Tema 10

Radiol. Clin. North Am. - May 1999 Temas de Revision - H.
Misericordia – Cirugía Plástica
Radiologic Clinics of North America.

Volume 37, Number 3, May 1999
ADVANCES IN EMERGENCY RADIOLOGY I

HELICAL CT AND THREE-DIMENSIONAL CT OF FACIAL AND
ORBITAL INJURY
James T. Rhea 1 MD
Patrick M. Rao 1 2 MD
Robert A. Novelline 1 2 MD
1
Harvard Medical School; and the Department of Radiology (JTR, PMR, RAN)
2
Division of Emergency Radiology (PMR, RAN), Massachusetts General Hospital, Boston,
Massachusetts
Address reprint requests to:

James T. Rhea, MD, Massachusetts General Hospital, White 239, Fruit Street, Boston, MA
02114
Because of the superimposition of bony structures on plain radiographs,

interpretation of facial injury can be intimidating and inaccurate. Helical CT with
two- and three-dimensional reformations greatly simplifies interpretation, is highly
accurate for diagnosing fractures and soft tissue injuries, and is more accurate than
plain radiographs for many fractures. [23] [24] [28] [29] [45] [46] [47] [57] Helical CT is also accurate in
assessing which areas of facial injury are stable or unstable for planning corrective
surgery and in determining the degree of displacement or rotation of major bony
fragments. Helical CT has been shown to be faster and to produce planar and three-
dimensional reformations with less motion artifact than conventional CT in the
assessment of facial trauma. [67] The diagnostic value of three-dimensional images has
been studied, and three-dimensional images have been shown to add significantly in
the evaluation of severe facial trauma in 29% of patients. [34] Three-dimensional
imaging appears superior in localization of complex fractures involving multiple
planes, [15] [41] in perception of fracture displacement, and in assessment of facial
symmetry. [18] Three-dimensional imaging has been used for fabrication of bone grafts
in complex facial restorations. [55] Although some mandible fractures may be
adequately assessed by plain radiographs, the sagittal splitting fracture of the condyle
is seen only with CT [73] and detection of anterior displacement of the condyle is
superior with CT. [50] It has been shown that the extent of comminution of mandibular
fractures and the location of stable bicortical bone for fixation should be assessed
with CT because this information is often not evident from plain radiographs or a
panorex view. [12] In the intubated blunt trauma patient, over half of facial fractures
are not suspected clinically. [51]
Given that CT has become the standard for imaging of most facial fractures, the
purpose of this article is to simplify the diagnostic task and to emphasize relevant
clinical findings seen with facial CT. The diagnostic task need not be intimidating if
there is an understanding of the five regions of the face that are prone to fracture and
if analysis of CT is done with knowledge of the types of fractures that are usually
encountered.
1
Radiol. Clin. North Am. - May 1999 Temas de Revision - H. Misericordia – Cirugía Plástica
THE FIVE REGIONS OF THE FACE
To simplify the diagnostic task, the face may be thought of as five regions that may
fracture as an entity or in combination with adjacent regions. These regions represent areas
of focus for presurgical planning and are as follows: (1) nasal, (2) orbital, (3) zygomatic,
(4) maxillary, and (5) mandibular. These regions and the supporting facial buttresses are
easy to analyze on CT and are involved with characteristic fractures and fracture patterns.
All but the mandibular region share bony surfaces and a single fracture line may involve
more than one region.
The nasal region includes the nasal bones and soft tissues, frontal processes of maxilla,
lacrimal bones, cartilaginous and bony nasal septum, and the ethmoid sinuses. The
conically shaped orbital region consists of the roof, medial and lateral walls, floor, and
orbital rim as well as the intraorbital soft tissues. The zygomatic region consists of the
zygoma and parts of the four other bones to which the zygoma attaches: (1) the maxillary,
(2) sphenoid, (3) temporal, and (4) frontal bones. The alveolar process of the maxilla,
palatine process of the maxilla, and palatine bone constitute the maxillary region of the
face. Lastly, the mandible and temporomandibular joints make up the mandibular region.
A given bone may not be confined entirely within the region bearing its name. The
maxilla, for example, forms part of the orbital floor and its frontal process forms part of the
nasal region.
The regions of the face are held in place by portions of the struts and the buttresses of the
face. For example, the maxillary region is supported by the walls of the maxillary sinuses,
the nasal septum, and the pterygoid plates. If the maxillary region were fractured and
separated from the rest of the face, fractures must be seen involving the walls of the
maxillary sinuses, the bony nasal septum, and the pterygoid plates (i.e., a classic Le Fort I
fracture).
The zygomatic region is supported by three thicker pieces of bone: (1) the lateral orbital
rim; (2) the inferior orbital rim; and (3) the zygomatic arch, all of which must be fractured
if the body of the zygoma is to be separated from the rest of the face. Such a fracture also
has to involve the thinner bones to which the zygoma contributes and to which it is
attached. These thinner bones form the lateral wall of the orbit, the floor of the orbit, and
the lateral and anterior walls of the maxillary sinus.
The nasal region is supported by the medial orbital rim and medial aspect of the inferior
orbital rim as well as by its attachments to the frontal bone. The nasal region shares with
the orbit the medial orbital wall.
The orbital region as defined by the conically shaped space does not separate from the rest
of the face as the zygomatic and maxillary regions can with injury. The strongest bones
supporting this space are those forming the orbital rim. The volume of the orbit, however,
is also critically dependent on the smaller and thinner bones forming its walls.
The mandible is the only bone of the face that does not have a suture with other facial
bones. As a result, it is self-contained and does not share borders with the rest of the face.
It is supported by its attaching muscles and by the glenoid fossa at the temporomandibular
joint.
2
TYPES OF FACIAL FRACTURES AND SOFT TISSUE INJURIES
Before considering the interpretation of facial CT and how thinking in terms of the five
regions of the face can greatly simplify this interpretation, it is useful to consider the
standard classifications of facial injuries.
Nasal and Naso-orbital-ethmoid Fractures
The nasal region fractures usually are grouped into simple nasal fractures and the more
complex naso-orbital-ethmoid (NOE) fractures (Fig. 1) . The simple nasal fractures involve
the nasal bones alone or the nasal bones and the frontal processes of the maxilla.
Displacement or angulation may occur inferiorly or laterally. At times, the anterior
maxillary spine may also be avulsed and is associated with disruption of the cartilaginous
nasal septum. [49] The NOE fractures involve the boundaries shared by the nasal and orbital
regions (i.e., the ethmoid sinuses and orbital rim). The NOE fractures involve posterior
displacement (telescoping) of the anterior nasal structures into the lacrimal bone (which
forms part of the medial orbital rim) and into the ethmoid sinuses. In addition to
telescoping, there frequently is lateral displacement of fracture fragments. Critical change
in orbital volume and injury to the medial canthal ligament, cribriform plate, nasofrontal
duct, and the nasolacrimal duct may occur with the NOE fractures. [28] [39]
Zygomatic Fractures
With a blow to the cheek, the body of the zygoma may be separated from the rest of the
face in a fracture pattern known as the zygoma complex fracture (Fig. 2) . Fractures should
be seen involving the three thicker pieces of bone supporting the zygoma; there frequently
is separation at the zygomaticofrontal suture (although the fracture line may involve the
frontal process of the zygoma instead); the inferior orbital rim is fractured; and there is
fracture of the zygomatic arch. The orbital floor is inevitably involved as is the lateral wall
of the orbit and the anterior and lateral walls of the maxillary sinus. The lateral wall
fracture may extend posteriorly and involve the orbital apex. [49] The body of the zygoma
may be displaced medially and posteriorly and may be rotated. The degree of displacement
and rotation is important to assess and may be well seen with three-dimensional
reformations. If orbital volume is affected by this fracture, reduction of displacement and
fixation are necessary. [53] If there are no symptoms or instability, zygomatic fractures may
be treated without surgery. [16]
In addition to the zygoma complex fracture, the zygomatic arch is vulnerable to isolated
fracture by a direct blow (Fig. 3) . There may be medial displacement of a portion of the
arch or the arch may be angulated medially through the sites of fracture. By impingement
on the temporalis muscle or the coronoid process of the mandible, the displaced arch
fracture may interfere with opening and closing of the mouth or may alter dental occlusion.
[49] [53]
3
Figure 1
Figure 1. Bilateral nasal and unilateral naso-orbital-ethmoid (NOE) fracture. A, The nasal bones and frontal
processes of maxilla are fractured (small arrows). Large arrow indicates naso-frontal suture. This could be an
isolated nasal, naso-orbital-ethmoid or part of a LeFort II or LeFort III fracture. B, The intact posterior-lateral
wall of the maxillary sinus (open arrow) and pterygoid plates (also seen to be intact on lower sections)
exclude the LeFort fracture possibilities. On the left side, the naso-lacrimal duct (large arrow) appears
posteriorly displaced, relative to the right, and there is a fracture of the anterior wall of the maxillary sinus
(small arrow) and nasal septum indicating a unilateral NOE. C, The fracture on the left is seen to involve the
inferior orbital rim (arrow) and medial wall of the orbit (open arrow), confirming a left NOE fracture. D,
Three-dimensional reformation gives a summary representation of the nasal displacement and fracture of the
orbital rim (arrow).
4
Figure 2
Figure 2. Zygoma complex fracture. A, Axial image

