Diagnostic Imaging of

Injuries
By: Sam Caruso
samrcaruso@gmailcom | 847.542.8131
Nice to meet you!

- From Kildeer, IL (suburb of Chicago)

- Clemson University Undergrad
- Philly, PA for UPenn Dental
- Start at Broward Health/NSU in July
History of Diagnostic Imaging

1895 ~ Wilhelm Conrad Rontgen

Developed the first radiographic image

1,500x Today’s Dose Credit unknown

History of Diagnostic Imaging
1977 ~ Godfrey Hounsfield Developed Computed Tomography
Buttresses

“A buttress is an architectural
structure built against or projecting
from a wall which serves to support
or reinforce the wall. “

- Wikipedia
Anatomy - Facial Buttresses

Facial butresses
Basics…?

● Radiography shows for densities

○ Bone, Air, Soft Tissue, & Fat
● Four S’s
○ Symmetry, sharpness, sinus, soft tissue
○ Fortunately facial structures are generally symmetrical, simplifying the process
● Air in sinuses, presents as darker (less dense) than orbits
● Soft tissue should be searched for air, foreign bodies and loss of normal fat
density
Others

Multi Detector-CT

● Gets submillimeter axial cuts and reformats to coronal and sagittal cuts

CT Angiography

● Previously, CT angiography was used evaluate stable patients with

suspected cervical vascular injury.
○ Occur in 25% of penetrating cervical injuries
● MDCTs are now very accurate replacing this angiography.
● Recent studies support 100% sensitivity and 98% specificity
Rendering Techniques

3D Imaging - Two types Shaded Surface Display (SSD) & Volume Rendering (VR)

SSD
Facial Frac / tures

“Efficient and accurate evaluation of facial bones is a radiologic challenge.

Familiarity with the pattern and typical location of such fractures greatly
expidites their evaluation”

● Zygomaticomaxillary
● Orbital
● Le Fort
Zygomaticomaxillary
~ Two major buttresses are upper
transverse & lateral vertical maxillary ~

● Dense bone, mostly fractured at sutures

○ Exceptions

1. Isolated fractures of the zygomatic arch (typically depressed)

2. Pneumatized inferior orbital rim/anterior maxillary sinus wall

● Lateral and coronal images are needed

● Do not confuse a suture with a fracture (look for symmetry)
● The curvilinear orbital floor should appear smooth and uninterrupted
Orbital

● Can occur in isolation or in pair with ZMC,

Naso-orbital-ethmoidal (NOE) or Le-Fort II fractures
● “Blow-out” (Floor) or “Blow-in” (medial Wall)
● Fat density of < -10HU (Houndsfield Units) in ethmoid air
cells is fracture until proven otherwise
○ This rule also applies to infraorbital air presence
● Entrapment is rare side effect, look for bony proximity to
rectus muscles, plan to relieve within 24-72 hours for
best healing
LeFort Fractures

Named after Rene Le Fort who would drop

bricks on skulls, administer blows to cadavers
with a wooden billy club, and drop cadavers
from multiple stories high.
Le Fort Fractures

“The defining characteristic of these fractures is the

interruption of the pterygomaxillary junction (pterygoid
plate or posterior maxillary sinus wall).”

Lefort I - Horizontal separation below base of nose

Lefort II “Pyramidal” - Zygomaticomaxillary and

frontomaxillary sutures above the nose

Lefort III “Craniofacial Dysjunction” - entire face moving

independently from the cranium
Radiographic & Imaging of Neck & Soft
Tissue Trauma

● Airway
○ Although apparent, MDCT offers excellent evaluation of crush and penetrating airway
injuries
○ Look for: Pneumomediastinum, Trauma, or Resulting Abscess
● Esophagus
○ Optimal radiographic study is single contrast fluoroscopic esophagram
○ Look for secondary injuries: pneumomediastinum, hematoma and paraesophageal
stranding
● Neurologic
○ Imaging is the gold standard for deciphering operative vs. non-operative repair of the
brachial plexus
○ Look for: Postganglionic injuries which constitute as operative
■ (Preganglionic are non-operative)
Mandibular & Dentoalveolar Imaging
● Mandibular Series
○ Historically the standard analysis. Phased out ~2003/2004~
○ Bilateral Lateral Obliques (Condyle, Ramus, Coronoid, Body, Angle, Limited to no parasymphyseal)
○ Posterior-Anterior (preferable) or AP projection (shows entire mandible, except condyles)
○ Towne’s View (condylar & subcondylar region, also shows medio-lateral displacement)
○ Lateral View (Optional: Rarely balanced, has good imagery. Shows alveolar fractures & condylar neck well)
○ Negative: In traumatized patient it may not be possible to complete a series & distinct crossover of imagery
● Supplemental
○ Nondisplaced Parasymphyseal not shown well with mandibular series, may only present with gingival
laceration and ecchymosis of the floor of the mouth. Consider Panoramic or Periapical film upon suspicion.
○ Occlusal Films very useful in identifying anterior fractures. Central ray directed 55 degrees to the midline
● Panoramic (Orthopanogram)
○ Superior, but noted to miss symphyseal & parasymphyseal fractures
○ May not be readily available, or in the case of trauma, a patient may not be able to sit upright
● CT
○ 3D Computed imaging, absence of distinct detail. Prior to technical advancements, were only used when
film did not suffice
Mandibular Fractures

