Maxillofacial Trauma
DR KIPTOO
FACILITATOR: DR
SITIENEI
overview
 Imaging
modalities
 Radiological anatomy
 Systematic inspection of the
radiographs
 Particular injuries
Imaging modalities
 Plain
radiographs
 Ct scans
 others
Plain radiographs
The number of routine projections varies
between hospitals.
 Occipitofrontal (OF) view
-forehead on the cassette.
-radiographic baseline at right
angles to the film.
-centre to the glabella
-x-ray beam angled 5 degr caudad
to show the petrous bone within the orbit.
-20 degr caudad to project the
petrous bone bellow the orbit.

Plain radiographs cont
 Lateral
-radiographic baseline is horizontal
and parallel to the cassette.
-centre to the zygomatic bone.
-lateral view should be taken with
a horizontal beam in order to show
free fluid in the air sinuses.
Occipitomental view.
 Most
useful view for the evaluation of
facial bone injuries.
-chin/nose are in contact with the
cassette.
-radiographic baseline is at an
angle of 45 degr to the vertical.
-centre to the lower orbital
margin.
Occipitomental view
30 degr Occipitomental view

Over tilted view.
-centre to the
lower orbital
margin.
-the tube is angled
30 degr caudad.
-this view provides
the best
demonstration of
the zygomatic
arches and the
walls of the
maxillary antra.
Orthopantomogram(OPG)
Used for imaging
of the mandible.
 It gives
‘unwrapped view
of the mandible.
 It reveals almost
all mandibular
fractures.

P/A mandible
 Technique:
-forehead is in contact with the
cassette.
-RBL is perpendicular to the
cassette.
-midline x-ray beam at the level of
the angles of the mandible.
-collimate the beam to include the
mandibles.
P/A of the mandible



The condyles are
difficult to see
because of
superimposition of
bones.
The body of the
mandible is displayed
well.
Used to identify
additional after OPG
has shown one abnor
Nasal bones
 Lateral
non-screen films are used.
 A small aperture and centre to the
nasion.
 Superior-inferior projection:
-pt sits/or lies with the chin raised.
-an occlusion film is placed
between the teeth.
-centre-right angles to the film.
Radiological anatomy
 OM
projections is used for our
purposes. It gives minimal overlap of
bones.
 Superior and inferior orbital margins.
 Frontal sinuses
 Zygomatic arches
 Maxillary antra
Anatomy cont


Zygomatic
arches,
frequent sites
of injury, are
easy to
identify.
Each arch may
be likened to
an elephant
trunk.
Systematic inspection of OM views
 Fractures
of the middle third of the
face are classified according to the
Le Forte fracture patterns.
 This is particularly useful for
maxillofacial surgeons when planning
treatment.
 In general practice a simpler
classification (McGrigor’s) concept is
used.
McGrigor’s three lines
normal om view
McGrigor’s line 1
Trace the line
through the
synchondrosis
and across
the forehead.
 Compare the
injured and
uninjured
sides.

McGrigor’s line 1

Look for:
-fractures.
-Widening of
zygomatico-frontal
suture.
-Fluid levels
(haemorrhage) in
the frontal sinus.
Line 2
Trace a line
upwards along
the superior
border of the
zygomatic
arch(up the
elephant’s
trunk).
 Continue on the
inferior margin of
the orbit and
over the bridge
of the nose.

Line 2

Look for:
-fractures of the
zygomatic arch.
-fracture through
the inferior rim of
the orbit
-soft tissue
shadow in the roof
of the maxillary
antrum(blow out
fracture)
Line 2
Tracing
McGrigor’s line
2 reveals a step
(fracture) in the
normal curve of
the left
zygomatic arch
(elephant’s
trunk)
 Compare with
the normal right
arch.

Line 3
Trace along the inferior
margin of the zygomatic
arch.
(under the elephant’s
trunk).
Lateral wall of the
maxillary antrum.
Inferior margin of the
antrum.
Across the maxilla. Plus
the
roots of the upper teeth.

Line 3
Look for:
-fractures of the
zygoma and of the
lateral aspect of the
maxillary antrum.
-fluid level in the
maxillary antrum.
In the context of trauma
assume that fluid level
represents
haemorrhage from a
fracture.

Line 3

Tracing line
3 reveals
fractures of
the right
zygomatic
arch and of
the lateral
wall of the
maxillary
antrum.
The midface injuries
 An
isolated fracture of the zygomatic
arch is a common finding.
 Isolated fractures through the
zygomatico-frontal suture, or
through the body of the zygoma, are
rare.
 Fractures often occur as part of a
combination injury known as a tripod
fracture.
Tripod fractures.
 This
comprises:
-widening of the zygomatico-frontal
suture
-a fracture of the zygomatic arch.
-a fracture through the body of the
zygoma. This is seen as a break in
the inferior margin of the orbit and a
break in the lateral wall of the
maxillary antrum.
Tripod fractures
 Cause-
often direct blow to the malar
eminence.
 Clinical features:
-loss of sensation below the orbit
-facial deformity
-diplopia/ ophthalmoplegia
-deficient mastication
Tripod fracture

On the OM view,
the fracture
through the body
of the zygoma will
appear as
fractures through
the inferior wall of
the orbit and
through the
lateral wall of the
maxillary antrum.
Tripod fracture
OM radiograph.
 Right tripod
fracture.

