外傷及感染之放射線影像檢查 Radiographic Interpretation of Trauma and Infection

內容綱要 顎顏面外傷之影像檢查 技術 顎顏面外傷分類 判讀 感染的影像檢查 軟硬組織感染

影像檢查在顎顏面外傷的應用 Plays a critical role Identify the location and orientation of fractures Indicate the degree of separation or displacement

顎顏面外傷常用 放射線影像檢查技術 -I Routine view bones 2. Lateral view of facial bone 1. Posterior-anterior (PA) view of facial bones 2. Lateral view of facial bone 3. Panorex 4. Water’s ( Occipitomental ) Suspect mid-face fracture

顎顏面外傷常用 放射線影像檢查技術-II 5. Periapical view 6. Occlusal view Occlusal view of nasal bone Occlusal view of mandible 7. Submental-vertex view 8. Lateral view of nasal bone

顎顏面外傷常用 放射線影像檢查技術-III 9. Tomography 10. Towne’s view 11. PA view of mandible 12. Oblique view of mandible

1. PA view Skull Jaws

2. Lateral view Skull Jaws Neck

Mandible, maxilla, dentition, 3. Panex Mandible, maxilla, dentition, 70 % of mid-face fracture

4. Water’ view (Occipito-mental ) Maxillary fracture Orbital fracture Frontal bone / sinus

5. Periapical view Tooth and alveolar injury

6. Occlusal view - Mandible Fracture line , direction Axial section

6. Occlusal view - Maxilla

7. Submental vertex view Zygomatic arch fracture Coronoid fracture

8. Lateral nasal view

9. Tomography Blow –out fracture TMJ fracture 185 180

175 170

165 160

10. Modified Town’s view Condylar fracture Mandibular angle fracture

11.PA symphysis view

12. Oblique lateral view Was replaced by Panoex Used when patient can not sit or stand

CT scan

Reconstructive 3-D CT scan

顎顏面外傷之影像檢查判讀 General interpretation of fracture line Condyle and other mandibular fracture Middle facial fracture Cavity: sinus, orbital Dento-alveolar fracture

General interpretation of fracture line Displacement ( deviation, dislocation ) Step, gap, overlapping Discontinuity Asymmetry Comminuted Malocclusion Cavity: (air-fluid level ) *** Degree and direction

Mandibular fracture

Angle and symphysis fracture Malocclusion Step Angle and symphysis fracture

Condyle and symphysis fracture Overlap , discontinuity and displacement Asymmetry Comminuted

Coronoid and ramus fracture Gap, Discontinuity Step , Displacement

Condyle Deviation Displacement Dislocation Displacement Undisplaced

condyle fracture Displacement

Bilateral condyle fracture Dislocation

Bone gap

Split fracture Coronoid fracture

Chin horizontal fracture

Mid-facial trauma Cavity: sinus, hernia of orbital soft tissue Tomography of orbital fracture CT Air-emphysema Middle fracture ( Le Fort I, II, III ) ZMC fracture Basilar skull fracture: air-fluid level in sphenoid sinus

Le fort I fracture

Air-fluid level

Le Fort II fracture

Le Fort III fracture

Blow-out fracture

Zygomatic arch fracture

Zygomatico-maxillary complex ( ZMC) fracture

Classification of dentoalveolar injuries A. Tooth structures B. Supporting structures 1. Crown craze or crack 2. Crown fracture 1) Enamel 2) Enamel-Dentin 3) Enamel-Dentin- Pulp 3. Crown and root fracture 1) Pulp involvement 2) No pulp involvement

Classification of dentoalveolar injuries 4. Root fracture 1) Apical third 2) Middle third 3) Cervical third Shift to another angle

B. Supporting Structure 1. Sensitivity ( concussion ) * percussion pain * no displacement * no mobility * Image  widening of PDL space 2. Subluxation * loosening, no displacement, * Image  portion of PDL widening

Classification of dentoalveolar injuries 3. Tooth displacement 1) Intrusion 2) Extrusion 3) Labial displacement 4) Lingual displacement 5) Lateral displacement 4. Avulsion 5. Alveolar process fracture

感染的影像檢查技術 Plain film radiography CT scan MRI Nuclear bone scans Tomography Ultrasonography

齒源性感染的常用影像檢查 Plain film radiography 根尖片 : 對於根尖及早期病變的顯示最佳 咬合片 : (Axial) Garrie’s osteomyelitis 全口片 (panoex) 有張口困難的病人, 同時對牙齒的情況做,骨頭的破壞檢查,

CT Scan Space infection Neck: Air way, pharynx Sinus Orbit Intracranial abscess Soft tissue

MRI Noninvasion, no radiation, high soft tissue resolution﹐high sensitivity and specificity 對骨的細部變化 space infection, presence of pus, cavitation TMJ abscess

選擇的要領 Plain film : 一般診斷及治療反應後的追蹤 CT / MRI : Extension into soft tissue , air way Bone scan: Response to treatment

Image finding and Bone changes Difficult to visualize by conventional techniques in early stage Until substantial mineral .. removed 35 - 50 % After infection :5 -14 days

感染部位與描述名稱 Margin: well or poor demarcation / defined Lesion: radiolucent / radiopaque Periapical changes: PDL , trabeculae . Cavity (sinus) : cloudy, air-fluid level… Osteomyelitis: periosteal reaction﹐moth eaten , rarefaction, …. Sinus tract ( fistula )

1. Periapical Infection ( acute / chronic ) Widening of PDL Lamina dura discontinuity Trabeculae destruction Chronic Periapical abscess Periapical granuloma Fistula Root resorption

2. Osteomyelitis (骨髓炎 ) Acute suppurative osteomyelitis Trabeculae: fuzzy, diffuse destruction﹐ Radiolucent area Poor demarcation Irregular border

Chronic suppurative osteomyelitis Necrotic Bone Moth eaten* Radiolucent area with poor demarcation Necrotic bone Sequestrum Radiopaque with peripheral rediolucent area Rarefaction

Moth eaten

Sequestrum Radiopaque with peripheral radiolucent area

Pathologic fracture

Expansion Rarefaction

Sclerosing Osteomyelitis Focal type Increasing density ( disposition of the bone ) rarefaction Periapical area Thickening of PDL Bone scar

Sclerosing Osteomyelitis Diffuse type Border between normal and sclerosis .. poor defined Cotton wool appearance。

Garre’s proliferative periostitis (Osteomyelitis) Subperiosteal reaction: onion skinning﹐ Duplication of the cortical layer of bone

ORN ( Osteo-Radio Necrosis ) No remodeling

90.1.18 90.3.12

Bone necrosis due to Arsenic Tooth germ, nerve damage…

軟組織感染 Infections involving soft tissues are not readily Demonstrated by many imaging techniques Gas producing organism

Infratemporal space Submasseteric space

Air way

MRI of TMJ space abscess

Sinusitis Cloudy Air-Fluid level

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