1. Imaging of Facial Trauma
Part 1: Introduction and Anatomy
Rathachai Kaewlai, MD
www.RadiologyInThai.com
Created: January 2007
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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
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3. Epidemiology
 Etiology (USA)
 Motor vehicle collision (MVC) most common cause
 Followed by fights, assaults
 Less common: fall, sports activities, industrial accidents, gun shot wounds
 Soft tissue injury is more common than fracture
 Co-existence of other injury
 3-14% of patients with facial fracture have skull fractures
 1-4% of patients with facial fracture have cervical spine fractures
 20% of patients with cervical spine fractures have facial injury (half soft tissue
injuries, half fractures)
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4. Epidemiology
 Distribution of fracture
 Vary with mechanism of injury
 In general, most common facial fracture is nasal bone fracture
 Most common fracture in admitted patients is zygomatic
complex (ZMC) fracture at 40%, followed by complex fractures
such as LeFort fracture
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5. Epidemiology
 Facial fracture in children
 Less common (< 10% of all facial fractures occur in children)
 Less severe than adults
 Most common etiology is fall
 Reasons: midface is less prominent, sinuses are less
pneumatized, more elasticity of bones
 Fractures that are more frequent in children than in adults
 Mandibular condyle
 Orbital roof
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6. ABC of Trauma
 Initial patient management is to secure airway (A), breathing (B) and
circulation (C)
 Evaluation of more serious injuries of the head, chest and abdomen
 Avoid blind insertion of endotracheal tube and nasogastric tube
 Significance of facial trauma for the initial management
 Facial fractures may impinge on oral or nasal airway
 Nasal bleeding may be life threatening
 Mandible fractures may cause loss of support for tongue, then airway
compromise
 Facial fractures may compromise vision
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7. When to Do
Imaging of the Face?
 When the patient is stabilized
 Clinically (Airway, Breathing, Circulation - stable),
 Initial goal is to preserve life - then later restore the form and
function of the face
 Cervical spine clearance
 Radiographically
 For cervical spine clearance
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8. When to Do
Imaging of the Face?
 Head CT should be thoroughly evaluated in a multi-trauma
patients
 Search for critical, emergent finding: some facial injuries may
compromise vision if not immediately recognized
 In stable patient, face CT can be performed with little
additional time when the patient is already in the scanner
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9. What Imaging to Do?
 Role of imaging
 Identify fractures, fragment displacement and rotation, stable bone
for use in surgical repair
 Identify soft tissue injuries
 CT is the imaging modality of choice because
 High accuracy for evaluation of both bony and soft tissue injuries
 Can be cost-saving screening exam when compared to multiple
views of plain film radiography*
 Radiation dose is far below the threshold for cataract formation
*Turner BG et al. AJR Am J Roentgenol 2004;183:751-754
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10. Normal Anatomy
 Face
 Face (midface) is the region
from supraorbital rims to
and including maxillary
FACE
alveolar process
 Mandible, including the
temporomandibular joints
(TMJ), considered separate
from the face
 This lecture series will
include both parts (face and
mandible)
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11. 3D CT
Anterior View
Major structures
are labeled in the
picture.
 Nasofrontal suture
 Zygomatico-
frontal suture
 Zygomatico-
temporal suture
SOF = Superior orbital
fissure
IOF = Inferior orbital
fissure
Orbital ‘rim’ is different
from the ‘wall’
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12. 3D CT
Left Lateral View

 Nasofrontal suture
 Zygomatico-frontal suture
 Zygomatico-temporal suture
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13. 3D CT
Base View
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14. Computed Tomography (CT)
 Preferred modality for imaging of the face
 More sensitive for fracture detection
 Show significant soft tissue injury, especially the globe
 Easier to perform, quicker than complete views of plain film
radiographs
 Pre-surgical planning for complex injuries
 Disadvantage of CT
 CT can miss subtle tooth fracture along the axial plane,
additional orthopanthogram may be helpful to detect tooth
fracture
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15. Computed Tomography (CT)
 CT protocol
 Axial scanning from above the frontal sinus down to below
hard palate (face), and can be scanned further to include the
mandible, if there is a clinical suspicion for fracture of
mandible
 For helical (spiral) scanner, axial images can be reconstructed
to coronal and sagittal planes without the need for direct
coronal scanning
 Viewing in both bone and soft tissue windows, in 3 planes
(axial, coronal and sagittal)
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16. • Posterior wall of
frontal sinus fracture
may co-exist with brain
injury
• Presence of
pneumocephalus
signifies dural tear
related with the fracture
• Inferior part of frontal
sinus constitute the
medial orbital wall
Key structures
A = Frontal sinus, anterior wall
B = Frontal sinus, posterior wall
*Note: The right frontal sinus is not pneumatized in this case.
