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2010-2011

RADIOLOGIC AND IMAGISTIC DIAGNOSIS INMAXILLO-FACIAL TRAUMA

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RADIOLOGIC EXAMINATION CONTRIBUTION

Diagnosis

Therapeutic planning

post-therapeutic evaluation of the treatmentaccuracy

Bone healing evaluation

The appearance of any complication

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MAXILLOFACIAL FRACTURE DIAGNOSIS – WHAT NEEDS TO

BE NOTED THROUGH RADIOLOGIC EXAMINATION?

The presence of a fracture

Localization

The path of fracture lineDisplacements

The presence and size of the bone

fragments Fracture’s complications

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EVALUATING MFT

CT –examination of choiceCBCT

1,04% from MFT are accompanied bycervical spine fractures

Brain damageCarotid arteries

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METHODS OF IMAGISTIC EXAMINATION

CT

CBCT

Conventional radiology Waters skull radiography (semiaxial)

PA skull radiography(Caldwell view)

lateral skull radiography

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CLASIFFICATION OF THE FACIAL FRACTURES

Dento-alveolar fractures

Mandibular fractures

Midface fracturesCentral midface fr.

Lateral midface fr.

Frontal fr.

Nasal fr.

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1.

DENTO-ALVEOLAR FARCTURES

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DENTAL FRACTURES

Crown fractures

Penetrating in pulp

chamber Non- penetrating

Root fractures

1/3 cervical – CRD?

1/3 medium – extraction?

1/3 apical - apical

rezection

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DENTAL LUXATIONS

Total dental Avulsion – x-ray – aspect of recent post-

extractional socket

Partial Intrusion – narrowed periodontal space, tooth

under the occlusion level plane

Extrusion –enlarged periodontal space, toothover the occlusion level plane

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SUBLUXATIONSDENTAL FRACTURES

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DENTAL FRACTURES

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TRAUMA

Root fractures

Subluxation 1.1

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2.

MANDIBLE FRACTURES

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MANDIBLE FRACTURES

70-80% from all cranio-facial fractures; 4:1: mand/max.

man> women, age 20-30

causes: agression, car accidents, work , sports acc.,

falling, iatrogenic Mechanism of apperance

directly

Indirectly

flexion

pressure(direct)

Compaction (indirect)

avulsion Share (ascending ram of mandible)

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CLASIFFICATION

Totally

Partially

Alveolar crest fracture

Fracture of the base partof the mandible

By number unique

double

triple multiple or cominutive

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By the site of the fracture symphyseal (menton and

paramenton)

horizontal ramus angle

Ascending ramus

condyle

Subcondylar (high, low)

Open/close (close: condyle,coronoid p., ascendingramus)

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FRACTURES ON A PATHOLOGICAL

BONE

TUMORS

GIANT BONE CYSTS

OSTEITIS/OSTHEOMYELITIS

OSTEORADIONECROSIS

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RADIOLOGIC EXAMINATION

Radiographs in at least 2 perpendicular

projectionsComparative radiographs

PA rgr. of the mandible

Unilateral rgr of the mandible

OPTOccluzal radiography

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RADIOGRAPHY UNILATERAL OF

THE MANDIBLE

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MANDIBLE FRACTURES

Fracture lineDirection

fragmentsdisplacements

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SYMPHYSEAL FRACTURES

MEDIAN – fracture in lambda

PARAMEDIAN

Usually withoutdisplacement

Displacements vertically-

occlusal and basal shifts horizontal plane

displacements – mentalarch foreshortening

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RADIOLOGIC EXAMINATION

Occlusal radiography

Submental radiography

Periapical radiography

Symphyseal fractures can be missed on

OPT

Unilateral of the mandible rgr.

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Can be obscured on rgr PA and OPT

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FRACTURES OF THE HORIZONTAL

PART

DISLOCATION FREQUENT AND LARGE

Deviation of the menton to

the side of the lesion,foreshortening of themandible arch

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FRACTURES OF THE HORIZONTAL PART =

LATERAL FRACTURES

Radiologic exam :• rgr unilateral of the mandible

• skull PA rg.

