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
9.
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
15.
16.
17.
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
21.
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
24.
25.
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
27.
28.
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