shows fracture of the zygomatic arch (large arrow)
and posterior-lateral wall of the maxillary sinus (small
arrow), with posterior displacement of part of the
body of the zygoma (open arrow). B, Frontal, three-
dimensional image shows the posterior and medial
displacement of part of the body of the zygoma and
the lateral orbital rim (open arrow). The extent of the
fracture into the posterior-lateral orbital wall is
apparent (white arrows). A right nasal fracture with
medial displacement also is noted (curved arrow). C,
Oblique, three-dimensional image shows the
depressed arch fractures (black arrows) and the
displacement of the lateral orbital rim (white arrow).
The position of fragments and presence of intact bone is shown well.
Figure 3
Figure 3. Isolated zygomatic arch fracture. A, Axial image shows a zygomatic arch fracture. The intact
posterior-lateral wall of the maxillary sinus (small arrows) excludes a zygomata complex fracture. The arch
fragments are depressed into the temporalis muscle and impinge on the coronoid process of the mandible
(large arrow). B, Coronal image also demonstrates impingement of the coronoid process (arrow), which can
limit mandibular motion.
5
Orbital Fractures
Although the walls and rim of the orbit are often fractured in conjunction with fractures of
adjacent regions, isolated fractures of the orbit may occur. The blow-in fracture, which
involves the orbital roof with inferior displacement of fracture fragments into the soft
tissues of the orbit, may be seen as an isolated injury but in more than half of cases is
associated with frontal sinus or skull fractures (Fig. 4) . [40] These blow-in fractures may
extend posteriorly and involve the orbital apex with potential for injury to the optic nerve.
[9]
These fractures usually are unilateral, but bilateral blow-in fractures may occur rarely. [25]
The blow-in fracture with an intact superior orbital rim is felt to be the result of a blow to
the frontal bone, which may not fracture but rather transmit the forces to the thinner orbital
roof resulting in its buckling downward. [40] If the roof is fractured in conjunction with other
fractures that involve a sinus, pneumocephalus may occur. [71] Ocular injuries are seen in
14% to 29% of patients with blow-in fractures. [30]
The blow-out fractures may involve either the orbital floor, medial wall, or both (Figs. 5 and
6) . CT imaging in both axial and coronal planes is necessary for accurate demonstration
of these fractures. [45] [49] The orbital rim is intact by definition if the blow-out designation is
used. With blow-out fractures, there is inferior displacement of a portion of the floor into
the maxillary sinus or medial displacement of a portion of the medial wall into the ethmoid
sinus. With sufficient force the medial blow-out may extend not only through the medial
wall but also through the floor of the ethmoid sinus into the nasal cavity. These fractures
occur with a blow to the orbit that increases intraorbital pressure sufficiently to break the
thinner bone of the floor or medial wall while leaving the orbital rim intact. The blow-out
fractures expand orbital volume due to the resulting herniation of orbital fat and possibly
extraocular muscle (medial or inferior rectus) through the site of fracture into the adjacent
sinus. Entrapment of muscle against the edge of intact orbital wall can occur with
limitation of ocular movement. Entrapment is more frequent with smaller fractures,
whereas enophthalmos is more frequent with larger fractures. [32] At CT entrapment may
be seen as an abrupt kink in the muscle as opposed to a smooth prolapse through the site
of fracture. [49] Release of entrapped muscles and restoration of orbital volume requires
surgical repair. It is thus important to visualize the size of these blow-out fractures and the
point at which intact bone exists for stabilization of prosthetic material, which must be
placed to restore the orbital wall. With blow-out fractures of the floor it is especially
important to know preoperatively whether the fracture extends to involve the upper
posterior wall of the maxillary sinus. If this portion of the sinus is involved, restoration of
orbital volume is more difficult. The oblique sagittal reformation parallel to the inferior
rectus is useful to assess large blow-out fractures and the relationship of the inferior
rectus to the intact bone of the orbital floor. [61]
Figure 4
6
Figure 4. Superior orbital rim fracture with extension

into orbital roof (orbital blow-in facture). A, Coronal
image shows bony fragments laterally (arrow) which
slightly depress the eyeball compared with the normal
side. B and C, Frontal and oblique three-dimensional
images show the limited extent of this rim and roof
fracture (arrows) with adjacent intact bone.
Figure 5
Figure 5. Blow-out fracture of both medial orbital wall and floor. A, Large medial wall fracture with
herniation of orbital fat into the ethmoid sinus (solid arrow) is well seen. There is hemorrhage into the
postbulbar fat (open arrow) and proptosis. B, Axial image shows fractures of the frontal processes of the
maxillae (open arrows), fragmentation of the orbital floor (large arrow) and intact anterior wall of maxillary
sinus (small arrows) immediately below an intact orbital rim.
Figure 5 C, The patient was unable

to assume a hyperextended position
for direct coronal CT, so coronal
reformations were made. The floor
fracture with herniation of fat is
noted (white arrow). The inferior
rectus is seen above the fracture
fragments (black arrow).
7
Figure 5 D, Coronal reformation

more posteriorly shows the
nondisplaced posterior extent of the
floor fracture (small arrow) and
medial wall fracture with herniated fat
(large arrow). The medial rectus is
displaced medially (open arrow) but is
not impinged on by bone.
Figure 6
Figure 6. Medial orbital blow-out fracture. A,

Axial image shows a large medial wall fracture
with herniation of the medial rectus (small
arrows). The smooth curvature of the rectus
makes entrapment less likely, although there is
approximation of the muscle and medial wall
anteriorly (large arrow)
Figure 6. Medial orbital blow-out fracture. B,