• OPT• occlusal film rg.

• Retroalveolar rgr.

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FRACTURES

AT GONION

Frequent

M3

Fragmentsdisplacements –

relationship with themasseter and the

internal pterigoidianmuscle insertion

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GONION FRACTURES (ANGLE OF THE MANDIBLE)

Radiologic exam :• rgr unilatreal of the mandible

• skull PA rg.

• OPT• periapicals rg.

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Dg. differential – air in the pharinx

!!!

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FRACTURES AT THE VERTICAL

RAMUS

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Radiographic projections:OPT

Unilateral of the mandible –radiography

Skull PA rgr

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FRCACTURES OF THE CORONOID

PROCESS Directly/avulsion

Usually withoutdisplacement

Isolated or associated with ATZ fracture

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MULTIPLE FRACTURES

Low Subcondylar+paramedian on theopposite side

cominutive

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CONDYLAR FRACTURES -

CLASIFFICATION

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LOW SUBCONDYLAR FRACTURES

OPT

skull PA

CT/CBCT

Radiologic projections

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INTRA-ARTICULAR CONDYLAR FRACTURES

OPTComparative radiography of TMJ

CBCT – it is always recommended whenthere are clinical signs of condylar fractureseven tough the OPT or PA radiography arenot showing any fracture – RISK OF TMJ

POSTRAUMATIC ANKYLOSISCT – in the absence of CBCT

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RADIOLOGICA EXAMINATION OF THE

TMJ – SCHULLER TRANSCRANIAL PROJECTION

Mouth opened Mouth closed

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HIGH CONDYLAR FRACTURES

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HIGH CONDYLAR FRACTURES

kids, falling on menton

DD

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CONDYLAR FRACTURE AND TMJ ANKYLOSIS

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CONDYLAR FRACTURE AND TMJ ANKYLOSIS

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6. TMJ ANKYLOSIS– CBCT

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MID- FACIAL FARCTURES

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! 1,04% from facial fractures areaccompanied with cervical column fractures

! Brain damage

! CA

CT IS THE EXAMINATION OF

CHOISE

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CT - axial + coronal sections aremandatory

- 3D CT - proves better the relationship between bone

fragments

Reduced value for the temporal bone fracture

Simulation of the bone fragments manipulation

On 3 D CT templates – one pour skeletalreconstructive prostheses

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MRI only for inflammatory complications

Meninges lesions

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NASAL FRACTURES

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NASAL FRACTURES

METHODES OFINVESTIGATION

ConventionalradiologyLateral radiography

for the nasal bones

Skull radiography –lateral projection

CT (CBCT)

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NASAL FRACTURES

•Side blow

•Vertical blow

Ist place (50% from MFT)

- Side blow > frontal blow

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NASAL FRACTURES

Laterala blow

- displacementlaterally of the nasal

bone +/- fracture of the

nasal septum

Frontal (vertical)

blow

Fracture of both nasalbones + nasalseptum

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CONVENTIONAL RADIOLOGY

Nasal bone rgr.

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CT - AXIAL AND CORONAL SECTIONS

nasal bonergr

CT axialCTcoronal

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CT – SECTIUNI AXIALE SI CORONALE

CT – fracture of the nasalbone with displacement

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CT - RECONSTRUCTIONS 3D

3D CT

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CBCT – 3D VOLUME

3D CBCT

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CBCT – 3D VOLUME

3D CBCT with soft tissue

reconstruction

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CBCT – AXIAL AND CORONAL SECTIONS

CBCT axial

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MID FACIAL CENTRAL FRACTURES

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MID-FACIAL CENTRAL FRACTURES

