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179]

Original Article

Diagnostic accuracy of ultrasonography verified

with computed tomography for the diagnosis of
maxillofacial fractures – A prospective study
Abhishek Shailesh Shah, Tejraj Kale, Virupaxi Hattiholi1, Husain Dhabaria2
Department of Oral and Maxillofacial Surgery, KLE Vishwanath Katti Institute of Dental Sciences, KAHER University, 1Department of
Radiology, Jawaharlal Nehru Medical College, KAHER University, Belgaum, 2Department of Oral Surgery, Yenepoya Dental Hospital,
Mangaluru, Karnataka, India

A B S T R A C T

Objectives: The objective of this study was to evaluate the diagnostic accuracy of ultrasonography (USG) if it can be used as a
primary diagnostic method for maxillofacial trauma and to determine the sensitivity and specificity of USG verified with a computed
tomography (CT) scan. Materials and Methods: This study was a comparative prospective study that consisted of a total of
32 patients. Patients reported to the Trauma Care and Emergency Center of KLES Dr. Prabhakar Kore Hospital with maxillofacial
trauma during October 2018–September 2020 were included in the study. Following a CT scan, based on the inclusion criterion, the
patient underwent an ultrasonographic examination of any maxillofacial fracture that had been confirmed by a CT scan to verify it.
Sensitivity and specificity were calculated to establish the accuracy of USG. Results: A total of14 sites were selected in the maxillofacial
region. Out of all the 14 anatomical landmarks, nine were able to detect all the fractures on USG with 100% sensitivity and specificity.
Intracapsular condyle fractures were not seen on USG. The region where all the fractures were not identified on USG was medial wall
and floor of the orbit, one nondisplaced ramus fracture. Conclusions: The overall sensitivity observed for the diagnosis of maxillofacial
fracture was 85.21% and specificity observed was 100%. In conclusion, USG can be a handy, diagnostic, additional, noninvasive,
and inexpensive tool in the detection of maxillofacial fractures when compared to CT in the primary health‑care center. Furthermore,
studies should be conducted with a considerable amount of sample size as the literature mentions limited work regarding USG as a
primary technique in maxillofacial fractures detection.

Key words: Accuracy, computed tomography, maxillofacial fracture, sensitivity, specificity, ultrasonography

Introduction a long time, computed tomography (CT) is considered

the gold standard for maxillofacial fracture diagnosis
and is used as the first modality. However, it has certain
Maxillofacial injuries are quite common following road
limitations such as access to facilities, high cost, and
traffic accidents (RTA), fall, and assault. If a clinical
radiation exposure.[2]
examination reveals the existence of a fracture of the
facial skeleton, standard evaluation in the form of imaging This is an open access journal, and articles are distributed under the
techniques is done for obtaining the final diagnosis.[1] For terms of the Creative Commons Attribution‑NonCommercial‑ShareAlike
4.0 License, which allows others to remix, tweak, and build upon the
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Cite this article as: Shah AS, Kale T, Hattiholi V, Dhabaria H. Diagnostic
DOI: accuracy of ultrasonography verified with computed tomography for the
10.4103/jomr.jomr_13_22 diagnosis of maxillofacial fractures – A prospective study. J Oral Maxillofac
Radiol 2022;10:40-4.

Address for correspondence: Dr. Abhishek Shailesh Shah, Department of Oral and Maxillofacial Surgery, KLE Vishwanath Katti Institute of
Dental Sciences, KAHER University, Belgaum, Karnataka, India.
E‑mail: abhi9153@gmail.com
Submission: 10‑05‑2022, Decision: 13‑06‑2022, Acceptance: 15‑06‑2022, Web Publication: 22-07-2022