Coronal image demonstrates blow-out of the
medial orbital wall and of the ethmoid sinus
floor into the nasal cavity (black arrow).
(Compare with the normal inferior ethmoid
wall [ white arrow]).
8
Fractures of the orbital rim may occur with a narrowly focused blow or a blow of more
force than that resulting in a blow-out fracture. These fractures may extend into the
adjacent orbital wall for varying distances. For example, an inferior rim fracture may
extend into the orbital floor with herniation of orbital contents through the floor fracture.
The rim fracture may require surgical plating, especially if there is a free fragment or rim
displacement. Because the required surgery is different than repair of the floor alone,
fracture of the rim with extension into the floor should not be called a blow-out fracture. If
there appears to be a single fracture of the rim, careful search should be made for a second
fracture because the orbital rim is a ring-like structure that may fracture in more than one
place.
Orbital Soft Tissue Injuries
The eyeball may be injured with or without accompanying fracture of adjacent bone.
Perforating injuries or sufficient blunt trauma may cause rupture of the vitreous (the
portion of the eye posterior to the lens). Because intraocular pressure is normally higher
than intraorbital pressure (15 mm versus 5 mm Hg), perforation can result in extrusion of
vitreous. [64] CT diagnosis is dependent on sufficient extrusion to allow reduction in ocular
volume. This is first seen as flattening of the posterior wall of the eyeball, the "flat tire"
sign described by Sevel et al [62] (Fig. 7) . Posteriorly, the optic nerve does not act as a tether
because in the neutral position the nerve is slack; the optic nerve is longer (25 mm) than
the distance between its attachment to the eyeball and the orbital apex (18 mm). [36] Another
sign of rupture of the vitreous is deepening of the anterior chamber between the posterior
surface of the cornea in the midline and the anterior surface of the lens. [70] This deepening
or elongation of the anterior chamber also is felt to result from the anterior portion of the
eye being held in peripheral suspension with depressurization posteriorly. The depth of the
normal anterior chamber is about 2 to 3.5 mm. In one investigation of eyeball rupture this
depth increased to 5 mm. [70] It is useful to compare this depth from side to side when there
has been orbital trauma because normally the difference from side to side is less than 2
mm.
Penetration of the eye anteriorly may result in avulsion of the cornea with decompression
of the anterior and posterior chambers (the posterior chamber is the space between the iris
and the lens and zonular fibers, which support the lens). This is readily seen at CT by
comparison with the uninjured side (Fig. 8) .
Injury to the lens may involve dislocation with complete tear of the zonular fibers,
subluxation with partial tear (Fig. 9) , and traumatic cataract. With dislocation, the lens
may sink through the vitreous and lie on top of the retina. With subluxation the lens may
act like a trap door and swing posteriorly remaining hinged by some intact zonular fibers.
Traumatic cataract results when the lens becomes acutely edematous. [60] Influx of fluid
into the lens results in lowering of its CT density. This may be detected by comparing
Hounsfield unit measurements from side to side. The abnormal lens may not be apparent
clinically and demonstrates a mean density difference 30 H lower than the normal side. [7]
9
Figure 7
Figure 7. Rupture of the eyeball. Axial

image shows collapsed eyeball resulting
from scleral laceration. The eyeball
maintains its contour anteriorly, and the
posterior part becomes flattened (arrows)
(the "flat tire" sign).
Figure 8
Figure 8. Axial image demonstrates avulsion

of the left cornea, absence of the left anterior
chamber, and laceration of the left eyelid
(white arrow) anterior to the lens (large black
arrow). The patient had cataract surgery on the
right eye with characteristic linear density seen
in the prior location of the lens (small black
arrow).
Figure 9
10
Figure 9. Lens subluxation. A, Axial image shows normal position of the lens on the left (arrow). B, On the
right, the lens has subluxed posteriorly from its medial attachment (arrow). The bilateral NOE fracture also is
apparent.
Figure 10
Figure 10. Vitreous hemorrhage. A, Patient sustained an inferior orbital rim fracture with slight extension
into the orbital floor and anterior wall of the maxillary sinus (small arrow), resulting in orbital emphysema
(large arrow). B, Soft tissue windows better demonstrate the rounded density in the vitreous consistent with
hemorrhage (arrows).
Hemorrhage into the vitreous or posterior to the sclera or retina may occur following
trauma (Fig. 10) . Intravitreous hemorrhage appears as an area of hyperdensity that forms
an acute angle if adjacent to the wall of the eye. Subscleral or subretinal hemorrhage forms
an obtuse angle between the wall of the eye and the vitreous. With penetrating injury,
vitreous hemorrhage and loss of vitreous volume and lens disruption are associated with
poor prognosis. [37]
The optic nerve may reflect injury by hemorrhage into its sheath, by avulsion from the
eyeball, or by direct penetration by bony fragments (Fig. 11) . It may also be injured by
ischemia caused by increased intraorbital pressure. Pressure may increase following
trauma caused by space-occupying lesions, such as extensive orbital emphysema,
intraconal hemorrhage, or reduction in orbital volume. Hemorrhage into the sheath may be
seen by CT as an asymmetry comparing side with side. Optic nerve avulsion is rarely
demonstrated by CT because the sheath may appear continuous.
Figure 11
Figure 11. Fracture at orbital apex. Skull and

zygomatic fractures extend to the orbital apex. A
11
bone fragment is seen within the optic canal, penetrating the optic nerve (arrow).
Figure 12
Figure 12. Metal intraorbital foreign body. A and B, Axial and coronal images allow exact positioning of this
metallic foreign body (large arrow). Despite artifact, it can be seen just superior to the eyeball at the roof of
the orbit. The fracture of the zygomatic process of the frontal bone also is evident (small arrow).
Intraorbital Foreign Body
Intraorbital foreign bodies are almost always detectable by CT (Figs. 12 , 13 , and 14) .
When seen, their exact position usually can be determined. It is important to assess
whether the foreign body is intraocular, within the sclera, or extraocular, although this
assessment may be uncertain if the foreign body is very close to the orbital wall. [27] Wood
presents difficulty in visualization if standard bone and soft tissue windows are used.
Wood that is dry may be isodense with air or fat. [36] [63] MR imaging has been found to be
excellent at detection of dry wood. [11] Wooden foreign bodies may be seen, however, if the
CT window is adjusted to a width of 1000 to 2000 H and a level of -500 H. [21] This allows
accentuation of soft tissue contrast and shows an attenuation difference of the wood or the
alternating density pattern of the grain of the wood may be seen. The Hounsfield unit
density of wood has been reported to range from -618 to +23 H, the highest densities for
glass varied from +522 to 2000 H, and plastic may have a density of -105 H. [44]
The size of the foreign body also influences its detectability. Steel foreign bodies greater
than 0.06 mm3 can always be seen with helical CT and steel foreign bodies less than 0.06
mm3 can be seen more than half the time. [8] The minimal size detectable by CT was found
to be 1.88 mm3 for glass and 0.7 mm3 for copper. [44] Due to detectability problems
resulting from the size and the density of foreign bodies, false-negative CT interpretations
should be expected rarely.
12
Small metal, glass, and stone foreign bodies tend to be inert and in some cases do not need
to be removed. Copper, however, tends to incite an inflammatory response and infection is
frequent with organic materials. [11]
Figure 13
Figure 13. Glass intraocular foreign body. Axial image shows three glass foreign bodies. One penetrated the
cornea with its tip in the anterior chamber (large arrow). The lateral foreign body penetrated the outer margin
of the sclera (open arrow). The medial foreign body is in the preseptal soft tissues (small arrow).
Figure 14
Figure 14. Wood intraorbital foreign body. The wood splinter (small arrows) is readily seen using wide
windows. Note the air bubble (large arrow) lateral to the splinter.
Fractures Involving the Maxillae
Portions of the maxillary bones are involved with NOE, orbital, and zygomatic fractures.
There are other midfacial injuries that result in fractures involving part or all of the
maxillae and adjacent regions of the face. Le Fort [31] developed the classification that
describes many of these fractures. These are easily remembered if one thinks of the
physical examination that accompanies each of the classic fracture types.
13
In the Le Fort I fracture, physical examination reveals that the maxillary alveolar bone and
hard palate are movable relative to the rest of the face, which remains attached to the skull.
For this to occur, there must be fractures of those structures supporting these parts of the
maxillae and palatine bones (i.e., fractures are seen of the pterygoid plates, the vertical
walls of the maxillary sinuses, and the nasal septum).
In the Le Fort II fracture, physical examination reveals that the maxillary and nasal regions
are movable relative to the rest of the face and skull. For this to occur, there must be
fractures of those structures supporting the pyramidally shaped maxillary and nasal unit
(i.e., fractures are seen of the pterygoid plates and the inferior and medial orbital rims, and
there are fractures across the nasal bones or diastases of the nasofrontal sutures. In the Le
Fort II injury the connected thinner bones also fracture including the lateral and anterior
wall of the maxillary sinuses, the orbital floors, and the medial walls of the orbits. In the Le
Fort II, the zygomatic bones remain attached to the skull by the lateral orbital rim and the
zygomatic arch (Fig. 15) .
In the Le Fort III fracture, physical examination reveals that the entire upper face (nasal,
maxillary, and zygomatic regions) are movable relative to the skull. For this to occur, there
must be fractures of those structures attaching the upper face to the skull (i.e., fractures are
seen of the pterygoid plates, the zygomatic arches, the lateral rims of the orbit, the medial
orbital rims, and fractures near or diastases of the nasofrontal sutures). The thinner bones
that must be fractured include the lateral walls of the orbits, orbital floors, and medial walls
of the orbits. The area that is mobile on physical examination in all Le Fort fractures is the
maxillary region; thus, the key to the presence of one of the Le Fort fractures is fracture of
the pterygoid plates, which is easily seen at CT.
Occasionally, Le Fort fractures exist without facial mobility on physical examination. [39] [54]
These fractures may present clinically as an abnormality of dental occlusion. Treatment of
these incomplete Le Fort fractures may be conservative or may require completion of the
fracture followed by fixation.
A given type of Le Fort fracture may not be bilateral but may occur in combinations. [33]
For example, there may be a Le Fort I of one side and a Le Fort II or III of the other side of
the face (Fig. 16) . The Le Fort classification provides a succinct way of describing
multiple fracture lines. In addition, use of the classification implies which bones are stable
for attachment during surgical repair. Given this latter concept, it is critical not to
misclassify the injury. For example, a bilateral Le Fort II plus a unilateral zygoma fracture
is not the same as a Le Fort II on one side and a Le Fort III on the other side. The reason
these classifications are not the same is the presence of the inferior orbital rim fracture
when there is a bilateral Le Fort II plus a unilateral zygoma. The inferior orbital rim is not
involved on one side in a Le Fort II and III combination. The inferior rim fracture cannot
be overlooked in preoperative planning due to the risk of enophthalmos if orbital volume is
not restored.
Another fracture involving part of the maxillary bone is the maxillary sagittal fracture. [69]
This may be thought of as a unilateral Le Fort I with the fracture line passing in a sagittal
plane through the hard palate. There may be an isolated fracture of part of the alveolar
process of the maxillae. This is noted on physical examination as several teeth that are
movable relative to the remainder of the teeth.
14
The midfacial smash fracture is a severely comminuted anterior facial injury. [30] [49] The
presence of severe comminution has implications for surgical repair and the portions of the
facial buttresses, which must be stabilized. Three-dimensional images help to determine if
adequate bone is present for placement of fixation devices. [41] Assessment of the degree of
comminution and bony discontinuities is necessary to decide if bone grafting is needed. [66]
Mandibular Fractures
Some mandibular fractures may be seen by plain radiographs, including a panorex view,
and do not require CT. [20] The sagittal condylar fracture, however, usually is not seen with
plain radiographs and if mandibular symptoms persist CT is indicated for evaluation of the
mandible (Figs. 17 and 18) . The tympanic plate of the temporal bone may fracture and is
best seen with CT. [1] Bleeding from the ear may occur with tympanic plate fractures.
Otorrhagia can also be present with an intact skull base when there is a high condylar
fracture. This type of condylar fracture is best imaged by coronal CT. [2] The mandible is
fractured in more than one place 50% to 60% of the time; about half the time a single
fracture is seen. Fractures are described based on their location: parasymphyseal, body,
angle, ramus, neck, condylar process, and coronoid process. The condylar fracture is the
most frequently undiagnosed facial fracture. [1] A condylar fracture or dislocation is readily
seen by coronal CT. [3] If the alveolar ridge is involved, the fracture must be considered
open. Mandibular fractures and their comminution, obliquity, and the degree of
displacement resulting from muscular pull are readily seen by CT. Axial CT with 3-mm
collimation in only the axial plane has been shown to be insufficient to detect posterior
mandibular fractures. [10] Helical CT should be performed in both axial and coronal planes
when feasible, or 1-mm axial reformations should be used to reconstruct coronal images if
the cervical spine has not been evaluated.
Frontal Sinus Fractures
The frontal sinus is a part of the calvaria but is frequently associated with facial bone
fractures or may constitute an isolated fracture (Fig. 19) . The least serious injury is an
isolated fracture of the anterior wall of the frontal sinus. These are usually depressed and
may require elevation for cosmetic restoration. More serious is the fracture that also
involves the posterior wall. Posterior wall fracture represents an open skull fracture and
requires treatment with antibiotics. The frontal sinus fractures may be more extensive and
involve the cribriform plate. Although difficult to demonstrate with CT, involvement of the
cribriform plate becomes apparent clinically as cerebrospinal fluid rhinorrhea.
CERVICAL SPINE INJURY ASSOCIATED WITH FACIAL