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17. 
Key structures
D = Orbit, medial wall
E = Orbit, lateral wall
F = Suture between
sphenoid and zygomatic
bones
= Nasomaxillary
suture
1 = Globe
2 = Ethmoid sinus
3 = Sphenoid sinus
4 = Nasal bone
5 = Maxilla, frontal
process
• Do not misinterpret the suture between nasal bone and frontal process of 6 = Orbit, lateral rim
maxilla for a fracture 7 = Sphenoid bone
• Look for a piece of fracture in the optic foramen, it is the true emergency of 8 = Optic foramen
facial fracture
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18. Key structures
F = Groove for
infraorbital nerve
G = Maxillary sinus,
posterolateral wall
5 = Maxilla, frontal
process
9 = Maxillary sinus
10 = Zygomatic arch
11 = Pterygoid bone
12 = Nasolacrimal duct
13 = Mandible, condyle
Clear maxillary sinuses
can almost rules out
certain fractures such as
ZMC, LeFort, blowout
fractures
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19. Key structures
H = Maxillary sinus,
anterior wall
I = Maxillary sinus,
medial wall
J = Medial pterygoid
plate
K = Lateral pterygoid
plate
9 = Maxillary sinus
14 = Mandible, ramus
Fracture of the
pterygoid plates may
represent LeFort
fracture
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20. Key structures
J = Medial pterygoid
plate
K = Lateral pterygoid
plate
L = Maxilla, spine
14 = Mandible, ramus
15 = Maxilla bone/ hard
palate
Lucency in midline of
the maxilla is a normal
finding seen
occasionally
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21. Coronal
Reformatted Image
Key structures
L = Maxilla, spine
= Nasomaxillary suture
4 = Nasal bone
5 = Maxilla, frontal process
• Do not confuse nasomaxillary suture for a fracture
• Remind yourself that CT can miss subtle tooth fracture,
although with the coronal and sagittal reformation. Obtain
orthopanthogram or dedicated tooth film when in doubt
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22. Key structures
D = Orbit, medial wall
M = Nasal septum
5 = Maxilla, frontal process
15 = Maxilla bone/ hard palate
16 = Frontal sinus
17 = Mandible, body
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23. Key structures
M = Nasal septum
N = Ethmoid bone,
perpendicular plate
O = Orbit, roof
P = Orbit, floor
Q = Maxillary sinus,
posterolateral wall
 = Zygomatico-frontal
suture
1 = Globe
2 = Ethmoid sinus
6 = Orbit, lateral rim
9 = Maxillary sinus
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24. Key structures
J = Medial pterygoid
plate
K = Lateral pterygoid
plate
N = Ethmoid,
perpendicular plate
3 = Sphenoid sinus
10 = Zygomatic arch
14 = Mandible, ramus
18 = Mandible, angle
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25. Sagittal Reformatted Image
Key structures
R = Temporomandibular joint (TMJ)
13 = Mandible, condyle
14 = Mandible, ramus
19 = Mandible, coronoid process
20 = Mastoid air cells
If patient opens his/her mouth during the
scan, there is a normal anterior gliding of
the mandibular condyle relative to the
glenoid fossa. That can look like
subluxation of the TMJ
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26. Key structures
P = Orbit, floor
7 = Pterygoid bone
9 = Maxillary sinus
15 = Maxilla bone /hard
palate
• Orbital blowout fracture is
best seen in sagittal and
coronal images
• Facial CT is not
completed without image
(2D) reformations
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27. Key structures
3 = Sphenoid sinus
4 = Nasal bone
15 = Maxilla bone/
hard palate
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28. CT Orthopanthogram
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29. Axial Coronal
Sagittal
Right Orbit, soft tissue window
Key structures:
ON = Optic nerve MR = Medial rectus
LR = Lateral rectus IOL = Intra-ocular lens
• Globe contour should be smooth
• Clean (dark) retro-bulbar fat
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30.  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.
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