Maxillofacial fractures

1. Maxillofacial Fractures
Copyright of Allan G. Farman

2. Teeth

3. Recent Tooth Fracture
 Thin radiolucent line(s) extending through
any portion of tooth.
 “Step defect.”
 Well-defined yet soft radiolucent band
(where central x-ray beam cuts fracture
line obliquely).
 For crown, transillumination and/or
disclosing solutions often useful.

4. Traumatic dental
injury:
root
fracture of
maxillary
left central
incisor
(topographic
occlusal view).

5. Fractured right maxillary
central incisor.

6. Tooth Displacement
 Concussion – no radiologic sign or pdl
widening, most frequently apically.
 Subluxation – often tooth mobility with no
radiologic sign or pdl widening.
 Luxation – Widened pdl (unless intrusive);
minor alveolar fracture(s); step in dental
occlusion.

7. Subluxation of mandibular
anterior teeth following
trauma.

8. Later changes following
luxation.
 Pulp necrosis – widened pulp due to
absence of continued 2y dentin formation.
 Apical periodontal pathosis.
 External root resorption and possible
ankylosis.
 Pulpal obliteration.

9. Resorption of root of maxillary central
incisor following trauma (thermal
print of RVG 32000 digital images).

10. Alveolus

11. Alveolar Fracture
 Sharply defined, uncorticated and
occasionally jagged radiolucent line in
alveolus.
 Fracture line(s) mostly horizontal.
 Segment of teeth may be displaced.
 Widened pdl spaces.
 Possible associated root fractures.

12. Alveolar fracture
in anterior mandible.

13. Alveolar fracture in anterior mandible
(red arrows).There is also a fracture in
the right molar region of the same jaw
(yellow arrow).

14. Alveolar fracture
combined with
fracture through
symphysis:
topographic
occlusal
projection.

15. Alveolar fracture in
anterior maxilla.

16. Mandible

17. Mandibular Condyle
 Condylar head “sheared off” and
telescoped inward on itself.
 Step defect.
 Overlap of trabecular pattern seen as band
of increased opacity.
 Deviation of mandible to affected side.
 Rarely, condylar head maintains integrity.

18. Fracture of right
mandibular condyle
and at left angle of
mandible.

19. R
Fracture of left mandibular condyle with
medial displacement of condylar head
(Reverse Towne’s projection).

20. R
Fractures of mandibular
symphysis and left condyle.

21. Mandibular Body
 Radiographic visible line of cleavage if x-
ray beam parallels fracture line.
 Line of cleavage may be indistinct if x-ray
beam is not parallel to fracture line.
 Step defect.
 Contralateral condylar head frequently
fractured.

22. Mandibular fracture (depressed) in
left canine/premolar region. Note
fracture line and step in cortical outline.

23. Fracture at left mandibular
angle shown on panoramic
dental radiograph.

24. Mandibular fracture of
left angle following
surgical realignment and
fixation.

25. R
Mandibular fracture at angle on right
side (PA view).

26. Mandibular fracture: this is the same case but
here the fracture is not so obvious. It is actually
at the right mandibular angle. Two views at right
angles are suggested when looking for fractures.

27. Mandibular fractures
in right molar and
left premolar regions
(incidentally, molars
are taurodonts).

28. L
Mandibular fracture
in right third
molar region.

29. R
Comminuted fracture of left
mandibular body (positioning error
are not unusual in trauma victims
– the patient’s chin was too low and
head too far forward in this case).

30. L
Comminuted fracture of left
mandibular ramus caused by
gunshot injury.

31. R
Comminuted fracture of left mandibular
ramus caused by gunshot injury (PA view
of same patient).

33. R

34. R

35. Pathological fracture associated
with large apical cyst in left
mandibular first molar region.

36. L
Pathologic fracture associated with
large radicular cyst (lateral-oblique view
from same patient).

41. Maxilla

42. Zygomatic Arch

43. Zygomatic Arch Fractures
 Together with zygomatico-maxillary
fractures, represent 25% of all facial
fractures.
 Depression of zygomatic arch on
submentovertex, Waters and PA views.
 Close proximity of coronoid process to
zygomatic arch.

44. Depressed fracture
of left zygomatic arch
(2 different cases):
(submentovertex
views).

45. Detail of depressed
fracture of left
zygomatic arch:
fracture
left side of
submentovertex
projection.

46. Zygomaticomaxillary Fractures
 Widening of zygomaticofrontal,
zygomaticomaxillary and zygomaticotemporal
suture lines.
 Step defects at junction of frontal and zygomatic
bones, zygoma and maxilla, or zygoma and
temporal bone (“tripod” fractures) .
 CT used for assessing on nasolacrimal canal,
lateral rectus muscle of eye and posible intra-
cranial hemorrhage .