FRACTURES
When facial fractures are present, the incidence of concomitant cervical spine injury has
been reported to be from 1% to 4%. In patients whose facial fractures are due to motor
vehicle accidents (MVA), the incidence of cervical spine injury is between 5% and 6%. In
15
a prospective study Beirne et al [6] reported that 6 (1%) cervical spine injuries were found in
582 patients with facial fracture. These six injuries constituted 6% of the patients whose
mechanism was MVA, and all the cervical spine injuries occurred in those patients who
had been involved in an MVA. Only two of the cervical spine injuries were diagnosable on
their standard three-view cervical spine plain radiograph series, four were diagnosable by
CT, and two that were not initially recognized required flexion and extension views for
diagnosis.
In addition to MVA being the primary mechanism when cervical spine injury was seen to
accompany facial injury, mandibular fractures were almost always present as one of the
facial fractures. These findings suggest that patients with facial fractures sustained in an
MVA should probably undergo cervical spine CT while in the scanner for their facial CT.
FACIAL INJURIES IN CHILDREN
Patterns of injury are different in children than in adults. Although nasal fractures are the
most common injury, mandible fractures are the most frequent cause of hospitalization. In
children the condyle accounts for more than half of mandible fractures [42] in contrast to
substantially less than half in adults. [28] Midfacial injuries are relatively rare in children
compared with adults and tend to increase in frequency as the sinuses are pneumatized.
[26]
When a midfacial fracture occurs due to major trauma the classic Le Fort patterns are
not seen but an oblique orientation of fracture lines occurs across the injured parts of the
face. [43] Orbital roof fractures are relatively more common in children. [25] Incomplete or
greenstick fractures of facial bones are more common due to the more elastic bone in
children. [26]
Figure 15
16
Figure 15. Le Fort II fracture. A, In this classic Le Fort II fracture, the most anterior coronal image shows a
fracture across the region of the naso-frontal suture (arrow). B, More posteriorly, fractures traverse the
medial orbital wall (small arrow) and inferior orbital rims (large arrows). The right medial orbital wall was
seen to be fractured on other images. The lateral orbital rims are intact.
Figure 15. C, Still more posteriorly, the fractures through the orbital floors (large arrows) and lateral walls
of the maxillary sinuses (small arrows) are seen. D, Most posteriorly are fractures through both pterygoid
plates (arrows).
17
Figure 15. E, Axial image shows nasal fractures (thin arrows) and an intact left zygomatic arch (thick
arrow). F, More inferiorly, the anterior and posterior walls of the left maxillary sinus are fractured (black
arrows). The fractures of the right maxillary sinus were seen on other images. The right zygomatic arch is
intact (white arrow). The intact zygomatic arches bilaterally exclude a Le Fort III fracture. The pyramidally
shaped pattern of fractures from the pterygoid plates through the maxillary sinuses, inferior orbital rims, and
across the nose are consistent with a bilateral Le Fort II fracture.
Figure 16
Figure 16. Right Le Fort I with left Le Fort II plus

zygoma fractures. A, The plane of a fracture across the
nasal region is apparent on this coronal image. There is
discontinuity of the maxilla just above the alveolar
process on the right (large arrow) and at the superior
aspect of the frontal process of the maxilla on the left
(small arrow).
B, More posteriorly, a coronal image shows fractures of

the lateral walls of the maxillary sinuses bilaterally (large
arrows) and fracture of the frontal process of the zygoma
and lateral wall of the orbit on the left (small arrow). The
lateral orbital wall on the right is intact. The orbital rim on
the right also was intact on other images.
18
C, Most posterior coronal image shows bilateral

fractures of the pterygoid plates (arrows), the
hallmark of all Le Fort fractures.
D, Axial image shows fracture in the inferior orbital

rim (small black arrow) and lateral orbital wall (large
black arrow) on the left. The right zygomatic arch is
intact (white arrow).
E, More inferiorly, an axial image shows fractures of

