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SEMINAR ON Various radiographic views in facial fractures

SUBMITTED BY Rajendran Navaradnasinkam C.R.I

The array of facial injuries was first describes by Hippocrates in 400 B.C. The French man, Rene Le Fort described three types of fractures in 1901. Radiography developed during the First World war leading to a better understanding and treatment of facial fractures. The advent of CT reconstruction, along with new surgical techniques has improved the final appearance immensely.

Le fort I fracture Le fort II fracture ( Pyramidal/ subzygomatic) Le fort III fracture ( suprazygomatic) Nasal Bone fracture Nasoethmoidal fracture Zygomatic arch fracture Zygomaticomaxillary arch fracture

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GENERAL ANATOMICA L AREA
Facial bones, upper mid third Zygomatic arch Orbits -

PROJECTIONS

COMMON INDICATIONS
Injuries Injury Injury Blow out fracture

1 2 3 4 5 6 7 8 9

Waters projection Jug Handle projection Occipitomental projection Lateral cephalometric projection Occipitomental projection Lateral cephalometric projection Oblique projection and Occlusal & periapical projection Posteroanterior projection Lateral jaw projection PA oblique projection Occlusal projection Lateral oblique projection Transcranial view Transpharyngeal view TMJ Tomography Occipitomental view Occipitofrontal view Lateral projection

Nasal bones
Maxilla Mandible Symphysis menti / Central Mandible TMJ

Minor injury Injury Injury Internal Dearrangement Secondary osteoarthritis Fracture dislocation

Maxillary Sinus

Lateral jaw projection is useful to examine the posterior region of the mandible. This radiographic projection is also called lateral oblique view. This radiograph is very useful in the diagnosis of fracture or any pathology in patients with restricted mouth opening.   Two types of Lateral jaw projections are :Body of mandible projection Ramus of mandible projection

Body of mandible projection is used in evaluation of impacted teeth, fracture of mandible. The film is kept first against the cheek of the required side and is centered over the body of the mandible. The patients head is titled 15 degree to the side being imaged and the chin is elevated and extended upwards. The central x-ray beam is directed perpendicular to the horizontal plane of the cassette with a vertical angulation of -15 to -20 degrees.

In the ramus of mandible projection , the film is held flat on the cheek of the required side and centered over ramus of mandible. Patients head is tilted 15 degrees towards the required side and the chin is elevated and extended. The central x-ray beam should be perpendicular to plane of cassette at vertical angulation of -15 to -20 degrees.

Lateral cephalometric projection is popularly known as lateral cephalogram. This projection shows bones of skull and face as well as soft tissues profile of the face. The cassette is kept perpendicular to the floor. The left side of the patients head is positioned close to the cassette. The mid- sagittal plane is perpendicular to the floor and parallel to the cassette. The teeth should be in occlusion and the lips should be gently closed. The central x-ray beam is directed through the centre of the cassette. The target to object distance is 60 inches.

Posteroanterior projection or PA view demonstrates the frontal and ethmoidal sinus, orbits and the nasal cavity. The long axis of the cassette is positioned vertically. The patient faces the cassette in such a way that the forehead and nose touch the surface. Frankfort plane is parallel to floor

Waters projection or Paranasal sinus projection is used in evaluation of maxillary sinus. This projection also demonstrates the frontal and ethmoid sinuses, the orbits and the nasal cavity. This projection is very useful in the diagnosis of maxillary sinusitis and Le fort II and Le fort III fractures. The patient faces the cassette with the chin touching the cassette. The tip of the nose is positioned half to one inch away from the cassette. The mid sagittal plane is perpendicular to the floor and head is positioned in the centre of the cassette. The central x-ray beam is directed from the centre of the head.

The submentovertex view(SMV) helps to identify the position of the condyle, visualize base of the skull and evaluate fractures of the zygomatic arch. This projection also demonstrates the sphenoid and theethmoid sinuses and lateral wall of maxillary sinus. Submentovertex view is of two types :Zygomatic arch projection Base of skull projection

ZYGOMATIC ARCH PROJECTION Zygomatic arch projection is also called as the JugHandle view. This radiograph is essentially similar to base of the skull projection with the exception that the radiation exposure and development time are less. BASE OF THE SKULL PROJECTION The cassette is placed perpendicular to the floor with the long axis vertical. The patients head and neck are extended backwards as far as possible. The vertex or top of skull touches the cassette. The head is centered on the cassette. X-ray beam is directed through the centre of the head and perpendicular to centre of the cassette

TRANSCRANIALVIEW Transcranial view helps in visualisation of superior surface of the condyle and the articular eminence. The joint space is also visualised. The cassette is placed flat over the ear of the required side in such a way that it is centered over the TMJ. The mid sagittal plane is perpendicular to the floor and parallel with the cassette. The central x-ray beam is directed to a point 2 inches superior to and 0.5inches behind the opening of the ear canal ( external auditory meatus

TRANSORBITAL VIEW
Transorbital view helps in the visualization of the joint with relatively less superimposition. This view is also called :Zimmer projection or Transmaxillary projection This view demonstrates the entire latero-medial articulating surface of both the condyle and the articular eminence and the condylar

 

neck.

The head of the patient is tipped down 10 degrees in such a way that the canthomeatal line is horizontal. The mid sagittal plane is kept at 30 degrees to the central x-ray beam by moving the head to the left for left side projection and to the right for right side projection. The cassette is positioned behind the patients head and the central x-ray beam is directed through the Ipsilateral orbit and through the required TMJ, exiting from the skull behind the mastoid process. During the exposure, the patient is asked to open the mouth as wide as possible.

TEMPEROMANDIBULAR JOINT TOMOGRAPHY
Temperomandibular joint tomography helps in the visualization of the condyle, articular eminence and glenoid fossa. It can be also used to determine the joint space and to evaluate the extent of movement of condyle when the mouth is opened.

TRANSPHARYNGEAL VIEW
Transpharyngeal view is also called as Infracranial view McQueen projection This projection demonstrates the angular process from the mid mandibular ramus to the condyle. This technique helps in the diagnosis of fractures of the condyle and the condyle neck and in detecting alterations in condyle morphology. The cassette is held over the ear in such a way that the TMJ of interest is in the centre of the cassette. The cassette is held parallel to the mid sagittal plane. The x-ray tube is kept on the side of the skull opposite to the TMJ imaged. It is angled in such a way that the mouth wide so that the central x-ray beam enteres through the tube side sigmoid notch, below the skull base and oropharynx.