47. R
Tripod fracture (depressed)
of left malar complex (arrow).

48. R
Tripod fracture of left zygomatic
complex (PA view).

49. Depressed fracture of left zygomatic arch
(blue arrow) and blow-out fracture of left
orbital floor (yellow arrow) - Water’s view.

50. Depressed fracture of left zygomatic arch
(blue arrow) and blow-out fracture (yellow
arrow) of left orbital floor (Water’s view).

51. Orbit

52. Blow-out Fracture
 Force transmitted to thin orbital floor, which
generally fractures near infraorbital canal.
 Soft tissue swelling over orbital rim.
 Opacification of affected maxillary sinus.
 Displaced orbital floor (“trap door”).
 Polypoid density in roof of maxillary sinus
through herniation of orbital contents.
 Cheek paresthesia if infraorbital canal involved.

54. Fracture of lateral wall plus blow-out
fracture of left orbit (coronal CT). Note lack
of continuity of orbital rim.

55. Blow-out fracture of left orbital floor in
region of infraorbital canal (coronal CT).

56. Blow-out fracture
of left orbital floor:
Water’s
projection.

57. Blow-out fracture of right orbital floor
indicated solely by thickening of mucosa
lining superior antral wall (Water’s view).

58. Blowout fracture of right orbital floor
indicated by thickening of roof of maxillary
sinus (PA tomographic view) – see arrow.

59. Blow-out fracture of right orbit shows typical
“trap door” sign. There is opacification
of the affected sinus (coronal tomograph).

60. Le Fort Type I
 Fracture above level of maxillary teeth involving
alveolar process, palate and pterygoid plates.
 Clouding of maxillary sinus on one or both sides.
 Discontinuity of lateral maxillary sinus walls on
plain radiographs.
 Sharp horizontal line of cleavage through
maxilla, pterygoid plates and sphenoid.
 Canted maxilla relative to cranial base and
mandibular teeth.

61. R
LeFort I midfacial fracture with bilateral fractures
of the walls of the left and right maxillary sinuses.
Both sinuses show opacification.

62. Le Fort Type II
 Pyramidal fracture across nasal bones and
frontal processes of maxilla, extending laterally
through lacrimal bones, inferior rim of orbit
near zygomaticomaxillary suture, lateral walls of
maxilla and pterygoid plates.
 Increased width of frontonasal suture.
 Radiolucent cleavage lines.
 Step defect in orbital rim.
 Sinus shadows obscurred by hemorrhage.
 Disruption in dental occlusion.

63. L
Le Fort II midfacial fracture: fracture lines
extend obliquely through nasofrontal sutures,
through the medial and inferior aspects of
both orbits and the lateral walls of both maxillary
sinuses (PA view).

64. PA view Axial CT
R
Le Fort II
fracture

65. Le Fort II fracture (same case) shown with
surface-rendered 3-D reconstruction of axial
CT slices.

66. Le Fort II fracture:
note lack of
continuity in
outlines of
maxillary sinuses
(axial CT).

67. Le Fort Type III
 Craniofacial dysjunction with shearing of facial
complex from cranial base. Involves nasofrontal,
maxillofrontal and zygomaticofrontal sutures
orbit, ethmoid sinus and sphenoid sinus floors.
 Widened frontonasal, maxillofrontal,
zygomaticofrontal and zygomaticotemporal
sutures.
 Radiolucent cleavage lines through frontal
processes of maxilla, both pterygoid plates and
one or both orbital floors.
 Sinus shadows obscurred by hemorrhage.

68. Le Fort III midface fractures: PA view shows
fractures of lateral walls of both maxillary sinuses
with concomitant opacification of the sinuses.
Glabella and right zygomaticofrontal sutures also
evidence fracture lines.

69. Le Fort III fractures involving
nasoethmoidal region (lateral view).

70. Le Fort III fracture: lateral view demonstrates
fracture lines in the nasoethmoidal region and
anterior maxilla (both Le Fort III and Le Fort I).

71. Grafts

72. R L
BUC LING
R L

73. R L R L R L
R L R L R L

75. Maxillofacial Fractures
(1) CT is both the state-of-the-art and the
current standard of care for maxillary fracture
evaluation.
(2) Panoramic radiography is the best modality for
evaluation of the mandible following trauma.