the zygomatic arch on the left (white arrow) and
posterior-lateral walls of the maxillary sinuses
bilaterally (black arrows). On the right, the intact
orbital rim rules out a right Le Fort II. The intact
zygomatic arch on the right rules out a Le Fort III.
This leaves a Le Fort I on the right to account for the
fractures of the right maxillary sinus anteriorly and
posteriorly and the fractured right pterygoid plate. On
the left, the zygomatic arch and frontal process of
zygoma would be consistent with a Le Fort III. The
inferior orbital rim fracture on the left, however,
should not be present with a Le Fort III. Therefore, the
best description of the fracture pattern on the left is a
Le Fort II plus zygoma fracture.
ANALYZING FACIAL CT
19
The ease of interpretation of facial injuries is facilitated by considering the previously

described regions of the face and their supporting attachments to the skull and rest of the
face as well as the types of fractures frequently seen. Visual patterns of search during
interpretation differ among different radiologists. Starting at the top and working down
using the axial images and then the coronal images is useful in detection of the first
abnormality. A common mistake, especially by those new to facial CT interpretation, is to
continue the top-down approach while making an unorganized list of each tiny fracture that
can be seen. Once the first fracture is seen, it is more efficient to think of which regions of
the face could be involved and to go immediately to their major supporting structures. For
example, starting with the axial images if the first fracture recognized is the zygomatic
arch, the patient has an injury involving the zygomatic region. The zygomatic arch may be
injured alone or as a component of a Le Fort fracture. Thus, after seeing the arch fracture it
is helpful to go to the images that
depict the frontal process of zygoma and the inferior orbital rim. If these are fractured, at
least there is a zygoma complex fracture. If these are intact, there may be only an isolated
arch fracture. If the zygomatic arch is fractured as a component of a Le Fort injury, it is
helpful to look for the pterygoid plates on the coronal images. All the Le Fort fractures
break the pterygoid plates. Intact pterygoid plates exclude all the Le Fort fractures
including the Le Fort III, which is the only Le Fort fracture that involves the arch.
The previous example illustrates one pattern for efficiently interpreting facial fractures:
find the first fracture

consider which region of the face is involved by this fracture
look at the major pieces of bone that support this region
if the major supporting bone also involves an adjacent region, then evaluate the
major bony structures supporting that adjacent region
when a type or classification of fracture becomes apparent, investigate whether
the thinner pieces of bone that should be fractured are in fact involved
conclude with similar analysis of the remaining regions of the face
It is essential not to terminate the search with the bone windows. Orbital and other soft
tissue injury are much more easily seen on the soft tissue windows. It is comforting to note
the absence of fluid in the sinuses. A clear sinus correlates with absence of midfacial
fractures that involve a sinus wall. [29] The presence of fluid can be ssen due to soft tissue
injury with or without fracture or incidentally with pre-existing sinusitis.
CLINICALLY RELEVANT INFORMATION
Facial Buttresses
The key to understanding Le Fort's work is the strength (thickness) of the bony supports of
the face. The alveolar process of the maxilla and the malar eminence of the zygoma are the
thickest bony areas and they are relatively resistant to fracture. The nasofrontal process of
the maxilla also tends to be spared. [49] [52] The bony attachments of the alveolar process of
20
maxilla and malar eminence are less strong but constitute the facial buttresses that hold the
thicker bony structures in place.
These are more likely to fracture than the thicker bone. These buttresses include the
pterygomaxillary buttress, the zygomatic buttress, the nasofrontal buttress, and the orbital
buttress. The pterygomaxillary buttress is formed by the pterygoid plates and posterior wall
of maxillary sinus. The zygomatic buttress is formed by the frontal process of zygoma and
zygomatic process of the frontal bone, the zygomatic arch, and the region connecting the
malar eminence to the alveolar process of the maxilla.
The nasofrontal buttress is formed by the nasal process of the maxilla and medial orbital
rim. The orbital buttress is formed by the entire orbital rim. [38] The mandible itself
constitutes the mandibular buttress.
After injury, return of the face to functional and cosmetic integrity involves restoration of
facial height, width, and depth. This involves identification of portions of the buttresses
that remain fixed to the skull. Reattachment of the fractured portions of the buttresses to
their stable components should restore facial alignment.
Figure 17
21
Figure 17. Mandible fracture. A, Axial image shows right parasymphyseal fracture (arrow). B, Coronal
image shows fracture of the left ramus (arrow). C, Three-dimensional image shows the parasymphyseal
fracture extending to the alveolar process (arrows), making this an open fracture. D, Tilting the three-
dimensional reformation into a base projection demonstrates the degree of displacement (arrow). E, The
orientation of the left ramus fracture (arrows) is seen easily on plain radiograph. F, The three-dimensional
image of the left side of the mandible shows only a crack in the cortex at the superior aspect of the ramus
(arrow). The remainder of the fracture is not apparent. Three-dimensional imaging is best suited for
demonstration of displacement and rotation and the relative position of fragments to each other. The absence
of fracture should be determined from axial and coronal images.
Figure 18
Figure 18. Sagittal fracture of mandibular condyle. Axial image (A) and coronal reformation (B) reveal
bilateral sagittally oriented fractures of the mandibular condyles (arrows). This patient also sustained a
parasymphyseal fracture, which is not shown.
Figure 19
22
Figure 19. Frontal sinus fracture. A, Axial image shows a

comminuted fracture of the anterior wall of the frontal sinus
(large arrow). The posterior wall is intact (small arrows). B and
C, Coronal images show the fracture extending to the superior
orbital rim and orbital roof (short arrows), with subcutaneous and
orbital emphysema (long arrows).
Facial Struts
In addition to the facial buttresses, an additional concept to plan repair of facial fracture
involves identifying the portions of the major struts of the face that remain attached to the
skull or the intact part of the face. These struts include the thicker and the thinnest bones of
the face, whereas the buttresses include only the thicker supporting bony areas. Gentry et al
[17]
described these struts as being oriented in the horizontal, sagittal, and coronal planes. [17]
[28]
The struts are constituted by all the facial bones excluding the mandible.
There are three horizontal struts: (1) the superior, (2) middle, and (3) inferior. The superior
horizontal strut is composed of the orbital roofs, planum sphenoidale, and the cribriform
plate. The middle horizontal strut is composed of the orbital floors and zygomatic arches.
The inferior horizontal strut is made up by the hard palate and alveolar process of the
maxilla.
There are two coronal struts: (1) the anterior and (2) posterior. The anterior coronal strut is
composed of the anterior walls of the maxillary sinuses.
There are five sagittal struts: the midline, two parasagittal, and two lateral. The midline
sagittal strut is composed of the bony and cartilaginous nasal septum including the vomer
and perpendicular plate of the ethmoid. The parasagittal struts are each composed of the
medial wall of the orbit, the medial wall of the maxillary sinus, and the ipsilateral
pterygoid plate. The lateral sagittal struts are each formed by the lateral wall of the orbit,
the lateral wall of the maxillary sinus, and the lateral alveolar process of the maxilla.
The concept of these struts in three planes requires imaging of the face in both axial and
coronal orientations if possible in order to determine the existence of fractures, their
comminution, and their displacement.
23
Orbital Volume
Restoration of normal orbital volume is necessary to prevent enophthalmos as a

