Facial and Mandibular Fractures 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

Simple Rules 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

Lines of Dolan Three anatomic contours The 2nd and 3rd 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

MOIs 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

Fracture Types and Prevalence 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%

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

LeFort Fractures 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

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

Alveolar Process of Maxilla Associated with several fractured teeth Chest film should be taken if all teeth are not accounted for

Smash Fracture Severe comminution of the face Underlying skull injury is likely

Blowout Fracture 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

Nasal Bone Fracture 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

Mandibular Fractures 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 30-40% Angle 25-31% Condyle 15-17% Symphysis 7-15% Ramus 3-9% Alveolar 2-4% Coronoid Process 1-2%

Mandibular Fractures

Mandibular Fractures

Double Mandibular Fractures Usually contralateral sides of the symphysis Common combinations include: Angle plus the contralateral body or condyle

Mandibular Dislocation 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