● At least 50% of head and neck injuries have at least one fracture in the
mandible
● Ellis found of patients with midface fractures 33% had associated mandible
fractures
● The condyle is the smallest portion, associated with other fractures
● The angle, the largest and thickest portion, is disadvantages including
trabeculae direction change, presence of impacted teeth.
● Diagnostic imaging varies (Intraoral, Pan, CT)
** Fracture Types ** (Take Home Slide)
1. Simple - do not communicate with the outside environment (Ramus or Condylar)
2. Compound - communicate through laceration or tooth socket
3. Comminuted - Two or more fractures at fracture site; signifies greater force
4. Complicated - Either directly or indirectly produce injuries to surrounding nerves,
vessels, or joints. (IAN Bundle coursing through the mandible makes almost all
fractures complicated)
5. Impacted - Where segments interlock so there is little to no movement at fracture site
(rare)
6. Greenstick - One cortex broken, opposite cortex bent (mostly pediatric subcondylar)
7. Pathologic - Occuring in a region weakened by pre-existing disease (infection, tumor,
metastasis)
Greenstick Fractures
Condylar & Subcondylar
● Most Common accounting for 25-40% of fractures
● Unilateral more common than bilateral, and are frequently associated with contralateral angle fractures
● Bilateral normally occur resulting a blow to the ching
● Intracapsular/intra-articular fractures are rare, normally occurring in children who take a direct blow to the chin
● Anterio-medial dislocation of the condylar head often occurs
○ Cortical Ring Sign - Well corticated density seen over the condylar neck on lateral views
○ Townes view is/was useful to determine this anterio-medial dislocation

Lindhall’s Number System (1977)

1. Level (condylar head, condylar neck, subcondylar

2. Relationship of the condylar fragment to the mandible
a. Undisplaced,
b. Deviated - displaced with medial, lateral, anterior or posterior overlap
c. No contact
3. Relationship of the fractured segment to the glenoid fossa (Undisplaced, Subluxated, Dislocated)
Coronoid Process & Ramus

Coronoid

● Process are 1-2% of fractures (protected by the zygoma)

● Normally superiorly displaced due to pull of temporalis

Ramus

● Rare due to dense bone

● Additional protection from Medial Pterygoid & Masseter
● Normally resulting from direct blow
Angle

● Most common single fractures seen

● 11-30% of fractures depending on study
● Usually a result of a blow to the chin on the CONTRALATERAL side or body
on the IPSILATERAL side
● Again, commonly associated with contralateral subcondylar or body
fractures
Mandibular Body

● Composes 16-36%
● Highest incidence patients involved in MVAs
● Primarily from a direct blow
● All fractures (except our edentulous patients without laceration) qualify as
compound fractures
● USUALLY, muscle pull reduces the fracture (favorable) but an oral airway
should be readily available
Symphysis & Parasymphysis

● 11.7-24% of fractures
● Again, difficult to see on films
● Commonly angulated obliquely
● Bilateral fractures is an airway risk due to muscle strain of the suprahyoids
Dentoalveolar

● Widely varying incidence form 0.8-14%

○ Commonly underreported due to oversight
● Highest incidence results from pediatric population
○ Although pediatric population results in low incidence of facial trauma fractures
Complications
● Historical Note: Mandible fractures USED to be life threatening
● Dependant on nature of injury, patient health,
● Non-union or Mal-union complication of:
○ inadequate reduction
○ Inadequate stabilization fixation
○ Infection
○ Combination of the three
● Infections
○ Most fractures should be considered compound
● Ankylosis
○ Increased time in stabilization = Increased risk for Ankylosis
○ Consider age of patient
● Malocclusions
The Future

● CBCT Virtual Surgical Planning

○ Transitioning to cutting guides, plates, etc.

● 1997 Use of imaging to design contralateral symmetry in ZMC

○ Watzinger et. al
Navigation or Image
Guided Surgery
● First used by Gleason in 1994 for 3D
linked neurosurgery
● Fusion, Stealth, etc. requiring CBCT or
medical grade CT
● Article from Nature: Randomized
control trials
https://www.nature.com/articles/s41598-018-25053-z
**Pop Quiz**

Scenario 1:
You are out to a consult at your other hospital across town and you get a call from the
trauma bay. They want advice on stabilizing the patient. What is the significance of determining
if your fracture is Simple vs Compound.

The Rx of Antibiotics - if the fracture is compound its exposed to the outside world

Also consider:
- NPO Status
- Pain Control
**Pop Quiz**

Scenario 2:
You are out getting slammed by consults at your other hospital across town and you get a
call from the children’s hospital trauma bay. They want advice on consulting a patient. To reduce
radiation to the patient they took a mandibular series which showed no fractures to the clinicians
at the hospital . What clinical evaluation should you suggest to consider CT imaging?

What to ask for:

- Isolated laceration
- Floor of mouth hematoma
- Discrepancy in height of teeth
- Mobility
Suggest CT Scan?
**Pop Quiz**

What is the most commonly post operatively infected site of the mandible?

The Angle
1. Presence of third molars
2. Dependant area (pooling of food)
3. Function - more likely to flex & move
Thank You & Questions?

References: Contact:

Fonseca 2nd Ed. samrcaruso@gmailcom

Fonseca 4th Ed. 847.542.8131

External References:

AAOMS 100 Year Presentation

Cross Reference with Fonseca Ed. 4