Department of Neuroradiology. Speciality Hospital. Rabat. Morocco S.BELABBES, M.FIKRI, M.R.EL HASSANI, M. JIDDANE 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 Horizontal Buttresses A. Frontal Bar B. Inferior orbital rim C. Hard palate Central box: Nasal cavity+ethmoid Side boxes: maxillary sinuses + orbits  Major resistance in the vertical axis  Low resistance to horizontal constraints (antero-posterior and lateral)  Fractures perpendicular to the pillars

DISCUSSION  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 "double- density" asymmetry of face CT semiology

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  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 Classification

Simple Fractures  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 Fractures of nasal bone and nasal pyramid fracture of the nasal septum ( ) (risk of hematoma) Fracture of nasal bone

Simple Fractures  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 Zygomatic arch fracture

Simple Fractures  Latero-facial fracture is the most common  Detaches the zygomatic bone of the maxilla, orbit and temporal bone  Combines:  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) Zygomaticomaxillary fracture (Zygomatic tripod fracture)

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) Fracture of orbital floor with inferior rectus plug by a bone splinter( ) Left zygomatic tripod fracture with involvement of the infraorbital canal( )

Simple Fractures  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) Fracture of the mandible 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 Clinical classification  Anterior table  Displaced  Un-displaced  Posterior table  Displaced  Un-displaced  Anterior and posterior table  Displaced  Un-displaced  Nasofrontal duct  Involved  uninvolved Fracture of the frontal sinus

Simple Fractures Simplified Clinical Classification 1. Fracture of anterior table 2. Fracture with disruption of posterior wall 1. Fracture involving floor of the sinus Fracture of the frontal sinus

Simple Fractures Fracture of the frontal sinus transfixing fracture of the frontal sinus with involvment of orbital roof

Complex Fractures 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. Transverse fractures of the face Lefort fracture

Complex Fractures 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. Transverse fractures of the face Lefort fracture

Complex Fractures 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 Transverse fractures of the face Lefort fracture

Complex Fractures Transverse fractures of the face Lefort III Lefort I Right Lefort II

Complex 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 Centro-facial fractures

Complex Fractures Centro-facial fractures fracture of naso-ethmoïdo- maxillo-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