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ROLE OF MULTIDETECTOR SPIRAL-CT IN THE MANAGEMENT OF MAXILLO-FACIAL TRAUMATIC LESIONS
Department of Neuroradiology. Speciality Hospital. Rabat. Morocco
S.BELABBES, M.FIKRI, M.R.EL HASSANI, M. JIDDANE
HN9
INTRODUCTION
The facial traumatisms are a common reason for recourse to the care in emergency
Young adults+++ circumstances of occurrence: roads
accidents+++, agressions+++, falls, sports accidents, work accidents.
Multiple functional and aesthetic impacts, rarely vital( if associated with brain and cervical lesions).
spiral CT has an important place in the exploration of facial trauma
INTRODUCTION
The objectives of imaging: Identification of fractures, irradiation and
their potential displacement Lesional type classification Research of lesions potentially serious,
requiring rapid intervention Research of associated extra-facial
lesions (cervical spine, brain ...)
MATERIALS and METHODS
retrospective study of 45 cases of maxillofacial traumatisms seen in emergencies and sent to the Department of Neuroradiology for evaluating
All our patients underwent CT in helical acquisition with multiplanar reconstruction and 3D
Results
The age of our patients was between 16 and 60 years.
Sex-ratio: 4m/1w
different CT aspects were found: Fractures of the orbit (floor, roof and lamina papyracea), fracture of the zygomatic process, sinus fracture, mandibular fracture (body, ramus and mandibular condyle), naso-ethmoido-maxilo-fronto-orbital complex fracture and Le fort fractures
DISCUSSIONPathophysiology-biomechanics
Buttress anatomy: line diagram showing important facial buttresses.
Vertical Buttresses1. Nasomaxillary2. Zigomaticomaxill
ary3. Pterygomaxillary4. Vertical
mandibleHorizontal ButtressesA. Frontal BarB. Inferior orbital rimC. Hard palate
Central box:Nasal cavity+ethmoidSide boxes:maxillary sinuses + orbits
Major resistance in the vertical axis Low resistance to horizontal constraints (antero-
posterior and lateral) Fractures perpendicular to the pillars
DISCUSSION
Indirect signs:• Swelling, soft tissue deformation• Fluid in a paranasal sinus,• Subcutaneous emphysema,
pneumoencéphalie,• pneumo-orbit
Direct signs:• nonanatomic linear lucencies • cortical defect or diastatic suture • bone fragments overlapping causing a
"double-density" • asymmetry of face
CT semiology
CT Indirect signes
Fluid in a paranasal sinus( )
Subcutaneous emphysema( )
• Pneumoencéphalie( )• pneumo-orbi ( )Given these signs, facial fracture is strongly suspected
Make reconstructions
with filter "hard" focused on the facial Helping if
necessary by 3D reconstructions
DISCUSSION
Isolated fractures: Fracture of the nose Fracture of the zygomatic arch zygomaticomaxillary fracture Fracture of the mandible Fracture of the frontal sinus
complex fractures Transverse fractures of the face (Le fort
I, II, III) Centro-facial fractures
Classification
Simple Fractures
The most common traumatic damage of the facial bone
Easy diagnosis clinically X ray is usually
sufficient( lateral view) Emergency: In case of
nasal septum hematoma
Fractures of nasal bone and nasal pyramid
fracture of the nasal septum
( ) (risk of hematoma)
Fracture of nasal bone
Simple Fractures
Can be identified in Hirtz ‘s incidence
Risk of blockage of the temporomandibular joint by: hematoma of the
temporal muscle fracture of the
coronoid process of the mandible
Zygomatic arch fracture
Simple Fractures
Latero-facial fracture is the most common Detaches the zygomatic bone of the maxilla, orbit and temporal bone Combines:
1. zygomatico-frontal disjunction 2. temporo-zygomatic disjunction 3. zygomatico-maxillary fracture 4. fracture of the zygomatic arch 5. fractures of the anterior and posterolateral maxillary sinus wall
Posterior extension: floor and side walls of the orbit, apex orbital and sphenoid body
Complications: Orbital (hematoma, incarceration or muscle plug) Nerve (infraorbitalduct injury) Masticatory ( temporalis muscle plug)
Zygomaticomaxillary fracture(Zygomatic tripod fracture)
