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Arthritis

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Radiology Book Facial and Mandibular Fractures

Facial and Mandibular Fractures

Facial Fractures

Appendicular Arthritis
Axial Arthritis
Lucent Lesions of Bone
Sclerotic Lesions of Bone
Periosteal Reaction
Soft Tissue Calcications
Fractures Without
Signicant Trauma
Facial and Mandibular
Fractures
The Painful Joint Prosthesis
Orthopedic Hardware

The bones of the skull and face collectively make up the most complex area of skeletal real estate in the body. Analysis of
the fractured face requires a knowledge of not only normal anatomy, but also of common fracture patterns in the face.
Although they represent serious injuries, the workup and treatment of facial fractures is often properly delayed until
more pressing problems have been addressed, such as the establishment of an adequate airway, hemodynamic
stabilization, and the evaluation and treatment of other more serious injuries of the head, chest and skeleton. Once these
problems have been managed, it is time to work up facial fractures.
At our institution, high resolution CT is currently the imaging procedure of choice for most facial fractures. The complex
anatomy and fractures of the facial bones are shown extremely well by CT, and soft tissue complications can be evaluated
to a far greater degree with CT. Therefore, the plain lm facial series has taken a back seat to CT in the past few years,
and is now used only in certain situations, such as when the facial trauma is very focal (nasal fracture), or when CT is
unavailable. However I nd it easier to initially teach the anatomy and fracture patterns of the face with plain lms. Once
these concepts have been grasped by the resident, one can then move on to the axial and coronal anatomy shown by CT.
A basic facial series consists of three or four lms: a Waters view (PA view with cephalad angulation), a Caldwell view (PA
view), a lateral view, and occasionally a submentovertex view. If a nasal fracture is suspected, then a lateral view of the
nasal bone with special nasal technique may be done. Of these views, the most consistently helpful view in facial trauma
is the Waters view. It tends to show all of the major facial structures at least as well and often better than other
radiographic views of the face.
It can initially be a bit daunting to think about ruling out fractures of the complex collection of bones that make up the

Scoliosis
Osteopenia
Osteonecrosis
Skeletal Dysplasias

face. However, here are several simplifying rules that can make life a lot easier:
1. Look at the orbits carefully, since 60 - 70 % of all facial fractures involve the orbit in some way. The exceptions: a
local nasal bone fracture, a zygomatic arch fracture, and the LeFort I fracture. It is especially important to examine
the orbital borders and apex, as well as the optic canal.
2. Know the most common patterns of facial fractures and look for them.
3. Bilateral symmetry can be very helpful. Normal radiopacities are usually bilateral, while abnormal ones are usually
unilateral.
4. Carefully trace along the lines of Dolan when examining the Waters view in a facial series.

the lines of Dolan and the elephants of Rogers

What are the lines of Dolan? They are three anatomic contours best seen on the Waters view of the face, and they were
rst popularized by Dolan et al. As you can see, the 3 lines of Dolan lead the eye along some facially important structures.
Lee Rogers pointed out that the 2nd and 3rd lines together form the prole of an elephant.
When you search for a fracture, you are really searching for one or more of the following radiographic signs.
Radiographic signs of facial fractures
Direct Signs
nonanatomic linear lucencies
cortical defect or diastatic suture
bone fragments overlapping causing a "double-density"
asymmetry of face
Indirect Signs
soft tissue swelling
periorbital or intracranial air
uid in a paranasal sinus
The most common mechanism producing facial fractures is auto accidents. About 70 % of auto accidents produce some
type of facial injury, although most are limited to soft tissue. The face seems to be a favorite target in ghts or assaults,
which are the next most common mechanism. The remainder of facial fractures are produced by falls, sports, industrial
accidents and gunshot wounds. Less than 10 % of all facial fractures occur in children, perhaps because of the increased
resiliency of a child's facial skeleton. The most common patterns of midfacial fractures are summarized in the table
below.
Fracture Type

Prevalence

Zygomaticomaxillary complex (tripod fracture)

40 %

LeFort

15 %

II

10 %

III

10 %

Zygomatic arch

10 %

Alveolar process of maxilla

5%

Smash fractures

5%

Other

5%

Probably the most common facial fracture is the tripod or zygomaticomaxillary complex fracture, so called because it
involves separation of all three major attachments of the zygoma to the rest of the face.