Tripod fractures
Blunt trauma.
Complex zygo
maxillary fractures.
 CT scans show
disrupted walls of
the left antrum.
The globe is
haemorrhagic and
ruptured.

Tripod fractures

Coronal scans.
Fractures of orbital
rim and floor.
Tripod fractures

Three dimensional
images show the
fracture lines.
The orbital walls: blow-out fractures
 The
orbital margin is made up of
strong, thick bones that protect the
orbital contents.
 Fractures of the orbital margin may
occur in isolation or may be part of
a more complicated fracture such as
tripod type.
 An isolated fracture of the margin
usually involves the inferior and
lateral aspects.
Blow-out fractures
Results from
direct
compressive
force to the
globe.
 A fist or a
small object
such as a
squash ball is
often the
culprit.

Blow-out fractures
The strong inferior rim remains intact.
 The walls fracture at the weakest margins.
-these are; the floor (roof of max
antrum),
and the medial wall of the orbit( the
lateral margin of the ethmoid sinus).
 Some of the orbital contents may herniate
downwards through the orbital floor. This
may give a teardrop sign.
 Tear drop may be the only radiological
evidence of a blow-out fracture.

Blow-out fracture.
The soft tissue
teardrop in the
roof of the
maxillary antrum.
 Herniation through
the medial wall of
the orbit into the
ethmoid sinus
commonly occurs
but is difficult to
detect on the plain
radiographs.

Blow-out fractures

Soft tissue
(the tear
drop) is seen
hanging from
the roof of
the left
maxillary
antrum.
Blow-out fracture
 Sometimes
a fracture through the
walls of the maxillary or ethmoid
sinus may only be inferred because
air from a sinus has entered the
orbit.
 The air may be seen on the
radiograph above the globe, giving
rise to the “black eyebrow sign”
Isolated blow-out fractures





Tear drop in antrum
Fluid level in antrum
Thin plate of bone
from the orbital floor
displaced into the
antrum
Black eyebrow sign
Opaque(blood filled)
ethmoid sinus.
Orbital fractures
Blunt
trauma.
 The
posterior
portion of
inferior
rectus is
pulled
down into
the
maxillary
antrum
with the
fracture
fragments

Orbital fractures
Medial wall
fracture.
 Opacificatio
n of ethmoid
air cells.
 Enlarged
medial
rectus from
haemorrhag
e.

The mandible
The mandible should be regarded as a
rigid ring of bone.
 When a bone ring is broken it is very
common for a second fracture to occur.
 Approximately 50% of mandibular
fractures are bilateral.
 Fractures of the body and angle of the
mandible are particularly common.(70%)

The mandible cont
 The
mandibular condyles must be
carefully scrutinized. Fractures occur
frequently at these sites.(18%).
 Symphysis menti fractures account
for 10% of the cases.
 Coronoid process fractures=2%
 It is important that radiological
evaluation is correlated with the
precise site of clinical injury.
The mandible


OPG shows a
fracture
through the
body of the
mandible on
the right side.
There is a
second
fracture
through the
left angle of
the mandible.
The mandible cont

OPG
shows
two
fractures.
PA view
reveals a
third
fracture
through
the left
condyle.
Mandible cont

Pitfall:
-occasionally OPG will fail to show a
fracture.
-the Symphysis is a particularly difficult
site
-a near normal appearance may be seen
when fragments override each other.
-clinical correlation must apply when OPG
view appears normal.
Le Fort fractures

All Le Fort fractures involve the pterygoid
process.
-Le Fort 1:transverse maxillary fracture
caused by a blow to the premaxilla.
-fracture line: alveolar ridge
lateral aperture of nose
inferior wall of maxillary
sinus
-detachment of alveolar process of the
maxilla occurs.
Le Fort II
 Referred
to as ‘pyramidal fracture’.
fracture line: forms an arch through,
-posterior alveolar ridge
-medial orbital rim
-across nasal bone
Separation of the midportion of the
face occurs.
Le Fort III
Also called ‘craniofacial disjunction’
-fracture line: takes a horizontal course.
-nasofrontal suture
-maxillofrontal suture
-orbital wall
-zygomatic arch.
Separation of the entire face from the base
of the skull occur.

Le Fort fractures cont
Comminuted
fracture through
the ethmoid and
bridge of the nose
with posterior
displacement.
 Fracture lines
cross the region of
crista galli and
cribriform plate.

Le Fort
Anterior and
posterior walls
of the frontal
sinus are
fractured.
 Note
pneumocephal
us

Le Fort

Fracture
involves
the right
zygomatic
arch and
both
maxillary
sinuses.
Le Fort

The pterygoid
plate is
fractured on
the right.
Injuries to the midface and orbit
key points
 Concentrate
on the OM views.
-note the elephant trunk appearance
of each zygomatic arch.
-trace the three McGrigor’s lines.
Look for bone and soft tissue
abnormalities.
-compare the injured side with the
normal side.
Key points
 Tripod
fracture: if you see any one of
the components of this fracture
complex then look for the other
associated fractures.
 With an isolated blow out fracture
look for a soft-tissue teardrop in the
roof of the maxillary antrum. Do not
expect to see a bone abnormality.
Injuries to the mandible.
Key points
 Regard
the mandible as a bone ring.
-solitary fractures do occur, but two
fractures are common.
 The OPG view detects almost all
fractures.
-but the sensitivity is not 100%.
-if clinical worry persists, additional
views should be obtained.