40 © 2022 Journal of Oral and Maxillofacial Radiology | Published by Wolters Kluwer - Medknow
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Shah, et al.: Accuracy of USG verified with CT for the diagnosis of maxillofacial fractures
On the other hand, ultrasonography (USG) has been widely
used in medical fields due to its remarkable features such
as nonradiation, quick, and painless technique. To date,
the use of ultrasound is known for its use associated with
soft‑tissue lesions and pathology.[3] The role of USG in
maxillofacial trauma is less widely recognized. USG uses
high‑frequency ultrasonic waves, which are transmitted to
the body and dispersed through the tissues by a transducer,
and echoes are reflected on the screen for the diagnostic
purpose.[2] The recent technological advancements can now
transmit ultrasound waves to bony lesions and fractures
of the maxillofacial region. The use of ultrasound for
the assessment of maxillofacial fractures is therefore
emerging.[1,2] As ultrasound is a cost‑effective, noninvasive,
and easily available imaging technique, it can be used
as a primary investigative imaging method. This study
determined the diagnostic accuracy of ultrasound and was
verified with CT for the detection of maxillofacial fractures.
Materials and Methods
Patients reporting to Trauma Care and Emergency Center
of KLES Dr. Prabhakar Kore Hospital with maxillofacial
trauma following a RTA, fall, assault, etc., during the
October 2018–September 2020 were included in the
study. This study was a comparative prospective study
which consisted total of 32 patients. All the patients
were explained the procedure and an informed consent
was signed by them. The study protocol was approved
by the ethical committee board of the institution. As
first‑line imaging, CT of the facial skeleton was carried out
and examined to establish a diagnosis. Later, the patient
underwent ultrasound examination of the affected region.
Inclusion criteria
1. Maxillofacial injuries with bone fractures
2. All age groups
3. Both male and female.
Exclusion criteria
Patients with any medical or surgical emergency were
excluded from the study.
Methodology
Thirty‑two patients (27 males and five females) presented
with clinically diagnosed injuries to the maxillofacial region
were included in the study. CT of the facial skeleton with a
three‑dimensional reconstruction was taken and examined,
to establish a diagnosis. The patients were subjected to an
ultrasound examination of the affected regions using GE
Voluson P8 ultrasound machine with linear probe (5‑7MHz)
and curvilinear probe (7‑12MHz) [Figure 1]. CT scans were
Journal of Oral and Maxillofacial Radiology / Volume 10 / Issue 2 / May‑August 2022
done with GE Voluson EVO‑Germany (Assembled in
India). The results of CT scans and USG were summarized
by two different radiologists. The radiologist conducting
the USG investigation was blinded to the findings of the
CT scan examination.
Patients selected were clinically examined to determine the
area for carrying out the USG. The linear/curvilinear probe
used for USG was cleaned and Medi gel ultrasound jelly
was placed over the affected area and on the probe. The
probe was applied on the affected area for the diagnosis
of underlying fracture. In case of patients with contused
lacerated wounds or any form of abrasion, they were given
primary care before any investigation was carried out. Care
was taken to ensure that no pressure was exerted, with
minimum mobilization of the patient during the procedure.
Absolute care was taken to perform the scan with total
precautions to prevent any infection due to the scan, in
the patients who had skin injuries.
Results
A total of 32 patients were selected based on the inclusion
criteria. The age group was classified into three categories:
≤30 years, 31–40 years, and ≥41 years. According to the
age group, 16 of 32 (50%) were below 30 years of age.
There were eight patients in the age group of 31–40 years
and eight patients were above 40 years of age [Table 1].
Of the 32 patients selected, 27 were males and five were
females. The majority of the patient, i.e., 27 of 32 had a
history of  RTA, four patients had a history of fall and one
patient gave a history of assault. The mean age for selected
patients was 35.78 ± 14.21 years as shown in Table 1.
The sites which were fractured on CT scans and identified
on USG with 100% accuracy were frontal bone, lateral
wall of the orbit, anterior wall of maxillary sinus, roof
of the orbit, zygomatic arch, zygomatic bone, nasal
bone, symphysis/parasymphysis, and angle of mandible,
respectively [Figure 2]. In this study, the sensitivity and
specificity for all these sites were 100%.
Table 1: Age-wise distribution of patients selected in the
study
n (%)
Age groups (years)
≤30 16 (50.00)
31–40 8 (25.00)
≥41 8 (25.00)
Total 32 (100.00)
Mean age±SD age 35.78±14.21
SD: Standard deviation
41
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Shah, et al.: Accuracy of USG verified with CT for the diagnosis of maxillofacial fractures
Figure 1: Placement of straight transducer probe
a b
Figure 3: (a) Orbital floor fracture-3D. (b) Orbital floor fracture – USG.
USG: Ultrasonography. 3D: Three-dimensional
In this study, it was found that nine out of 14 sites taken up
