented invoving inferior portion of maxillary antra , medial wall of maxillary sinus and inferior nasal septum, posteriorly through pterygoid plates + # hard palate Palate along with maxillary ridge and alveolus of maxilla- free fragment –FLOATING PALATE Mid face swelling, echymosis/naso pharyngeal bleed
  • Le Fort type II Most common among le fort # Involves orbits and upper nasal cavity structures 3D triangular configuration –PYRAMID # Apex at nasal bridge +fronto naso ethmiodal complx Lateral side wall- medial orbital wall, orbital floor, inferolaterally anterior and posterolateral wall of maxillary sinus terminating to pterygoid plates Central pyramid displaced posteriorly- DISH FACE DEFORMITY
  • Le Fort type II-contd No involvement of medial wall of maxillary sinus,inferiornasal septum,hard palate,lateral orbital wall,zygomatic arches Severe cosmetic deformity Malocclusisn Infra orbital nerve injury
  • Lefort type 3 Craniofscial dysjunction Le fort 2 + lateral orbital wall and zygomatic arches SMASH FRACTURES High energy injuries causing severe communition ,usually associted with IC bleed, temporal bone # and cervical spine injuries
  • MANDIBULAR FRACTURE 50% SOLITRY,50% MULTIPLE SIMPLE-no communication to oral cavity/skin COMPOUND COMMINUTED-multiple fragments IMPACTED-foreshortening + restricted movements GREEN STICK- only one side of cortex PATHOLOGIC-underlying osseous disease
  • Mandibular fracture -contd Commonest site- condyle/sub condylar area INTRA CAPSULAR- less common, in children,secondary OA changes EXTRACAPSUALR-unilateral> bilateral Unilateral associated with contralateral angle# Rarely force of impact of condyle transmitted to temporal bone –carotid canal –ICA injury 1 mm axial ,MPR /curved reformats similar to OPG
  • Radiological evaluation and interpretation Plain films –limited role-screening Conventional CT-Direct Coronal  Orbital roof and floor  Cribriform plate  Plannum sphenoidale  Hard palate  SPIRAL CT/ MD CT  HR images in seconds  High quality axial and MPR,curved 2D and 3D with single tissue(bone) /multiple tissue(bone ,fat and muscle)
  • IMAGING GOALS SCREEN FOR INJURY- plain film occipitomental 15 3-5 mm sections CT DETECTING AND DIAGNOSING – high quality axial, MPR including curved reformats DEPICTION OF INJURY-3D – surgical planning and Patient education Advances in 3D- volumetric assessments Advanced volume rendering techniqus Virtual surgery
  •  MDCT- additional sagital and oblique coronal- orbital floor/mandibular # Curved reformats- condyle /coronoid orocess NEW HORIZONS INTRA OPERATIVE CT REAL TIME 3D New stabilization /fixation materials –non metallic and resorbable
  • SURGEONS PERSPESTIVE Ct added a 3rd dimension to the craniofascial trauma analysis- ct guided surgery CT acurately visualizes the fracture Shows comminuted parts Direction of displacement Associted soft tissue injury Catogorized and designated as low,mid,high velocity Relationship of fracture fragments to critical soft tissues like optic nerve/extra ocular muscles Alterd orbital volume
  •  Sublle TM joint effusion or haemoarthrosis ROLE OF PLAIN RADIOGRAPHY Fractures in proximity to the dentition, Teeth root and related structures Root tip fractures Peri apical pathologies Periodontal/dental pulp diseases Post.op assessment of fixation
  • CONCLUSION Craniofascial trauma remains a prevalent condition nowadays and typically requires intense and immediate clinical decision – that is largely dependant on radiologic detection and depiction of injuries Recent advances in spiral CT and computer post processing technologies made CT to evaluate CFT patients thouroughly and efficiently and become the IMAGING MODALITY OF CHOICE
  • THANK YOU