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Imaging Of Facial Trauma Part 2
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Imaging Of Facial Trauma Part 2


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  • 1. Imaging of Facial Trauma Part 2: Introduction and Anatomy Rathachai Kaewlai, MD Created: January 2007 1 quot;
  • 2. Outline   Facial fracture epidemiology   Types of facial fracture   Nasal bone fracture   Initial management   Naso-orbital-ethmoid fracture   Frontal sinus fracture   Imaging: CT versus radiography   Orbital fracture   Zygomatic fracture   Normal anatomy   Maxillary fracture   3D   Mandibular fracture   CT (axial, coronal and sagittal planes)   Radiography   Imaging approach   Biomechanics 2
  • 3. Plain Film Radiography   Can be obtained to screen for facial injury if CT is not immediately available   If plain film identify a fracture other than a simple nasal bone fracture, further evaluation by CT is indicated   Multiple plain film projections are relative to ‘canthomeatal line’; an imaginary line drawn from outer canthus to external auditory meatus   Proper positioning (of patient’s head), alignment of x-ray beam is critical for evaluation because facial skeletal anatomy is complex 3
  • 4. Plain Film Radiography   Remember: plain film is a 2D image of a 3D object   Overlapping structures significantly obscure anatomic detail   This problem is solved by standard views (to minimize overlap, allow visualization of important structures, familiarity for interpretation)   Rule of symmetry: two sides of the face are quite symmetrical   Symmetry is usual, and asymmetry is suspect   Multiplicity: fractures of facial bones are frequently multiple. Do not stop looking for others when see one 4
  • 5. Plain Film Radiography   Facial series   Mandible   Water’s view (PA view with   Oblique view, Towne’s view cephalad angulation)   Caldwell view (PA view)   Orthopanthogram   Towne’s view   Lateral view   Base view   Additional view   Lateral view of the nasal bone (nasal technique) Note: The lecture series are focused on CT scan 5
  • 6. Water’s View The most comprehensive single projection display Excellent view of - Maxilla - Maxillary sinuses - Zygoma - Zygomatic arches - Rims of orbits, esp. floor - Nasal bones 6
  • 7. Water’s View Key structures 1 = Frontal sinus 2 = Maxillary sinus 3 = Frontal process of Zygoma 4 = Body of Zygoma (malar eminence) 5 = Temporal process of Zygoma Dotted line = zygomatico- frontal suture Dolan’s lines of reference Line A, B, C Rule: smooth, non-disrupted, same contour on both sides 7
  • 8. Line A - Begins at inner surface of zygomatico-frontal suture, follows orbital surface of zygoma, maxilla, frontal process of maxilla and arch of nasal bone - If drawn to both sides, the line is similar to lazy ‘W’ or half frame of reading glasses Line B -  egins at lateral and inferior B margin of maxilla and extends along lateral wall of maxillary sinus and inferior surface of zygomatic arch - Ends at glenoid fossa 8
  • 9. Line C - Begins at lateral and inferior margins of maxilla, extends along lateral wall of maxillary sinus and inferior surface of zygomatic arch - Ends at glenoid fossa “Friendly Line” - Medial half of Line C is the anterolateral wall of the maxillary sinus. - If it is disrupted, the possibilities of fx include 1) Isolated maxillary antrum 2) Zygomatico-maxillary complex (ZMC) 3) LeFort (unilateral or bilateral) 9
  • 10. Caldwell’s View Excellent view of - Entire rim of orbit, esp. superomedial rim - Ethmoid sinus - Floor of orbit may be well seen in petrous bones are projected below the inferior orbital rim (not in this example) 10
  • 11. Key structures 1 = Ethmoid sinuses 2 = Orbit Line A, B, C, D = superior, 2 lateral, inferior and medial walls of the orbit, respectively Line E = midline nasal septum and vomer Rule: - Ethmoid sinuses density should be equal, darker than orbit - Smooth non-disrupted orbital walls 11
  • 12. Lateral View Excellent view of - Frontal sinus: anterior wall - Maxillary sinus: anterior and posterior wall - Sphenoid sinus - Pterygoid plate - Floor of anterior cranial fossa, hard palate - Lateral rim of orbit 12
  • 13. Key structures 1 = Frontal sinus 2 = Maxillary sinus 3 = Sphenoid sinus 4 = Hard palate 5 = Anterior wall of temporal fossa Between green arrows = Pterygoid plate Line A = Anterior wall of frontal sinus Line B = Anterior cranial fossa Line C = Anterior wall of maxillary sinus Line D = Posterior wall of maxillary sinus 13
  • 14. Line A - Connects anterior surface of frontal sinus and anterior surface of hard palate Line B - Connects anterior wall of temporal fossa and posterior edge of hard palate Line C - Along planum sphenoidale Line D - Along hard palate Rule: - Line A & B parallel - Line C & D parallel 14
  • 15. Towne’s View Excellent view of - Maxillary sinus: posterolateral wall - Zygomatic arch 15
  • 16. Key structures 1 = Zygomatic arch Line A = Posterolateral wall of maxillary sinus Rule: - Smooth, non-disrupted line 16
  • 17. Orthopanthogram or Panorex® Key structures R = Temporomandibular joint 13 = Mandible, condyle 14 = Mandible, ramus 17 = Mandible, body 18 = Mandible, angle 19 = Mandible, coronoid process 20 = Mandible, symphysis 17
  • 18. 8 9 25 24 Counting the teeth on Orthopanthogram or Panorex® American Dental Association (ADA) system preferred this system because you will speak same ‘language’ with dentists. Count from midline and go laterally (some individuals may not have #1, #16, #17, and #32) Maxillary Arch ADA#1 - 8 (right), #9-16 (left) Mandibular Arch ADA#32-25 (right), #24-17 (left) 18
  • 19. Oblique View of Mandible Key structures R = Temporomandibular joint 13 = Mandible, condyle 14 = Mandible, ramus 17 = Mandible, body 18 = Mandible, angle 19 = Mandible, coronoid process 20 = Mandible, symphysis 19
  • 20. Biomechanics   LeFort described areas of relative strength within the facial skeleton   Alveolar process of maxilla (1)   Frontal process of maxilla (2)   Body of zygoma or malar eminence (3)   Line of fracture tends to avoid these areas 20
  • 21. Checklist for Facial Radiograph/CT   Facial structures are quite symmetrical   Do not stop searching when see one abnormality   If suspect for more than simple nasal fracture, do CT   Significant (but can be subtle) fractures   Fracture involves the optic foramen which can cause permanent visual loss if not treated promptly   Fracture of the posterior wall of frontal sinus requires neurosurgical evaluation and may require antibiotics prophylaxis   Fracture/dislocation of the TMJ usually missed on initial survey. It can cause significant disability if left untreated   Look for significant soft tissue injuries   Globe rupture, hemorrhage 21
  • 22.   To be continued in Part 2 and 3 22
  • 23.   The information provided in this presentation…   Is intended to be used as educational purposes only.   Is designed to assist emergency practitioners in providing appropriate radiologic care for patients.   Is flexible and not intended, nor should they be used to establish a legal standard of care.   Thanks, MGH Radiology, for cases I’ve seen and things I’ve learned. R.K. 23