for the ultrasound examination were able to identify all the
fractures with 100% accuracy which were verified with CT
scans. Only in the cases of condylar/subcondylar region,
floor of the orbit, medial wall of the orbit, and body and
ramus of mandible all the fractures were not seen with the
help of ultrasound. The visualization of the posterior wall
of maxillary sinus was not possible with the help of linear
probe in cases of midface fractures. However, fracture of
the anterior wall of the maxillary sinus was easily identified
using a convex probe with low resolution (2‑5 MHz).
Fractures of the floor of the orbit were identified in 10
of 12 cases, respectively [Figure 3]. The sensitivity and
specificity of the same were 83.33% and 100%, respectively.
Fractures of the medial wall of the orbit were seen in five
of seven cases. The sensitivity and specificity were 71.43%
and 100%, respectively. There was no false‑positive case
reported. The remaining fractures could not be identified
due to the poor sound wave penetration in cases of orbital
fractures. Subcutaneous edema and hematoma were used
as a guide to spot the fracture location.
The fractures in case of the body of the mandible were
identified in two of three cases with sensitivity and
specificity were 66.67% and 100%, respectively. The ramus
42 Journal of Oral and Maxillofacial Radiology / Volume 10 / Issue 2 / May‑August 2022
a b
Figure 2: (a) Nasal bone fracture – CT Axial. (b) Nasal bone fracture – USG.
CT: Computed tomography, USG: Ultrasonography
a b
Figure 4: (a) Left condylar neck fracture-3D. (b) Left condylar neck fracture
– USG. USG: Ultrasonography. 3D: Three-dimensional
of mandible showed fracture in one of two cases with
50% sensitivity. Each fracture of the ramus and body
of mandible were undisplaced fractures of mono‑cortex
which was diagnosed on CT scan and was not identified
on USG. The fracture of the condyle/subcondyle region
was identified in one of four cases which gave sensitivity
and specificity of 33.33% and 100%, respectively. The
negative predictive value of 93.55% indicated that three
of four cases were false negative [Figure 4].
Discussion
USG is a diagnostic technique that is noninvasive and does
not contain ionizing radiation. It is a quick and painless
technique and has no known harmful effect on the body.
When it was applied to head‑and‑neck medicine, it was
limited to the imagery of superficial structures of the
head and neck and was considered to have a limited role in
bone lesions.[4] On the other hand, CT was introduced in
the 1970s and it has become an important tool in medical
imaging to supplement X‑rays and USG.
Many literature studies have already identified the
possibility of ultrasonographic fracture visualization in the
maxillofacial region.[5] USG has its own set of advantages
when compared to CT scans such as no exposure to
radiation, painless technique and inexpensive. and easy
availability, patient cooperation required is less and there
is no requirement of patient positioning.[4] Second, USG is
portable which makes it available intraoperatively to check
the reduction of the fracture in cases of isolated zygomatic
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Shah, et al.: Accuracy of USG verified with CT for the diagnosis of maxillofacial fractures
arch fractures and nasal bone fractures. However, ultrasound
cannot penetrate deeper bony structures, and thus its use is
only restricted to superficial facial landmarks.[3]
Ord et al. used ultrasound for the first time in 1981 to
detect orbital wall fractures.[6] In that study, USG showed
95% sensitivity to screen all the fractures.[2] In the literature,
the lowest sensitivity found for the identification of medial
and lateral wall fractures in the literature was 56% and
88%, respectively, while the lowest specificity was 90%
and 87%, respectively. The precision for detecting orbital
wall fractures typically varies from 90% to 100%.[4] In
the present study, medial orbital wall fracture showed the
values for sensitivity and specificity of 71.43% and 100%,
respectively. For the lateral orbital wall, the sensitivity and
specificity were 100%, i.e., all fractures were identified.
The orbital floor fracture has their sensitivity and specificity
varying from 85% to 100% and 57% to 100%, respectively,
and accuracy varies from 86% to 98%.[1,7‑9] It was repeatedly
found out that orbital floor fractures beyond 4 cm to the
orbital margin which is present posteriorly, are poorly
identified by ultrasound.[1] The current study showed us the
sensitivity and specificity of 83.33% and 100%, respectively,
for orbital floor fracture. Using a curved array transducer,
recently published results demonstrated good to excellent
reliability in the diagnosis of orbital fractures involving
the infraorbital rim and the orbital floor.[10] The literature
mentioned little work on orbital roof fractures. The present
study showed a sensitivity and specificity of 100% for the
diagnosis of orbital roof fracture. The overall diagnostic
accuracy for all orbital wall fractures was seen ranging
from 90% to 100% which shows a good reliability.[7,8,10,11]
In patients with only minor clinical symptoms, ultrasound
could be used to rule out a fracture. USG of the medial