Simple FracturesZygomaticomaxillary fracture(Zygomatic tripod fracture)
Right zygomatic tripod fracture with the involvement of the
nasolacrimal duct( ) and lateral orbital wall causing
lateral rectus plug( )
Simple FracturesZygomaticomaxillary fracture(Zygomatic tripod fracture)
Fracture of orbital floor with inferior rectus plug by a
bone splinter( )
Left zygomatic tripod fracture with involvement
of the infraorbital canal( )
Simple Fractures
Fracture of the toothed portion and processes condylar
reaching the mental foramen
Fracture of the toothed maxillary or mandibular portion: open fracture
IT should always a seek joint damage (TMJ) associated
sub-condylar Fracture (extra articular)
Condylar fracture (intra articular)
Fracture of the mandible
Risk of ankylosis
Simple FracturesFracture of the mandible
Distribution of mandibular fractures in order of frequency
Simple FracturesFracture of the mandible
Forces acting on the mandible and the relationship between muscle pulls and fracture angulation. A: Horizontally unfavorable. B: Horizontally favorable. C: Vertically unfavorable. D: Vertically favorable.
Simple FracturesFracture of the mandible
Transverse fracture of the alveolar portion of the
mandible
Simple FracturesFracture of the mandible
unfavorable Para-symphyseal right
fracture associated with left condylar fracture
Simple FracturesFracture of the mandible
Bilateral para-symphyseal fracture
with depression of the intercalary fragment
associated with a right condylar fracture
Simple Fractures
Clinical classification Anterior table
Displaced Un-displaced
Posterior table Displaced Un-displaced
Anterior and posterior table Displaced Un-displaced
Nasofrontal duct Involved uninvolved
Fracture of the frontal sinus
Simple Fractures
Simplified Clinical Classification
1. Fracture of anterior table
2. Fracture with disruption of posterior wall
3. Fracture involving floor of the sinus
Fracture of the frontal sinus
Simple FracturesFracture of the frontal sinus
transfixing fracture of the frontal sinus with
involvment of orbital roof
Complex Fractures
The LeFort I (Low-level fracture): runs between the maxillary floor
and
the orbital floor. It may involve the medial and
lateral
walls of the maxillary sinuses and invariably involves the pterygoid processes of the sphenoid. Clinically, the floating fragment
will be the lower maxilla with the maxillary teeth.
Transverse fractures of the face
Lefort fracture
Complex Fractures
The LeFort II(Pyramidal fracture): fracture crosses the nasal
bones on the ascending process of the maxilla and lacrimal bone and crosses the orbital rim.
highest incidence of infraorbital nerve hypesthesias.
extends posteriorly to the pterygoid plates at the base of the skull.
Transverse fractures of the face
Lefort fracture
Complex Fractures
The LeFort III(Craniofacial dysjunction): Fracture traverses
the frontal process of the maxilla,
the lacrimal bone, the lamina papyracea, and the orbital floor.
Often involves the posterior plate of the ethmoid.
Highest rate of cerebrospinal fluid (CSF) leaks
Transverse fractures of the face
Lefort fracture
Complex FracturesTransverse fractures of the face
Lefort III
Lefort IRight Lefort II
Complex Fractures
fracture of naso-ethmoïdo-maxillo-fronto-orbital complex
The nasal bones Nasal septum The ethmoid (including the cribriform plate) The naso-frontal channels The frontal process of maxilla Orbital walls The frontal sinus
High risk of osteo-dural breach by fracture of the posterior wall of the frontal sinus, the cribriform plate and roof of the ethmoid
Possible association with other fractures including Lefort
Centro-facial fractures
Complex FracturesCentro-facial fractures
fracture of naso-ethmoïdo-maxillo-
fronto-orbital complex
CONCLUSION
One must bear in mind that facial traumatism is above all a head trauma and cervical spine
The CT is the key in the exploration of facial trauma
The radiological must make an exhaustive study of the lesions
Indicate severe lesions requiring supervision or an urgent care
