Facial and Mandibular FracturesPresented by M.A. Kaeser, DCSpring 2009

Basic Facial Series

Three filmsWaters view PA view with cephalad angulation This is the most consistently helpful view in facial traumaCaldwell view PA viewLateral view

A fourth film may be warrantedSubmentovertex view through the foramen magnum

Simple RulesLook at orbits carefully60-70% of all facial fractures involve the orbit Know the most common patterns of facial fractures and look for themBilateral symmetry can be very helpfulCarefully trace along the lines of Dolan when examining the Waters view in a facial series

Lines of DolanThree anatomic contoursThe 2nd and 3rd lines together form the profile of an elephant

Direct Radiographic Signs of Facial FracturesNonanatomic linear lucenciesCortical defect or diastatic sutureBone fragments overlapping causing a double-densityAsymmetry of face

Indirect Radiographic Signs of Facial FracturesSoft tissue swellingPeriorbital or intracranial airFluid in a paranasal sinus

MOIsAuto accidents 70% of auto accidents produce some type of facial injury (most are limited to soft tissue)Fights/AssaultsFallsSportsIndustrial AccidentsGunshot Wounds

*Less than 10% of all facial fractures occur in children

Fracture Types and PrevalenceZygomaticomaxillary 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%

Tripod FractureMost common facial fractureUsually occurs as a diastasis of the zygomaticofrontal suture

LeFort FracturesComplex, bilateral fracures associated with a large unstable fragment Involve the pterygoid plates

Three Main Planes of Weakness in the FaceMaxillary Plane Between the maxillary floor and the orbital floorSubzygomatic or Pyramidal Plane MOI = down ward blow to the nasal areaCraniofacial Plane Uncommon as an isolated injuryOccurs in association with severe skull and brain injuries

Zygomatic Arch FractureUsually due to a blow from the side of the faceCause flatness of the lateral cheek area, inability to open mouth

Alveolar Process of MaxillaAssociated with several fractured teethChest film should be taken if all teeth are not accounted for

Smash FractureSevere comminution of the faceUnderlying skull injury is likely

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

Nasal Bone FractureMost commonly missed facial fracture Most frequently injured facial structureMost nasal bone fractures will run perpendicular to the bridge of the noseMay be associated with more extensive injuriesOrbital rim or floorEthmoid or frontal sinuses

Mandibular FracturesClinical findingsFacial distortionMalocclusion of the teethAbnormal mobility of portions of the mandible or teeth

Ring Bone Rule AKA Pretzel-Bagel SpectrumIf 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 PrevalenceBody30-40%Angle25-31%Condyle15-17%Symphysis7-15%Ramus3-9%Alveolar2-4%Coronoid Process1-2%

Mandibular Fractures

Mandibular Fractures

Double Mandibular FracturesUsually contralateral sides of the symphysisCommon combinations include:Angle plus the contralateral body or condyle

Mandibular DislocationMay occur spontaneously during a large yawnConsiderable painCondyle (c) is anterior to the articular eminence (e)

Important Thoughts About Mandibular FracturesRemember the ring bone ruleSymphyseal fractures can be hard to seePanorex view provides the best single view of the mandibleLook carefully along the cortical margin of the whole mandible for discontinuitiesCarefully examine the mandibular canal for discontinuitiesPathologic fractures can occur in the mandible look for tumors or abscesses