orbital wall and floor of orbit fracture requires highly
experienced investigators.
Nasal bone, frontal bone, and zygomatic arch fractures have
100% precision in the ultrasound detection of fractures
shown in the literature.[6] In 2019, Rajeev et al. conducted
an analysis in which ultrasound identified all the fractures
at some anatomical landmarks, i.e., the zygomatic arch, the
frontal sinus (anterior wall), infraorbital margin, roof of
the orbit, and mandibular symphysis/parasymphysis and
mandibular angle.[3] The current study showed a similar
result in diagnosing fractures with 100% accuracy at all
these sites.
In this contemporary study, fractures of the anterolateral
wall of the maxillary sinus and zygoma (malar bone)
were detected easily by ultrasound with a sensitivity
Journal of Oral and Maxillofacial Radiology / Volume 10 / Issue 2 / May‑August 2022
and specificity of 100%. This is in agreement with a
study conducted by McCann et al.[1] who concluded that
ultrasound as an initial examination is a valuable method
in imaging facial injuries, which may help to cut down on
the total number of radiographs required for the detection
of zygomatic‑orbital complex fractures.
Kleinheinz et al. [12] and Friedrich et al. [13] reported
ultrasonographic sensitivity and specificity of 100% and
100%, respectively, and 66% and 52%, respectively, in the
detection of mandibular subcondylar/ramus fractures.
In our study, the mandibular ramus and condylar/
subcondylar region showed the sensitivity of 50% and
33.33%, respectively, while it showed the specificity of
100%. Only in one case of the subcondylar fracture, it was
identified on ultrasound because there was subluxation
of temporomandibular joint. Other fractures seen on CT
scan were condylar head and intracapsular fracture of
condyles. Friedrich et al.[13] highlighted the shortcomings
of ultrasound to detect intracapsular condylar fractures
due to its overlap by the zygomatic arch.
A systematic review conducted by Adeyemo and Akadiri
has mentioned the factors affecting the credibility of USG
in maxillofacial trauma:[4]
1. Expertise of sonographer
2. Transducer’s type and its resolution
3. Lack of a traditional facial skeleton scanning technique
4. Visualization in real‑time is better than hard copy
interpretation
5. Ultrasound evaluation from the time of injury.
The systematic review also mentioned limitations of
ultrasound imaging in maxillofacial fractures which
included;[4]
1. Inability to represent multiple facial fractures that are
complex in nature. In this study, all the fractures were
identified even in patients with pan facial fractures
2. Difficulty in detecting undisplaced fractures. In the
present study, all the fractures were identified by USG
except in the case of one ramus fracture which was
undisplaced
3. Not able to investigate posterior orbital floor ≥4 cm.
Orbital floor fractures were not seen in some cases as
they were present posteriorly in the current study
4. Inability to detect the intracapsular fracture of condyles
due to the overlapping of the zygomatic arch.
Conclusions
In this study, the overall sensitivity observed for diagnosis
of maxillofacial fracture was 85.21% and the specificity
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Shah, et al.: Accuracy of USG verified with CT for the diagnosis of maxillofacial fractures
observed was 100%. Fractures of the nasal bone,
uncomplicated orbital wall fractures, anterior maxillary wall
of maxillary sinus, zygomatic arch fractures, mandibular
fractures of symphysis/parasymphysis, and body and
angle were readily detected on ultrasound. USG shows
favorable results in the detection of extracapsular
subcondylar fractures, but maxillofacial surgeons must
know its shortcomings in undisplaced fractures, complex
maxillofacial fractures, posterior orbital floor fractures,
and intracapsular mandibular condyle fractures. The
sonographic techniques need to be upgraded and special
transducer probes should be made for certain regions to
detect fractures without any difficulty. The maxillofacial
surgeons should be trained for the use of ultrasound
so that intraoperative and postoperative reduction of
fractures can be checked and radiation exposure can be
avoided. USG gives a good utility in the diagnosis and
treatment of maxillofacial trauma. If properly developed
and implemented, the relative advantages of USG over
CT could minimize the use of CT scans for exclusive
circumstances and thus revolutionize maxillofacial imaging
in trauma care.
Furthermore, studies should be conducted with a
considerable amount of sample size as the literature
mentions limited work regarding USG as a primary
technique in maxillofacial fractures detection. Furthermore,
it should be validated as a procedure along with CT scans
and conventional radiographs in medicolegal cases for
detection of fractures.
In conclusion, USG can be a handy, diagnostic, additional,
noninvasive, and inexpensive tool in the detection of
maxillofacial fractures when compared to CT in primary
health‑care centers.
Financial support and sponsorship
Nil.
44 Journal of Oral and Maxillofacial Radiology / Volume 10 / Issue 2 / May‑August 2022
Conflicts of interest
There are no conflicts of interest.
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