CALSIFFICATION

Mid facial central fractures

NASAL-ORBITARYFRACTURES Fractures of the bone

hard palate / IZOLATEDOF THE MAXILLA

LE FORT I LE FORT II LE FORT III

CONTRAFORTURI


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Methds of investigation

Rgr skull- semiaxial Rgr skull – lateral

CT (CBCT)


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Methods ofinvestigation

Rgr skull-semiaxial

Rgr skull – lateral

CT (CBCT)


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Methods ofinvestigation

CT (CBCT)Sections axial and

coronal aremandatory

3D CT (CBCT – 3D)

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CLASIFFICATION


NASAL-ORBITARYFRACTURES Fractures of the bone

hard palate / IZOLATEDOF THE MAXILLA


CONTRAFORTURI

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NAZAL ORBITAL FRACTURES

Mechanism : posterior movementof the nasal pyramid => bonesnasal, fractures,of the frontal

proces of the maxillary bone,lacrimal bone, ethmoid bone,nasal septum, frontal sinus wall.

Clinic:hyperthelorism,Lesions of the lacrimal

apparatus

! Optic canal

!FCA dura mater adherent firmly tothe periosteum => accumulation of airintracranial => intracranial infections

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NASAL-ORBITAL FRACTURES

Nasal bone lateralradiography

DOES NOT

EVIDENTIATE THE

DISPLACEMENT

OF FRAGMENTS

Does not show

FCA

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CT –axial section

Medial orbital wall-Nasal septum-Optic canal

-FCA

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CBCT – section axial

CBCT hi h l ti

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CBCT – high resolutionmultiplan reconstruction

-Sagital sections in the orbit

axis- l orbital floor

- Optic nerve canal

- FCA

-- coronal sections

- Orbital floor- Medial orbital wall

- FCA

NASAL ORBITAL FRACTURES

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NASAL-ORBITAL FRACTURES

MRI Inflammatory complications

HemosinusMeningeal damages

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MID-FACIAL CENTRAL FRCATURES

CONTRAFORTS


NASAL-ORBITARY

FRACTURES Fractures of the bone hard

palate / IZOLATED OF THEMAXILLA


Classification:

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2.

FRACTURES OF THE HARD PALATE

Classification:

Sagital

Lateral

transversal cominutive

CBCT /CT

- Axial sections- - topography of the

fracture

- - bone fragments

-Cross section:

- - dental socketsinvolvement

Through direct action of a thin

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3. ISOLATED MAXILLARY FRACTURES

Through direct action of a thinobject → ant./ lat. Wall of the

maxilla

Location:• anterior/lateral wall of the

maxillary sinus • Alveolar bone fractures

Radiography- skull semiaxial

• Sinus opacification• Discontinuity of the infraorbitarl

rim

CT/CBCT

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3. ISOLATED MAXILLARY FRACTURES

CT/CBCT

Axial sections

- anterior wall

- lateral wall- Hemosinus

-Coronal sections

- - orbital floor

-Cross section- - dental alveolar

bone

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CONTRAFORTS


NASAL-ORBITARY




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FRACTURI LE FORT I

Impaction at the level of

superior lipDetach of thesuperior alveolarprocess,inferior part of the nasalseptum,

inferior wall of MS,inferior part of pterygoidprocesses

–posterior displacement

Clinic: MalocclusionMaxillary hemosinusDento-alveolar

fractures

Methods of investigation:

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LE FORT I FRACTURES

Methods of investigation:- lateral skull radiography

- PA skull radiography

CT/CBCT

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LE FORT I FRACTURES

CT/CBCT

- cross section

- Relationship with dentalroots

- Sinusal floor

- Hemosinus/sinusal content

- alveolar crest ant-post

-Coronal section –lateraldisplacement of the crest

- Axial sections – lessdiagnostically importance

CT/CBCT

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LE FORT I FRACTURES

CT/CBCT

- - 3D – path and

displacements

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CONTRAFORTS


NASAL-ORBITARY




Detach of a pyramidal

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LE FORT II FRACTURES

Detach of a pyramidalshape fragment of acentre –facial part

Zygomatic bone remainsattach at the skull

Clinic:.• Facial deformation ;

