Presented by M.A. Kaeser, DC
Spring 2009

Basic Facial Series
 Three films
 Waters view – PA view with cephalad angulation
 This is the most consistently helpful view in facial trauma
 Caldwell view – PA view
 Lateral view
A fourth film may be warranted
Submentovertex view – through the foramen magnum

 Look at orbits carefully
 60-70% of all facial fractures involve the orbit
 Know the most common patterns of facial fractures and look for them
 Bilateral symmetry can be very helpful
 Carefully trace along the lines of Dolan when examining the Waters view in a facial series

 Three anatomic contours
 The 2 nd and 3 rd lines together form the profile of an elephant

Direct Radiographic Signs of Facial
Fractures
 Nonanatomic linear lucencies
 Cortical defect or diastatic suture
 Bone fragments overlapping causing a
“double-density”
 Asymmetry of face

Indirect Radiographic Signs of
Facial Fractures
 Soft tissue swelling
 Periorbital or intracranial air
 Fluid in a paranasal sinus







Auto accidents – 70% of auto accidents produce some type of facial injury (most are limited to soft tissue)
Fights/Assaults
Falls
Sports
Industrial Accidents
Gunshot Wounds
*Less than 10% of all facial fractures occur in children









Zygomaticomaxillary complex – AKA Tripod fracture = 40%
LeFort I = 15%
LeFort II = 10%
LeFort III = 10%
Zygomatic arch = 10%
Alveolar process of maxilla = 5%
Smash Fractures = 5%
Other = 5%

 Most common facial fracture
 Usually occurs as a diastasis of the zygomaticofrontal suture



Complex, bilateral fracures associated with a large unstable fragment
Involve the pterygoid plates

Three Main Planes of Weakness in the Face
 Maxillary Plane
 Between the maxillary floor and the orbital floor
 Subzygomatic or Pyramidal Plane
 MOI = down ward blow to the nasal area
 Craniofacial Plane
 Uncommon as an isolated injury
 Occurs in association with severe skull and brain injuries

 Usually due to a blow from the side of the face
 Cause flatness of the lateral cheek area, inability to open mouth

 Associated with several fractured teeth
 Chest film should be taken if all teeth are not accounted for

 Severe comminution of the face
 Underlying skull injury is likely



 MOI – blow to the eye, forces are transmitted by the soft tissues of the orbit downward to the thin floor of the orbit
Symptoms – enophthalmos and diplopia (usually an upward gaze)
24% are associated with ocular injury

 Most commonly missed facial fracture
 Most frequently injured facial structure
 Most nasal bone fractures will run perpendicular to the bridge of the nose
 May be associated with more extensive injuries
 Orbital rim or floor
 Ethmoid or frontal sinuses

 Clinical findings
 Facial distortion
 Malocclusion of the teeth
 Abnormal mobility of portions of the mandible or teeth

Ring Bone Rule – AKA Pretzel-Bagel
Spectrum
 If you see a fracture or dislocation in a ring bone or ring bone equivalent, look for another fracture or dislocation

Common Sites of Mandibular
Fractures and Prevalence
 Body
 Angle
 Condyle
 Symphysis
 Ramus
 Alveolar
 Coronoid Process
30-40%
25-31%
15-17%
7-15%
3-9%
2-4%
1-2%

 Usually contralateral sides of the symphysis
 Common combinations include:
 Angle plus the contralateral body or condyle




May occur spontaneously during a large yawn
Considerable pain
Condyle (c) is anterior to the articular eminence (e)

Important Thoughts About
Mandibular Fractures






Remember the ring bone rule
Symphyseal fractures can be hard to see
Panorex view provides the best single view of the mandible
Look carefully along the cortical margin of the whole mandible for discontinuities
Carefully examine the mandibular canal for discontinuities
Pathologic fractures can occur in the mandible – look for tumors or abscesses