complication of fractures that cause increased volume of the orbit. The degree of
enophthalmos measured clinically correlates with the increase in orbital volume quantified
at CT. [59] The normal orbital volume is 30 to 35 cm3 , and a 10% change in volume is
sufficient to cause significant change in position of the eyeball. [19] Because the orbit is
shaped like a cone, its volume varies with the square of the radius of the cone (formed by
the orbital rim). Volume also varies in linear relationship with the height of the cone (the
anteroposterior distance from the rim to the orbital apex). Thus, rotation or displacement of
the rim in the coronal plane increases orbital volume more than displacement in the sagittal
plane. Assessment of displacement and rotation of the portions of the orbital rim are
necessary in presurgical planning. Three-dimensional CT offers a superior picture of this
displacement or rotation than planar images.
With blow-out fractures, orbital volume also increases. Restoration of volume may require
placement of a prosthetic medial wall or floor. Of prime importance in successful surgery
is knowledge of the position of intact bone anteriorly and posteriorly, which is used to
support the prosthesis. It is particularly important to assess whether the posterior aspect of
the orbital floor near the orbital apex and adjacent to the inferior orbital fissure is intact or
not.
Decrease in orbital volume is less frequent than increase in volume as a sequella of injury.
The orbital blow-in fracture, however, may result in a decrease in volume.
Causes of Blindness Following Facial Fracture
Although blindness occurs in only about 3% of facial fractures, [35] the potential for loss of
vision must be realized if its causes are apparent at CT. The causes of blindness include
orbital compartment syndrome, optic neuropathy resulting from penetration or hematoma
of the optic nerve, or perforation of the eyeball. Orbital compartment syndrome results
from increased intraorbital pressure caused by retrobulbar hemorrhage or by orbital
emphysema, both of which are readily apparent at CT. [4] [22] Increased pressure can result in
occlusion of the vessels to the optic nerve or occlusion of the retinal artery or vein.
Increased pressure may produce proptosis, which stretches the optic nerve. Optic
neuropathy occurs with intraocular pressures greater than 50 to 70 mm Hg for 90 to 180
minutes. [22] [58] The primary assessment of intraocular pressure is done clinically. If possible,
in the presence of visual loss and increased intraocular pressure, all radiologic evaluation
should be delayed for immediate therapy. [4] In the multiple trauma patient, however, large
amounts of retrobulbar hemorrhage or emphysema and proptosis might first be seen at CT,
which should trigger an emergent ophthalmologic consultation.
CT is not well suited for the diagnosis of optic nerve avulsion, another cause of possible
blindness. [28] There were six cases of optic nerve avulsion seen at the Massachusetts Eye
and Ear Infirmary between 1991 and 1995. CT was performed in five patients; avulsion
was seen in only one as a linear hypodensity at the junction of the nerve and eyeball, a
thickened nerve was noted in five, and the nerve appeared normal in one patient. [13] Part of
the difficulty in visualization of this entity with CT is that the optic nerve sheath may
remain intact around an avulsed nerve.
24
Airway Compromise
Mandibular fractures that are bilateral may allow the tongue to displace posteriorly and
obstruct the oropharynx in the supine patient. [48] Also, maxillary fracture fragments may
displace posteriorly and cause airway obstruction. Although most multiple trauma patients
with serious injury have an endotracheal tube, caution should be taken if CT is obtained in
the less severely injured patient with suspected mandibular or maxillary fracture. [1]
The nasopharynx may demonstrate hemorrhage in several well known entities including
occipitocervical subluxation, upper cervical spine injuries, and base of skull fractures. The
nasopharynx may also be narrowed by hemorrhage resulting from fractures involving the
posterior maxillary sinus and the pterygoid plates. These structures bound the
pterygopalatine fossa, and thus the terminal branches of the maxillary artery may be
injured. In adults the normal nasopharyngeal soft tissue thickness in the region of the
adenoids on lateral skull films is about 10 mm. In one investigation of fractures around the
pterygopalatine fossa, the distance between the base of the skull and nasopharyngeal
airway measured between 14 and 20 mm. [72]
Radiation Exposure
The lens exposure in a study 10 years ago using axial scanning with 5-mm collimation
averaged 4.2 rad with a range of 0.47 to 6.29 rad. [65] Exposure for polytomography of the
face for evaluation of major trauma was found to be 50% higher than for CT. [56] The
minimum dose for production of cataracts is a single dose of 200 rad or a fractionated dose
of 550 rad over 12 weeks. Prolonged occupational exposure of 600 rad is necessary for
cataract formation. [65] Use of CT in evaluation of facial trauma is well within the safety
range relative to cataract formation.
COST OF FACIAL CT AND FACIAL PLAIN RADIOGRAPHS
Articles [68] and correspondence [5] [14] have voiced concern about the added costs or high
costs of using CT in the evaluation of facial trauma. Although the selective use of CT is
clearly advisable, it may be impossible to select prior to CT those patients who need
corrective therapy for facial injury and benefit from the information available at CT. The
value of negative information, for example the absence of comminution or the stability of
the intact portion of a facial buttress, must be considered in any analysis. Physical
examination, especially in the acute setting with facial edema, ranges in accuracy from
100% for detection of frontal fracture to 68% for detection of mandibular fracture. [68]
Depending on the type of facial fractures present, for example, simple nasal fractures and
some mandibular fractures, plain radiographs may be adequate.
If imaging is needed, the decision to use CT or plain radiographs must be based on a

number of factors, such as the availability of CT, the speed with which diagnosis can be
made, and the likelihood of surgical repair and need of presurgical imaging for planning.
Consideration is also being given today to the relative costs of imaging methods.
The variable and total costs to our hospital, the resources used to produce imaging
examinations (not the hospital charge), are available through the hospital cost data base,
25
which allocates all expenses incurred by the hospital to the various departments within the
hospital. Within a department, the costs are allocated to the products and services provided
by that department. Variable costs are those that change with an added volume of
examinations, such as costs of film or technologists' labor. Fixed costs are overhead items
of the hospital or department that do not change within a range of added volume, such as
the costs of hospital computer systems or departmental administrative labor. Total costs are
the sum of variable and fixed costs.
Table 1 gives the costs of facial CT and facial plain radiographic examinations and is
based on cost data from October 1997 through April 1998. The CT costs do not take into
account the lesser costs, which are incurred if the patient is already in the scanner for
another scan. Lesser costs occur in this circumstance because less time is needed to obtain
the examination if the patient is already on the table. Nonetheless, the total costs to the
hospital of producing a facial CT are less than twice the total costs of a single plain
radiographic examination and are less than the total costs of two plain radiographic
examinations, such as a facial series and a nasal series. The variable costs to the hospital
are less for a facial CT than for a single facial plain radiographic series.
TABLE 1 -- COSTS TO THE HOSPITAL OF PRODUCING FACIAL CT AND VARIOUS

FACIAL PLAIN RADIOGRAPHIC EXAMINATIONS
Variable Costs Fixed Costs Total Cost
Imaging Study ($ ) ($ ) ($ )
CT
Facial CT 34.21 91.62 125.83
Three-dimensional reformation 25.62 68.61 94.23
Plain radiographic study
Facial series 39.35 52.93 92.28
Mandible 30.99 41.68 72.67
Panorex 28.53 38.37 66.90
TMJ 41.81 56.24 98.05
Nose 26.07 35.07 61.14
TMJ = temporomandibular joint.
*
TABLE 2 -- PROTOCOL FOR FACE AND PARANASAL SINUS CT
Algorithm Bone; reconstruct to standard for soft tissues
Contrast material None
Helical scanning
Coronal From in front of nasal bones to behind sphenoid sinuses

3-mm collimation
4.5 mm/s table speed (1.5 pitch)
3-mm image spacing
26
Axial From below maxillae to above the frontal sinuses

Include mandible if a mandible fracture is suspected
3-mm collimation
3-mm image spacing
Reformations Reconstruct axial images to 1-mm spacing and standard
algorithm for three-dimensional reformations, § or if unable
to do direct coronal scans to allow for satisfactory coronal
reformation
Filming Bone and soft tissues windows, 20 on 1
A facial CT scan should be performed as a separate CT scan, not a continuation of a head CT.
*A cervical spine fracture should be excluded before placing patient in the coronal scanning position.
For nontrauma (paranasal sinus disease) coronal images only are performed. Axial images can be
performed at the radiologist's discretion.
If necessary, do 1-mm-thick slices at 1.5 pitch through areas of special interest, such as for intraorbital
foreign body.
§Filming of facial three-dimensional reformations should include a 6 on 1 page of the following: right and left
lateral views; Water's view (35-degree upward tilt); Caldwell view (15-degree downward tilt); axial view (90-
degree upward tilt); and Towne's view (35-degree downward tilt).
*
TABLE 3 -- PROTOCOL FOR ORBIT CT AND FOREIGN BODY
Algorithm Detail
Contrast material None
Helical scanning
Coronal Through orbits. Coronal slices should extend from the front
of the eyelids to behind the optic canals
1-mm collimation
1-mm image spacing
Axial Through orbits
1-mm collimation
1-mm image spacing
Filming Soft tissue and bone windows, 20 on 1
Consider the following two options: (1) use plain radiographs for screening all patients
who need imaging and supplement with CT in patients requiring further information, and
(2) use CT for screening all patients who need imaging. Based on the total costs of a facial
plain radiographic series ($92.28) and the total costs of facial CT ($125.83), use of CT as
the screening option for all patients needing imaging is less expensive to the hospital if as
many as 27% of patients require CT following plain radiographs. Based on variable costs
of a facial plain radiographic series ($39.35) and the variable costs of CT ($34.21), CT is
the less expensive screening option for the hospital if sufficient CT capacity is available.
27
HELICAL AND THREE-DIMENSIONAL CT PROTOCOLS
Protocols may vary depending on the type of scanner and the patient's condition. Tables 2
and 3 give protocols for helical scanning of the face and orbits.
SUMMARY
Knowledge of the regions of the face and their buttresses and knowledge of the types of
facial injuries frequently encountered simplifies the diagnostic task. The indications for CT
include detection of suspected fractures and preoperative planning. The cost of facial CT to
the hospital has declined and is little different than the cost of plain films. CT may become
the screening modality of choice depending on the cost structure at any given hospital.
*For radiopaque foreign bodies, a three-dimensional reformation may be helpful.

