post graduate lecture

1. DR.ANILRAJ K.K, MD,DNB.DMRD
PROFESSOR AND HOD
TDMCH,ALAPUZHA

2.  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

3. CRANIOFACIAL ANATOMY
 THREE DIMENSIONS
 Recognize bony structures
 Functional dimension in terms of struts and
buttresses
 General relationship between face and skull base

4. 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

5. 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

6.  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

7. 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

8. 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

10. Site of union between facial
skeleton 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

11. 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-

12. 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

13. 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

14. 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

18. 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

19. 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

20. 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

22. 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

23. 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

26. 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

29. 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

30. 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

31. 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

32. 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

33. 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

34. 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

35. 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)

36. 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

37.  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

38. 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

39.  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

40. 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

41. THANK YOU