ROLE OF MULTIDETECTOR SPIRAL-CT
IN THE MANAGEMENT OF MAXILLOFACIAL TRAUMATIC LESIONS
S.BELABBES, M.FIKRI, M.R.EL HASSANI, M. JIDDANE
Department of Neuroradiology. Speciality Hospital. Rabat.
Morocco
HN9
INTRODUCTION
 The facial traumatisms are a common reason for




recourse to the care in emergency
Young adults+++
circumstances of occurrence: roads accidents+++,
agressions+++, falls, sports accidents, work accidents.
Multiple functional and aesthetic impacts, rarely vital( if
associated with brain and cervical lesions).
spiral CT has an important place in the exploration of
facial trauma
INTRODUCTION
 The objectives of imaging:
 Identification of fractures, irradiation and their
potential displacement
 Lesional type classification
 Research of lesions potentially serious, requiring
rapid intervention
 Research of associated extra-facial lesions
(cervical spine, brain ...)
MATERIALS and METHODS
 retrospective study of 45 cases of maxillofacial
traumatisms seen in emergencies and sent to the
Department of Neuroradiology for evaluating
 All our patients underwent CT in helical acquisition
with multiplanar reconstruction and 3D
Results
 The age of our patients was between 16 and 60
years.
 Sex-ratio: 4m/1w
 different CT aspects were found: Fractures of the
orbit (floor, roof and lamina papyracea), fracture of
the zygomatic process, sinus fracture, mandibular
fracture (body, ramus and mandibular condyle),
naso-ethmoido-maxilo-fronto-orbital complex
fracture and Le fort fractures
DISCUSSION
Pathophysiology-biomechanics
Buttress anatomy: line diagram showing important facial buttresses.
Vertical Buttresses
1. Nasomaxillary
2. Zigomaticomaxillary
3. Pterygomaxillary
4. Vertical mandible
Central box:
Nasal cavity+ethmoid
Side boxes:
maxillary sinuses +
orbits
Horizontal Buttresses
A. Frontal Bar
B. Inferior orbital rim
C. Hard palate
 Major resistance in the vertical axis
 Low resistance to horizontal constraints (antero-posterior and lateral)
 Fractures perpendicular to the pillars
DISCUSSION
CT semiology
 Indirect signs:
• Swelling, soft tissue deformation
• Fluid in a paranasal sinus,
• Subcutaneous emphysema, pneumoencéphalie,
• pneumo-orbit
 Direct signs:
• nonanatomic linear lucencies
• cortical defect or diastatic suture
• bone fragments overlapping causing a "doubledensity"
• asymmetry of face
CT Indirect signes
 Fluid in a paranasal sinus(
)
 Subcutaneous emphysema(
)
• Pneumoencéphalie( )
• pneumo-orbi (
)
Given these signs, facial fracture is
strongly suspected
 Make reconstructions
with filter "hard" focused on
the facial
 Helping if necessary by
3D reconstructions
DISCUSSION
Classification
 Isolated fractures:
 Fracture of the nose
 Fracture of the zygomatic arch
 zygomaticomaxillary fracture
 Fracture of the mandible
 Fracture of the frontal sinus
 complex fractures
 Transverse fractures of the face (Le fort I, II, III)
 Centro-facial fractures
Simple Fractures
Fractures of nasal bone and nasal pyramid
 The most common
traumatic damage of the
facial bone
 Easy diagnosis clinically
 X ray is usually sufficient(
lateral view)
 Emergency: In case of
nasal septum hematoma
Fracture of nasal bone
fracture of the nasal septum
(
) (risk of hematoma)
Simple Fractures
Zygomatic arch fracture
 Can be identified in Hirtz
‘s incidence
 Risk of blockage of the
temporomandibular
joint by:
 hematoma of the
temporal muscle
 fracture of the
coronoid process of
the mandible
Simple Fractures
Zygomaticomaxillary fracture
(Zygomatic tripod fracture)
 Latero-facial fracture is the most common
 Detaches the zygomatic bone of the maxilla,
orbit and temporal bone
 Combines:




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1. zygomatico-frontal disjunction
2. temporo-zygomatic disjunction
3. zygomatico-maxillary fracture
4. fracture of the zygomatic arch
5. fractures of the anterior and posterolateral maxillary sinus wall
 Posterior extension: floor and side walls of the orbit, apex orbital
and sphenoid body
 Complications:



