help to humanity.serve the patients.

1. Dr. Ayesha Isani Majeed
MCPS, FRCR
Assistant Professor & Consultant
Department of Radiology
Pakistan Institute of Medical Sciences
Islamabad Radiology Clinic; Blue Area

2.  This forum is an excellent opportunity to assess the
approach to maxillo facial injuries. We have a composite
comprising of maxillo facial surgeons, plastic surgeons, and
radiologists.
 As a radiologist my aim is to give an idea about the input we
can give to the clinicians by the various imaging modalities at
our disposal.
 I would like this discussion to be an interactive one and
would appreciate a feedback as to what the clinicians require
so that our output as radiologists is fruitful. It has to be a
team effort because teams are what win matches not
individuals.

3. 1. Plain radiographs in two planes
2. CT
3. MRI

4.  The history and physical examination have long been
identified as the most important initial steps in the diagnosis
of a medical disorder. The clinical evaluation of all trauma
patients must be done first, and a through documentation of
all components of their injury is necessary in order to enable
the correct radiographic examination.
 A word about radiation exposure
Lowest radiation dose x-ray
CT 0.4-4.7c Gy (average 2.5c Gy)
(skin dose)
Gonadal 0.1-0.3 u Gy
Tomography skin dose 6 u Gy

6. 1. Line 1 look for:
 Fractures
 Widening of the zygomatic-frontal suture
 Fluid level (haemorrhage) in a frontal sinus
2. Line 2 look for:
 Fractures of the zygomatic arch
 A fracture through the inferior rim of the orbit
 A soft tissue shadow in the roof of the maxillary antrum
3. Line 3 look for:
 Fractures of the zygoma and of the lateral aspect of the
maxillary antrum
 A fluid level in the maxillary antrum.

7. 1. Separation sign
2. Overlap sign
3. Suture diastasis
4. Bony steps
5. Periodontal ligament widening
6. Abnormal linear density
7. Disappearing fragment sign
8. Abnormal angulation / curve
9. Displaced bone
Radiographic signs of bone fracture
Indirect
1. Soft tissue swelling
2. Sinus opacification
3. Air in soft tissues
4. Occlusal plane changes
5. Dental injuries

8.  ‘Gold standard’ in multi planar evaluation of
midface trauma
 Little value in:
 Uncomplicated mandibular fractures
 Le Fort I level fractures

9.  CT’s can be evaluated by a concept of a series of horizontal,
coronal, and saggital struts or buttresses. These can be used to
evaluate the ct images of patients with facial trauma.
 Horizontal plane struts
Superior Orbital roof
Middle Orbital floor
Inferior Hard palate
 Saggital plane struts
Midline Perpendicular plate of ethmoid
Parasaggital Medial orbital walls
Lateral Lateral orbital walls
 Coronal plane struts
Anterior Anterior wall of frontal sinus
Posterior Posterior wall of maxillary antra

10.  No extra information beyond plain CT
 Better 3D assessment for some surgeons
 Easier fracture localization
 Valuable in planning information; esp in
panfacial trauma
 Patient counseling & education
 Be wary of false bone fenestrations

13.  Mandibular fractures:
Mandibular fractures as a group,
are best evaluated and diagnosed with plain films +
polytomographs. The mandibular series involves
a) A right and left oblique view
b) PA view
c) Lateral skull film
d) Towne’s view combined with a pantomogram
images of a) subcondyler d) angle
b) coronoid e) body fractures
c) ramus f) symphysis and alveolar
fractures

16.  OPG
 PA Face
 Reverse Towne’s view
 Transcranial arthrograms
 CT

24.  See beyond swelling
 Occipitomental projections
 Water’s view
 Occipitofrontal projections
 Submentovertex view for arch
 CT images best

33.  Lateral view of face
 Occipitomental projection

36.  OM view; ‘hanging drop’; little information
 CT in all three planes; extremely valuable
 Floor; Coronal & sagittal sections
 Roof; All three planes
 Lateral & medial walls; Axial & coronal sections

44. Image 1a and 1b (Magnetic Resonance Imaging): Sagittal proton density image of
the right TMJ with mouth closed showing anteriorly displaced degenerate
articular disc (Image 1a). This fails to recapture in open mouth series (Image 1b)
(arrow).

45. Normal sagittal
oblique imaging
anatomy of the
temporomandibular
joint.This closed-
mouth proton density
image shows the
mandibular condyle
(asterisk), articular
eminence [a], and the
interposed articular
disc, seen as a
hypointense bandlike
structure (between
the arrowheads).

46. Joint effusion. Sagittal
oblique short tau
inversion recovery
imaging shows an
abnormally flattened
mandibular condyle [c].
Fluid collections are
seen in the superior
(large arrow) and
inferior (small arrows)
joint spaces, separated
by the anteriorly
displaced articular disc
(the arrowhead
indicates the anterior
band).

47.  Do x rays only if necessary
 Digital x rays are better
 Correct angulation is important
 CT has become increasingly popular; more so
with increasing employment of ORIF (open
reduction internal fixation) in facial fractures;
3D is an invaluable tool for planning
treatment
 MRI’s role is being defined