Wood foreign bodies may be very low in CT density and may be best demonstrated with
widened windows (2000 H window width and -500 H window level).
References
Assael LA: Clinical aspects of imaging in maxillofacial trauma. Radiol Clin North Am 31:209, 1993
1.
abstract
2. Avrahami E, Frishman E, Katz R: CT evaluation of otorrhagia associated with condylar fractures.

Clin Radiol 49:877, 1994 abstract
3. Avrahami E, Rabin A, Mejdan M: Unilateral medial dislocation of the temporomandibular joint.

Neuroradiology 39:602, 1997 abstract
4. Bains RA, Rubin PA: Blunt orbital trauma. Int Ophthalmol Clin 35:37, 1995 citation
5. Bauchner
H: Three-dimensional CT diagnosis of maxillofacial trauma (correspondence). N Engl J
Med 330:69, 1994 citation
6. BeirneJC, Butler PE, Brady FA: Cervical spine injuries in patients with facial fractures: A 1-year
prospective study. Int J Oral Maxillofac Surg 24:26, 1995 abstract
7. Boorstein JM, Titelbaum DS, Patel Y, et al: CT diagnosis of unsuspected traumatic cataracts in
patients with complicated eye injuries: Significance of attenuation value of the lens. AJR Am J
Roentgenol 164:181, 1995 abstract
8. Chacko JG, Figueroa RE, Johnson MH, et al: Detection and localization of steel intraocular
foreign bodies using computed tomography: A comparison of helical and conventional axial
scanning. Ophthalmology 104:319, 1997 abstract
9. Chirico
PA, Mirvis SE, Kelman SE, et al: Orbital "blow in" fractures: Clinical and CT fractures. J
Comput Assist Tomogr 13:1017, 1989 abstract
28
10. Creasman CN, Markowitz BL, Kawamoto HK Jr, et al: Computerized tomography versus
standard radiography in the assessment of fractures of the mandible. Ann Plast Surg 29:109, 1992
abstract
11. Dunya IM, Rubin PA, Shore JW: Penetrating orbital trauma. Int Ophthalmol Clin 35:25, 1995
citation
12. Evans GR, Clark N, Manson PN, et al: Role of mini- and microplate fixation in fractures of the
midface and mandible. Ann Plast Surg 34:453, 1995 abstract
13. Foster BS, March GA, Lucarelli MJ, et al: Optic nerve avulsion. Arch Ophthalmol 115:623, 1997
abstract
14. Fox LA, Vannier MW, Evans RG: Three-dimensional CT diagnosis of maxillofacial trauma
(correspondence). N Engl J Med 330:69, 1994
Fox LA, Vannier MW, West OC, et al: Diagnostic Performance of CT, MPR and 3DCT imaging in
15.
maxillofacial trauma. Comput Med Imaging Graph 19:385, 1995 abstract
16. Freeman LN, Selff SR, Aguilar GL, et al: Self-compression plates for orbital rim fractures.
Ophthal Plast Reconstr Surg 7:198, 1991 abstract
17. Gentry LR, Manor WF, Turski P, et al: High resolution CT analysis of facial struts in trauma. AJR
Am J Roentgenol 140:523, 1983 abstract
18. Gillespie
JE, Isherwood I, Barker GR, et al: Three-dimensional reformation of computed
tomography in the assessment of facial trauma. Clin Radiol 38:523, 1987 abstract
19. Grant MP, Iliff NT, Manson PN: Strategies for the treatment of enophthalmos. Clin Plast Surg
24:539, 1997 abstract
20. Hermans R, Van der Goten A, DeFoer B, et al: Imaging of maxillo-facial trauma. J Belge Radiol
80:25, 1997 abstract
21. Ho
VT, McGuckin JF Jr, Smergel EM: Intraorbital wooden foreign body: CT and MR
appearance. AJNR Am J Neuroradiol 17:134, 1996 abstract
22. Hunts JH, Patrinely JR, Holds JB, et al: Orbital emphysema: Staging and acute management.
Ophthalmology 101:960, 1994 abstract
23. Iinume
T, Hirota Y, Ishio K: Orbital wall fractures: Conventional views and CT. Rhinology 32:81,
1994 abstract
24. Johnson DH Jr, Colman M, Larsson S, et al: Computed tomography in medial maxilla-orbital
fractures. J Comput Assist Tomogr 8:416, 1984 abstract
25. Karesh JW, Kelman SE, Chirico PA, et al: Orbital roof "blow-in" fractures. Ophthal Plast
Reconstr Surg 7:77, 1991 abstract
26. Koltal PJ, Rabkin D: Management of facial trauma in children. Pediatr Clin North Am 43:1253,
1996 full text
27. Kuhn F, Hulda T, Witherspoon CD, et al: Intraocular foreign bodies: Myths and truths. Eur J
Ophthalmol 6:464, 1996 abstract
29
28. Laine FJ, Conway WF, Laskin DM: Radiology of maxillofacial trauma. Curr Probl Diagn Radiol
22:145, 1993 abstract
29. Lambert DM, Mirvis SE, Shanmuganathan K, et al: Computed tomography exclusion of osseous
paranasal sinus injury in blunt trauma patients: The "clear sinus" sign. J Oral Maxillofac Surg
55:1207, 1997 abstract
30. Lawrason JN, Novelline RA: Diagnostic imaging of facial trauma. In Mirvis SE, Young JWR
(eds): Diagnostic Imaging in Trauma and Critical Care. Baltimore, Williams & Wilkins, 1992, p 243
31. LeFort R: E'tude experimentale sur les fractures de la machoire superieure. Rev Chir 23:208,
1901
32. Leone CR Jr: Periorbital trauma. Int Ophthalmol Clin 35:1, 1995 citation
33. Levine RS, Grossman RI: Head and facial trauma. Emerg Med Clin North Am 3:447, 1985
abstract
34. Levy RA, Edwards WT, Meyer JR, et al: Facial trauma and 3D reconstructive imaging:
Insufficiencies and correctives. AJNR Am J Neuroradiol 13:885, 1992 abstract
35. Li
KK, Caradonna D, Lauretano AM, et al: Delayed blindness after facial fracture repair.
Otolaryngol Head Neck Surg 116:251, 1997 citation
36. Lustrin ES, Brown JH, Novelline R: Radiologic assessment of trauma and foreign bodies.
Neuroimaging Clin N Am 6:219, 1996 abstract
37. Maguire AM, Enger C, Eliott D, et al: Computerized tomography in the evaluation of penetrating
ocular injuries. Retina 11:405, 1991 abstract
38. Manson PN, Hoopes JE, Su CT: Structural pillars of the facial skeleton: An approach to the
management of Le Fort fractures. Plast Reconstr Surg 66:54, 1980 citation
39. Manson PN, Markowitz B, Mirvis S, et al: Toward CT-based facial fracture treatment. Plast
40. Martello JY, Vasconez HC: Supraorbital roof fractures: A formidable entity with which to
contend. Ann Plast Surg 38:223, 1997 abstract
41. Mayer JS, Wainwright DJ, Yeakley JW, et al: The role of three-dimensional computed
tomography in the management of maxillofacial trauma. J Trauma 28:1043, 1988 abstract
42. McGrath CJ, Egbert MA, Tong DC, et al: Unusual presentations of injuries associated with the
mandibular condyle in children. Br J Oral Maxillofac Surg 34:311, 1996 abstract
43. Moore MH, David DJ, Cooter RD: Oblique craniofacial fractures in children. J Craniofac Surg
1:4, 1990 abstract
44. Myllyla V, Pyhtinen J, Paivansalo M, et al: CT detection and location of intraorbital foreign
bodies. Fortschr Rontgenstr 146:639, 1987
45. NolascoFP, Mathog RH: Medial orbital wall fractures: Classification and clinical profile.
Otolaryngol Head Neck Surg 112:549, 1995 abstract
46. Novelline RA: Three-dimensional CT of facial trauma. In Thrall JH (ed): Current Practice of
30
Radiology. St. Louis, Mosby-Year Book, 1993
47. Novelline
RA, Liebig T, Jordan J, et al: Computed tomography of orbital and occular injuries.
Emergency Radiology 1:56, 1994
48. Park SS: Blunt trauma to the face & neck: Initial management. Comp Ther 23:730, 1997
49. Pathria
MN, Blaser SI: Diagnostic imaging of craniofacial fractures. Radiol Clin North Am
27:839, 1989 abstract
50. Raustia AM, Pyhtinen J, Oikarinen KS, et al: Conventional radiographic and computed
tomographic findings in cases of fracture of the mandibular condylar process. J Oral Maxillofac
Surg 48:1258, 1990 abstract
51. Rehm CG, Ross SE: Diagnosis of unsuspected facial fractures on routine head computerized
tomographic scans in the unconscious multiply injured patient. J Oral Maxillofac Surg 53:522, 1995
abstract
52. Rogers LF: The face. In Rogers LF (ed): Radiology of Skeletal Trauma. New York, Churchill
Livingstone, 1982, p 229
53. Rohrich RJ, Hollier LH, Watumuli D: Optimizing the management of orbitozygomatic fractures.
Clin Plast Surg 19:149, 1992 abstract
54. Romano JJ, Manson PN, Mirvis SE, et al: Le Fort fractures without mobility. Plast Reconstr Surg
85:355, 1990 abstract
55. Rose EH, Norris MS, Rosen JM: Application of high-tech three-dimensional imaging and
computer-generated models in complex facial reconstructions with vascularized bone grafts. Plast
56. Rowe ED: Computed tomography in maxillofacial trauma. Laryngoscope 91:745, 1981 abstract
57. Russell JL, Davidson MJ, Daly BD, et al: Computed tomography in the diagnosis of maxillofacial
trauma. Br J Oral Maxillofac Surg 28:287, 1990 abstract
58. Schabdach DG: An animal model of visual loss from orbital hemorrhage. Ophthal Plast Reconstr
Surg 10:200, 1994 abstract
59. Schuknecht B, Carls F, Valavanis A, et al: CT assessment of orbital volume in late post-
traumatic enophthalmos. Neuroradiology 38:470, 1996 abstract
60. Segev Y, Goldstein M, Lazar M, et al: CT appearance of a traumatic cataract. AJNR Am J