• malocclusion ,

• anesthesia/paresthesiainfraorbital nerve territory

Skull semiaxial radiographyWATERS

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Infraorbital rim

zygomatico-alveolar

apophysis Sinus content

temporo-zygomatic achintact

fronto-ziyomatic suture

intact

CT/CBCT

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CT/CBCT

Axial sections Nasal bones

anterior sinus wall lateral sinus wall

posterior sinus wall

Pterygopalatin plates

Sinus content

ATZ temporo-zygomaticach intact

fronto-zygomatic sutureintact

sagital and coronal sections

CT/CBCT

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CT/CBCT

sagital and coronal sections

Orbital floor – involved

only infra-orbital rim Maxilary sinus content

CT/CBCT

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CT/CBCT

3D CT

Path and displacement

Associated fractures

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CONTRAFORTS


NASAL-ORBITARY




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LE FORT III FRACTURES

bilateral

cranio-facial Disjunction

+ ATZ (temporo-zygomatic ach) fractures

Clinical-facial deformity-hemorrhage-CRF fistula-lesions of lachrymal apparatus

-malocclusion-n. Infraorbital →interested in 69% of

the cases

On skull semiaxial

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radiography Waters Infraorbital rim

ATZ temporo-zygomaticach

Le Fort III fractures

CT/CBCT

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Axial sections

Nasal bones

fronto-zygomatic suture ATZ –temporo-zygomatic ach

Infraorbital canal

-Coronal and sagital sections for

the orbiteOrbital floor, orbital contentdisplacement inside themaxillary sinus

CT/CBCT

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Axial sections

Nasal bones

fronto-zygomatic suture ATZ temporo-zygomatic ach

Infraorbital canal

-Coronal and sagital sections for

the orbiteOrbital floor, orbital contentdisplacement inside themaxillary sinus

3D CT/CBCT

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FRACTURES path

Movement direction

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LATERAL MID-FACIAL FRACTURES


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LATERAL MID FACIAL FRACTURES

1. ZYGOMATIC2. ZYGOMATIC-MAXILLARY

3. ZIGOMATIC-MANDIBLE

4. ATZ (temporo-zygomatic arch)5. ORBITAL FLOOR –Blow Out, Blow in

ZYGOMATIC BONE FRACTURES

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II-nd place Tripod fracture, unilateral

Clinic - infraorbital nerve in94,2% cases

ocular lesions 16% cases 3D CT – movement and

rotation direction of thefragments


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Skull semiaxialradiography -Waters fronto-zygomatic suture

Infraorbital rim

pterygo-maxillaryapophysis

ATZ

Sinus opacification displacement, rotation

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CT/CBCT

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ZYGOMATIC FRACTURES

Coronal and sagitalsections

Orbital floor – displacement

Malar bone fragmentdiplacement

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CBCT – reconstruction for theorbital floor

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ZYGOMATIC FRACTURES

3D CT – fractures path and malar

fragment displacement


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LATERAL MID FACIAL FRACTURES





ATZ (TEMPORO-ZYGOMATIC ARCH ) FRACTURES

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- - mechanism

- TRISMUS

ATZ radiography

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ISOLATED ATZ FRACTURES

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Semiaxial radiographyWaters

CT- if there is alsomalar bone disjunction


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ORBITAL FLOOR FRACTURES

Mechanism for orbital floorfractures

Blow in –bone fragment

from orbital floor herniateinside the orbit.

Blow out =trauma produced bylarge dimension object

- force absorbed by the orbitalwalls and transmitted to orbital

floor- the eye is pushed posteriorly- usual the infraorbital rim is not

affectedCl.: -transitory diplopia is due toedema and hemorrhage


ORBITAL FRACTURES

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ORBITAL FRACTURES

Clinic:

- Diplopia 41%

- Enoftalmia 12%

- Blindness 2%

- Imaging identifying orbitalcontent collapse

- Intra-orbital emphysema

CT/CBCT

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ORBITAL FRACTURES

- Coronal sections

mandatory foridentifying orbitalcontent collapse

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Coronal sections !!!