Orbital (hematoma, incarceration or muscle plug)
Nerve (infraorbitalduct injury)
Masticatory ( temporalis muscle plug)
Simple Fractures
Zygomaticomaxillary fracture
(Zygomatic tripod fracture)
Right zygomatic tripod fracture with
the involvement of the nasolacrimal
duct(
) and lateral orbital wall
causing lateral rectus
plug(
)
Simple Fractures
Zygomaticomaxillary fracture
(Zygomatic tripod fracture)
Left zygomatic tripod fracture with
involvement of the infraorbital
canal(
)
Fracture of orbital floor
with inferior rectus plug by
a bone splinter( )
Simple Fractures
Fracture of the mandible
 Fracture of the toothed portion and processes condylar
 reaching the mental foramen
 Fracture of the toothed maxillary or mandibular portion:
open fracture
 IT should always a seek joint damage (TMJ) associated
sub-condylar Fracture (extra articular)
Condylar fracture (intra articular)
Risk of ankylosis
Simple Fractures
Fracture of the mandible
Distribution of mandibular fractures in order of frequency
Simple Fractures
Fracture of the mandible
Forces acting on the mandible
and the relationship between
muscle pulls and fracture
angulation.
A: Horizontally unfavorable.
B: Horizontally favorable.
C: Vertically unfavorable.
D: Vertically favorable.
Simple Fractures
Fracture of the mandible
Transverse fracture of the
alveolar portion of the
mandible
Simple Fractures
Fracture of the mandible
unfavorable Para-symphyseal
right fracture associated with
left condylar fracture
Simple Fractures
Fracture of the mandible
Bilateral para-symphyseal
fracture with depression of
the intercalary fragment
associated with a right
condylar fracture
Simple Fractures
Fracture of the frontal sinus
Clinical classification
 Anterior table
 Displaced
 Un-displaced
 Posterior table
 Displaced
 Un-displaced
 Anterior and posterior table
 Displaced
 Un-displaced
 Nasofrontal duct
 Involved
 uninvolved
Simple Fractures
Fracture of the frontal sinus
Simplified Clinical Classification
1. Fracture of anterior table
2. Fracture with disruption of posterior wall
1. Fracture involving floor of the sinus
Simple Fractures
Fracture of the frontal sinus
transfixing fracture of the frontal
sinus with involvment of orbital roof
Complex Fractures
Transverse fractures of the face
Lefort fracture
The LeFort I (Low-level fracture):
 runs between the maxillary floor and
the orbital floor.
 It may involve the medial and lateral
walls of the maxillary sinuses and
invariably involves the pterygoid
processes of the sphenoid.
 Clinically, the floating fragment will
be the lower maxilla with the
maxillary teeth.
Complex Fractures
Transverse fractures of the face
Lefort fracture
The LeFort II(Pyramidal fracture):
 fracture crosses the nasal bones on
the ascending process of the
maxilla and lacrimal bone and
crosses the orbital rim.
 highest incidence of infraorbital
nerve hypesthesias.
 extends posteriorly to the
pterygoid plates at the base of the
skull.
Complex Fractures
Transverse fractures of the face
Lefort fracture
The LeFort III(Craniofacial dysjunction):
 Fracture traverses
 the frontal process of the maxilla,
 the lacrimal bone,
 the lamina papyracea,
 and the orbital floor.
 Often involves the posterior plate of the
ethmoid.
 Highest rate of cerebrospinal fluid (CSF)
leaks
Complex Fractures
Transverse fractures of the face
Right
Lefort II
Lefort I
Lefort III
Complex Fractures
Centro-facial fractures
fracture of naso-ethmoïdo-maxillo-fronto-orbital complex
 The nasal bones
 Nasal septum
 The ethmoid (including the cribriform plate)
 The naso-frontal channels
 The frontal process of maxilla
 Orbital walls
 The frontal sinus
 High risk of osteo-dural breach by fracture of the
posterior wall of the frontal sinus, the cribriform plate
and roof of the ethmoid
 Possible association with other fractures including
Lefort
Complex Fractures
Centro-facial fractures
fracture of naso-ethmoïdomaxillo-fronto-orbital
complex
CONCLUSION
 One must bear in mind that facial
traumatism is above all a head trauma and
cervical spine
 The CT is the key in the exploration of facial
trauma
 The radiological must make an exhaustive
study of the lesions
 Indicate severe lesions requiring supervision
or an urgent care