Neuroradiol 16:1174, 1995 abstract
61. Seiff SR, Good WV: Hypertropia and the posterior blowout fracture. Ophthalmology 103:152,
1996 abstract
62. Sevel D, Krausz H, Ponder T, et al: Value of computed tomography for the diagnosis of a
ruptured eye. J Comput Assist Tomogr 7:870, 1983 abstract
63. Specht CS, Vargas JH, Jalali MM, et al: Orbitocranial wooden foreign body diagnosed by
magnetic resonance imaging. Surv Ophthamol 36:341, 1992
64. Stamper RL: Measurement regulation and flow relationships. Biomed Found Ophthalmol 7:2,
31
1982
65. Storrs
BB, Byrd SE: Radiation exposure to the ocular lens during CT scanning. Pediatr Neurosci
14:254, 1988 abstract
66. Szachowicz EH: Facial bone wound healing. Otolaryngol Clin North Am 28:865, 1995 abstract
67. Tello R, Suojanen J, Costello P, et al: Comparison of spiral CT and conventional CT in 3D

visualization of facial trauma: Work in progress. Comput Med Imaging Graph 18:423, 1994
abstract
68. Thai KN, Hummel RP III, Kitzmiller WJ, et al: The role of computed tomographic scanning in the
management of facial trauma. J Trauma 43:214, 1997 abstract
69. Thompson R, Myer CM III: Sagittal palate fracture. Ann Otol Rhinol Laryngol 97(4 pt 1):432,
1988 citation
70. Weissman JL, Beatty RL, Hirsch WL, et al: Enlarged anterior chamber: CT finding of a ruptured
globe. AJNR Am J Neuroradiol 16(4 suppl):936, 1995 abstract
71. Wesley RE, McCord CD: Tension pneumocephalus from orbital roof fracture. Ann Ophthalmol
14:184, 1982 abstract
72. Wittram C: Nasopharyngeal cavity narrowing associated with posterior maxilla and pterygoid
plate fracture: report of three cases. Eur J Radiol 24:222, 1997 abstract
73. Yamaoka M, Furusawa K, Iguchi K: The assessment of fracture of the mandibular condyle by
use of computerized tomography: Incidence of sagittal split fracture. Br J Oral Maxillofac Surg
32:77, 1994 abstract
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Radiol. Clin. North Am. - May 1999 Temas de Revision - H.

Misericordia – Cirugía Plástica

Radiologic Clinics of North America.

ADVANCES IN EMERGENCY RADIOLOGY I

Address reprint requests to:

Because of the superimposition of bony structures on plain radiographs,

THE FIVE REGIONS OF THE FACE

TYPES OF FACIAL FRACTURES AND SOFT TISSUE INJURIES

Nasal and Naso-orbital-ethmoid Fractures

Figure 2. Zygoma complex fracture. A, Axial image

Figure 4. Superior orbital rim fracture with extension

Figure 5 C, The patient was unable

Figure 5 D, Coronal reformation

Figure 6. Medial orbital blow-out fracture. A,

Figure 6. Medial orbital blow-out fracture. B,

Orbital Soft Tissue Injuries

Figure 7. Rupture of the eyeball. Axial

Figure 8. Axial image demonstrates avulsion

Figure 11. Fracture at orbital apex. Skull and

Intraorbital Foreign Body

Fractures Involving the Maxillae

Frontal Sinus Fractures

CERVICAL SPINE INJURY ASSOCIATED WITH FACIAL

FACIAL INJURIES IN CHILDREN

Figure 16. Right Le Fort I with left Le Fort II plus

B, More posteriorly, a coronal image shows fractures of

C, Most posterior coronal image shows bilateral

D, Axial image shows fracture in the inferior orbital

E, More inferiorly, an axial image shows fractures of

The ease of interpretation of facial injuries is facilitated by considering the previously

find the first fracture

CLINICALLY RELEVANT INFORMATION

Figure 19. Frontal sinus fracture. A, Axial image shows a

Restoration of normal orbital volume is necessary to prevent enophthalmos as a

Causes of Blindness Following Facial Fracture

COST OF FACIAL CT AND FACIAL PLAIN RADIOGRAPHS

If imaging is needed, the decision to use CT or plain radiographs must be based on a

TABLE 1 -- COSTS TO THE HOSPITAL OF PRODUCING FACIAL CT AND VARIOUS

Coronal From in front of nasal bones to behind sphenoid sinuses

Axial From below maxillae to above the frontal sinuses

HELICAL AND THREE-DIMENSIONAL CT PROTOCOLS

*For radiopaque foreign bodies, a three-dimensional reformation may be helpful.

2. Avrahami E, Frishman E, Katz R: CT evaluation of otorrhagia associated with condylar fractures.

3. Avrahami E, Rabin A, Mejdan M: Unilateral medial dislocation of the temporomandibular joint.

Radiology. St. Louis, Mosby-Year Book, 1993

60. Segev Y, Goldstein M, Lazar M, et al: CT appearance of a traumatic cataract. AJNR Am J

67. Tello R, Suojanen J, Costello P, et al: Comparison of spiral CT and conventional CT in 3D

MD Consult L.L.C. http://www.mdconsult.com

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Misericordia – Cirugía Plástica