frontal view of a zygomaticomaxillary complex fracture

submentovertex view of a zygomaticomaxillary complex fracture

Although it may be fractured, the separation of the frontal process of the zygoma from the frontal bone usually occurs in
the form of a diastasis of the zygomaticofrontal suture. This fracture is usually due to a direct blow to the body of the
zygoma. This fracture will generally cause contour abnormalities of all three of the lines of Dolan. Occasionally,
extraocular muscles may become entrapped in the zygomaticomaxillary component of the fracture complex. The
displaced tripod fragment may physically restrict motion of the mandible. In some cases, force may propagate along the
long axis of the lateral orbital wall and involve the orbital apex or optic canal, resulting in diminished vision. CT is
extremely helpful in evaluating these fractures.
Fractures may be isolated to the zygomatic arch. Clinically, these injuries are usually due to a blow from the side of the
face. Patients with this injury often present with atness of the lateral cheek area and inability to open their mouth, due
to impingement of the zygomatic arch fragment upon the coronoid process of the mandible or the temporalis muscle.
Adequate visualization of this fracture may require a submentovertex view or CT.
Another focal fracture type is a fracture of the alveolar process of the maxilla, which involves a small piece of the maxilla,
associated with several fractured teeth. The main treatment goal here is to maintain viability of the teeth. If all of the
fractured teeth cannot be accounted for, a chest lm should be carefully examined to look for evidence of aspirated tooth
fragments.
Another common fracture is the orbital oor fracture, or "blowout" fracture. The usual mechanism is a blow to the eye,
with the forces being transmitted by the soft tissues of the orbit downward to the thin oor of the orbit. The oor is
usually the path of least resistance, and fractures downward into the maxillary sinus. Common clinical signs are
enophthalmos and diplopia (especially on upward gaze), and one should remember that about 24 % of these fractures
are associated with ocular injury as well. On a Waters view, one may see a soft tissue mass on the superior margin of the
maxillary sinus, representing the herniated periorbital tissues into the sinus. One may also see a "trapdoor" fragment of
bone protruding down into the sinus, often hinged on the ethmoidal side. CT will, of course, show these fractures and
soft tissue mass much better.

"blowout fracture" -- the arrows point to the fracture fragments and periorbital tissue which have herniated into the
maxillary sinus
The nose is the most frequently injured facial structure, undoubtedly because of its prominent position on the face.
Likewise, the most commonly missed facial fracture of the face is a fracture of the nasal bone. Although one can
occasionally see a nasal bone fracture well on a standard lateral skull lm, these fractures are much better seen when the
lm is shot with special low kVp nasal bone technique (essentially soft tissue technique). One should always look at the
inferior nasal spine (part of the maxilla) as well for subtle fractures. Common pitfalls in viewing the nasal bone are the
normal sutures lining the nasal bone, as well as the linear channel for the nasociliary nerve, which may all be mistaken for
a fracture. A helpful rule is that this channel runs parallel to the bridge of the nose, while most nasal bone fractures will
run perpendicular to the bridge. It is well to remember that the humble nasal bone fracture may be associated with more
extensive injuries, such as the orbital rim or oor and the ethmoid or frontal sinuses.

normal nasal bone anatomy

The next set of fractures in this rogue's gallery of common facial fractures are the LeFort complexes. These are complex
bilateral fractures associated with a large unstable fragment ("oating face") and invariably involve the pterygoid plates.
Legend has it that LeFort dropped skulls o of a French tavern roof and analyzed the resulting fracture patterns. This
certainly sounds like the kind of study that we would all like to do, even without NIH funding. In reality, LeFort studied
fracture patterns produced in cadavers. He found three main planes of "weakness" in the face, which correspond to
where fractures often occur: the transmaxillary plane, the subzygomatic or pyramidal plane (this is really two planes with
an apex up at the bridge of the nose), and a craniofacial plane.

frontal views of LeFort complex fractures I - III

lateral views of LeFort complex fractures I - III

The LeFort I, or transmaxillary fracture runs between the maxillary oor and the orbital oor. It may involve the medial
and lateral walls of the maxillary sinuses and invariably involves the pterygoid processes of the sphenoid. Clinically, the
oating fragment will be the lower maxilla with the maxillary teeth.
The LeFort II occurs along yet another weak zone in the face, and is sometimes called a pyramidal fracture because of its
shape. A common mechanism is a downward blow to the nasal area.
The most severe of the classic LeFort fracture complexes is the LeFort III. I suppose that this is pretty obvious, given a
three-part grading system. In this case, the large unstable (oating) fragment is virtually the entire face! Thus, this fracture
is also referred to as craniofacial disassociation. This is a very severe injury, and is often associated with signicant injury
to many of the soft tissue structures along the fracture lines. Generally, considerable force is necessary to produce this
injury, and it is uncommon as an isolated injury. It may also occur in association with severe skull and brain injuries.
With the exception of the LeFort I injury, "pure" LeFort injuries are not commonly seen. More commonly seen are variants
of the LeFort classication. One of the most common of these is the LeFort II - tripod fracture complex. This complex is
usually due to the large forces encountered in a motor vehicle accident. LeFort was probably unable to apply this much
force to the cadaver faces in his study, and it is therefore not too mysterious why he didn't describe these more complex
injuries. When describing these injuries, one should probably give a separate diagnosis to each half of the face. Even
more complex patterns may be encountered, such as a mixed LeFort II/LeFort III complex or a LeFort III/LeFort II/tripod
complex.
Besides the classic LeFort patterns and the mixed LeFort variants, there is another common pattern which is called, for
obvious reasons, a "smash" fracture. In these injuries, severe comminution of the face is present, and underlying skull
injury is likely. These patients are often in unstable condition with associated axial and appendicular skeletal injuries as
well. This category includes several varieties of otherwise unclassiable fractures, which are named for the portion of the
face primarily involved. Subclassications of smash fractures include the frontal, naso-frontal (naso-ethmoid) or central
facial smash syndromes. CT is mandatory for adequately displaying all of the bony and soft tissue components of these
injuries.

