1. Facial and Mandibular Fractures
Presented by M.A. Kaeser, DC
Spring 2009

2. 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

3. 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

4. Lines of Dolan Three anatomic contours
The 2nd and 3rd lines together form the profile of an elephant

5. Direct Radiographic Signs of Facial Fractures
Nonanatomic linear lucencies
Cortical defect or diastatic suture
Bone fragments overlapping causing a “double-density”
Asymmetry of face

6. Indirect Radiographic Signs of Facial Fractures
Soft tissue swelling
Periorbital or intracranial air
Fluid in a paranasal sinus

7. 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

8. 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%

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

10. LeFort Fractures
Complex, bilateral fracures associated with a large unstable fragment
Involve the pterygoid plates

11. 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

12. 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

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

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

15. 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

16. 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

17. Mandibular Fractures Clinical findings Facial distortion
Malocclusion of the teeth
Abnormal mobility of portions of the mandible or teeth

18. 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

19. Common Sites of Mandibular Fractures and Prevalence
Body %
Angle %
Condyle %
Symphysis %
Ramus %
Alveolar %
Coronoid Process 1-2%

20. Mandibular Fractures

21. Mandibular Fractures

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

23. Mandibular Dislocation
May occur spontaneously during a large yawn
Considerable pain
Condyle (c) is anterior to the articular eminence (e)

24. 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