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intra-orbitar emphysema

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CBCT MPR

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ORBITAL FRACTURES

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Sagital sections Coronal sections

FRONTAL FRACTURES

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Investigations Semiaxial rgr Waters PA skull rgr CT

Anterior corticalbone 67%

Ant. and post.cortical 28%

Post. cortical 5%

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FRONTAL FRACTURES

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FRONTALE FRACTURES

Skull radiography

- LATERAL- PA

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FRONTAL FRACTURES

CT/CBCT

POSTERIOR CORTICALINVOLVMENT – RISK FORMENINGEAL LESION

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cases

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POST-THERAPEUTIC RADIOLOGIC AND IMAGING

EXAMINATIONS

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NORMAL BONE CONSOLIDATION EVOLUTION

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6-8 days – fibrino - proteic callus (hemorrhagic -exudative phase) Demineralization of bone fragments, becoming more

radiotransparent Fracture line is more visible

8- 16 days – fibrous or chondroid callus (fibro-chondroid phase) Cartilage tissue, not visible radiological

From day 16 –several months - primitive bone callus (provisoryossification phase) Oval opacity, inhomogeneous, around the fracture fragments 6 months -1-2 years – definitive bone callus Intense opacity , net contour, reduced dimensions

Mandible fractures that are reduced and correctly immobilized consolidatesin 4-6 weeks

THE ROLE OF RADIOLOGIC EXAMINATION

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Normal/pathological healing Fragments reduction

Complication appearance

FRACTURES COMPLICATIONS

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Ê LATE FORMING CALLUS

Ê VICIOUS CALLUS

Ì PSEUDARTHROSISÍ OSTEITIS/OSTEOMYELITIS

Î POSTRAUMATIC ARTHRITIS/ANKYLOSIS

LATE CALLUS FORMATION

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Ê 2 monthsÊ Fracture line persistency

Ê osteoporosis at fracture fragments end

Ê Clinic :mobility of the fragmentsÊ Causes:

Ê general:Ê age, avitaminosis, fosfo-calcic metab., hypofisar insuf.

Ê Local:Ê incorrect or late immobilization

Ê Soft tissue interposition

VICIOUS CALLUS

In large displacements of the fracture

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In large displacements of the fracture

fragmentsMandible deformation, occlusion

disturbances

PSEUDARTHROSIS

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at 6 months: persistentfracture line

Fractured bone edges arerounded, condensed

Clinic mobility of thefragments

Causes: loss of bonesubstance, large, cominutive

fractures, wrongimmobilization with soft tissueinterposition, importantdisplacements

PSEUDARTHROSIS

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OSTEOMYELITIS

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Osteoporosis Osteolysis - patchy aspect of the bone

Periostitis – lamellar

Bone Sequestrum

Endosteal osteosclerosis

Healing – bone sclerosis, thickened, deformed, bone

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OSTEITIS/OSTEOMYELITIS

Mixed image,

inhomogeneous, withradio- transparencies andopacities

Bone sequestrum

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Osteomyelitis of thecallus

CHRONIC OSTEOMYELITIS

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OSTEOMYELITIS

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Brodie Abscess

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SUBMANDIBULAR ABSCESS

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GARRE OSTEOMYELITIS

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NON-SPECIFIC OSTEOMYELITIS

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POSTTRAUMATIC ARTHRITIS/ANKYLOSIS

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In intra-articular TMJ fractures

OSTEONECROSIS

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ASEPTIC

SEPTIC:SEQUESTRUM

OSTEORADIONECROSIS

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OSTEORADIONECROSIS

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OSTEOMYELITIS

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OSTEOMYLEITIS

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OSTEOMYELITIS

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trauma 2011-curs

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