JURNAL READING

IMAGING IN MAXILLOFACIAL TRAUMA

Central India Journal of Dental Sciences, Vol. 3 (4), Oct - Dec 2012

SITI DEINAR ANDHITYA 160121150003

ANDI ARFANDI ARIFUDDIN 16012115007
NYOMAN AYU ANGGAYANTI 160121150008
(PPDGS Bedah Mulut dan Maksilofasial FKG
UNPAD)
Dosen Pembimbing : dr Atta Kuntara, Sp. Rad (K)

Introduction
Injury to the face can occur to
include the dentition or maxillofacial
skeleton in isolation,
or in combination with neck,
multisystem, or cranial fractures.
Clinical evaluation assisted by :
1. Conventional X rays
2. Computed tomography (CT)

Conventional X-rays
In the late 1940s and 1950s numerous
radiographic techniques were reported for
the assessment of dentoalveolar, midfacial,
mandibular , and panfacial injuries
Mandibular and condylar fractures were
identifed using a combination of lateraloblique,
occlusal,
transcranial,
and
posterioranterior projections

Dentoalveolar injuries
Intraoral radiography remains the principal
imaging modality in the assessment of dental
trauma :
1. Periapical radiograph
2. Occlusal radiographs
. intraoral radiography to radiovisuography
(RVG) having more opportunity of image
enhancement is much more helpful to assess
dento alveolar injuries.

Mandibular fracture
The standard view for mandibular
fractures as:
1. Lateral facial views
2. PA View
3. Occlusal Radiograph
4. IOPA
5. Panoramic X-ray.

 According to S Rogers et. al. 1995 in emergency

department in UK three radiographs are used these
are so called maxillofacial views
They comprise of:
1. occipitomental views (typical an OM and OM 30o)
2. Lateral View

A Pogrel et. al. 2000 found that in emergency

department of USA Mid Face Series is used.
These are:
1. PA View / Occasionally AP if patient can't lie prone
2. Lateral Facial View
3. SMV
4. 30o of OMV or Waters View

 Hristina Mihailova 2008 standardized the Xray methods for diagnosis of isolated
mandibular fractures into different projections
of the mandible named mandibulo facial
series.
It includes the following projections
methods :
1. PA View/ en face
2. Oblique View of Rt Mandible
3. Oblique View of Lt Mandible
4. OMV

and

 If in the emergency department

panoramic view of X-ray is available,
the mandibulo facial series can
include :
1. PA View/ en face
2. OPG
3. OMV

Fig. 1 - OPG having fracture of symphysis and bilateral condylar

fracture of mandible

Fig. 2 - Lateral view of face showing

fracture of body of mandible

Fig. 3 - PA view of mandible

showing fracture of body of
mandible

Fig-4 Submento vertex view

showing fracture of zygomatic
arch

Fig. 5 Occipitomental view

radiograph showing zygomatic
complex fractures

Additional consideration
In case where missing teeth, perform
a chest X ray to evaluate for
aspiration
Cervical spine fractures are present
in approximately 2% of patients with
mandibular fractures and should be
evaluated routinely

 For the imaging of mandibular

fracture with suspected cervical
spine fracture PA view supported by
lateral oblique view of the fracture
side provide sufficient information
If the patient is unconscious then
axial, coronal and 3-D CT should be
prescribed.

Midface fractures
Plain radiographs are useful in initial
evaluation of suspected mid face fracture
as is dental panoramic tomography for
suspected mandibular fracture
In our experience for the imaging of mid
face fracture plain X-ray OMV and SMV
provide sufficient information. These views
can be supplemented by axial, coronal cuts
with 3-D CT for detailed information.

Computed tomography
The application of computer processing to the
principles
of
tomography
by
Godfrey
Hounsfield and Allan M. McCormack resulted
in
the
introduction
of
computerized
tomography (CT) in the late 1970s and 1980s
CT was the first technology capable of
allowing visualization of both hard and soft
tissues of the facial bones by image
processing enhancement

 Markowitz et al found coronal CT to be the

most accurate method in the diagnosis of
mandibular fractures, followed by mandibular
series and panoramic radiography.
Interestingly they found axial CT detected
significantly fewer angle fractures (60%) than
standard radiographs (98%) and coronal CT
(100%) and identified lack of fracture
CT scan become the standerd of care for
imaging paediatric maxillofacial trauma

 CT is the modality of choice for the evaluation of

complex facial fractures, especially those
involving the frontal sinus, nasoethmoidal region
and the orbits
Kapil Saigal (2005) found 3-D CT as most useful
in imaging comminuted fracture of the middle
third of the face and zygomatico maxillary
complex
CT provides the highest accuracy for not only for
the identification of fractures involving disruption
of the orbital rim, but in soft tissue assessment in
orbital blow-out and blow-in fracture

 Rhea et al (1991) also observed that 3D

images provided an easy detection of
specific characteristics of facial asymmetries,
midface defects and skull vault defects, and
a clear localization of fractures associated
with extensive bone displacement
The 3D
image displays the spatial
relationships of dislocated fracture segments
and provides surgeons with graphic displays
of the actual anatomic presentation that
guides us in treatment planning and surgical
approach in the operating room

Fig.6 - CT coronal cut image of

face showing right orbital floor
fracture

Fig. 7 Axial CT cuts

of midface showing
left lateral wall of
orbit & floor of left
orbit fractures

Fig 8. 3-D reconstruction of mid face showing zygomatic

complex fracture

 Additional consideration
A CT of head is obligatory if the
patient has sustained a loss of
consciousness due to trauma

Ultrasonography
Ultrasonography has been proposed
as a complementary diagnostic
procedure to augment CT in the
assessment of patients with midfacial
fracture, as ultrasonography is easy
and quick to be performed; it is
noninvasive and free of any risks

 Restricted to fractures of the orbital

margin and nasal bone, zygomatic arch,
and the anterior wall of the frontal sinus
Unable to provide true coronal scans and
unable to detect nondislocated fractures
Kleinheinz et al proposed using the
modality
for
the
evaluation
of
subcondylar
fractures
not
directly
accessible for direct clinical examination

 Maha Sallam et al (2010) found that

the sonography is a reliable method
as an imaging modality in cases of
suspected midfacial fractures
The displaced fracture of orbit
zygomatic arch and malar bone were
better seen in sonography than
undisplaced fractures

Cone beam CT
The increasing use of CT in imaging carries the risk of
patient overexposure to radiation
Exposure minimization is more important for children
and young adults
The development of Cone Beam CT (CBCT) reduces
exposure by using lower radiation dose; compared to
conventional CT
CBCT in maxillofacial imaging produces 8- to 10-fold
lower effective dose than a conventional CT examination
using standard protoco

Magnetic Resonance Imaging

(MRI)
MRI is the technique of choice in the
evaluation of Temporomandibular joint
pathology
Excellent soft tissue contrast resolution
makes it ideal for the detection of internal
derangement of the joint
Cardiac pacemakers and other implanted
electronic devices are contra indications for
MRI.

Stereo Lithography (SL)

Emerging as a potentially important adjunct
for
treatment
planning
in
complex
maxillofacial trauma
The advantages of this technology include
facilitating anatomical reduction, minimizing
surgical approaches, saving operating time by
facilitating
preoperative
selection
and
adaptation of bone plate, and potentially
leading to improved postoperative results

Conclusion
Imaging is and will stay as an adjunct
to help and document the diagnosis
and these aids should never be
considered as a replacement to through
clinical examination
There
is
no
current
universally
accepted diagnostic algorithm to assist
imaging selection in maxillofacial
trauma

TERIMA KASIH