Wise sayings about facial fractures

1. Look at the orbits carefully, since 60 - 70 % of all facial fractures involve the orbit in some way.
2. Bilateral symmetry can be very helpful.
3. Carefully trace along the lines of Dolan.
4. Use CT liberally in working up facial fractures.
Mandibular Fractures
The mandible is another commonly fractured bone in the head, and most of these fractures are obvious on clinical exam.
Clinical ndings include facial distortion, malocclusion of the teeth, or abnormal mobility of portions of the mandible or
teeth.
The mandible is one of those bones covered by the "ring bone rule", which may be stated thusly: if you see a fracture or
dislocation in a ring bone or ring bone equivalent, look for another fracture or dislocation. You can experiment with this
tendency of ring bones to break in more than one place by going through a bag of pretzels and trying to break one of
them in just one place. Then try it with a bag of bagels. You should now have a good appreciation for Lee Rogers'
corollary to the ring bone rule, which he calls the "pretzel-bagel spectrum". To wit, the stier a ring bone is, the more
likely it is to break in more than one place. The more exible it is, the more likely it is to break in just one place. The
mandible has some exibility, due not only to the mobility around the temporomandibular joints (TMJ's) but also to the
tendency of the TMJ's to absorb some forces during trauma. What this boils down to is that one sees an average of 1.5 to
1.8 mandibular fractures per customer, depending on whether the mechanism is blue collar (st or other anonymous
blunt object) or white collar (automobile crash) respectively. Like the nose, the mandible also has a prominent position on
the face, making it a favorite target for either of these mechanisms. Mandibular fractures have traditionally occurred at
twice the prevalence of facial fractures, but this ratio has been decreasing with the increasing prevalence of high-speed
auto accidents. Only 5 % of all mandibular fractures occur in children, and most of these are also caused by auto
accidents, with about 1/3 due to bicycle accidents.
Mandibular fractures can occur at any of the following sites.

common sites of mandibular fractures

Fracture Type
Body

Prevalence
30 - 40 %

Angle

25 - 31 %

Condyle

15 - 17 %

Symphysis

7 - 15 %

Ramus

3-9%

Alveolar

2-4%

Coronoid process 1 - 2 %
When double fractures occur, they are usually on contralateral sides of the symphysis. Common combinations include
the angle plus the contralateral body or condyle. Triple fractures occasionally occur, and the most common type is
fracture of both condyles plus the symphysis.
The mandible may also be dislocated without fracture, sometimes spontaneously during a large yawn. The patient usually
presents with considerable pain. Spasm in the masseter and pterygoid muscles tend to force the condyles up the anterior
slope of the articular eminence and prevent normal mouth closure.

mandibular dislocation -- the condyle (c) is anterior to the articular eminence (e)
Wise sayings about mandibular fractures
1. Remember the ring bone rule.
2. Symphyseal fractures can be diabolically hard to see, even on a well-exposed AP lm
3. Remember the Panorex view -- this can usually only be taken by a special machine in the oral surgery department,
but it provides the best single view of the mandible and will show you fractures that cannot be seen by any other
method short of CT.

4. Look carefully along the cortical margin of the whole mandible for discontinuities. This may be the only sign of a
fracture that you will see.
5. Also carefully examine the mandibular canal for discontinuities.
6. A fracture line entering the root of a tooth is considered an open fracture by denition.
7. Pathologic fractures can occur in the mandible. Look carefully for evidence of a periapical abscess or a mandibular
tumor, especially if there doesn't seem to be enough trauma to match the injury.
References
1. Dolan KD, Jacoby CG. Facial fractures. Semin Roentgenol 1978;13:37-51.
2. Dolan KD, Jacoby CG, Smoker WR. The radiology of facial fractures. Radiographics 1984;4:575-663.

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