7. Maxillofacial and Dentoalveolar Trauma

Question 1

Selection of appropriate radiographs
􏰅 Ideal radiograph maybe ____ or impossible to obtain I
due to the nature of the injury or patient discomfort.
􏰅 At least ____ views at ____ angles to each other may be necessary.
􏰅 Panoramic radiographs provide easy and good coverage of the jaws and part of the facial structures. However, panoramic radiographs may lack the ____ necessary for diagnosis. More over, the focal trough is limited in the anterior mandible and maxilla.
􏰅 ____ and ____ views are best for fractures of the teeth and alveolus.

Answer 1

difficult
two
right
resolution
periapical
occlusal

Question 2

• Selectionofappropriate
radiographs – Planar Views
􏰅 Reverse Towne views are excellent for viewing fractures of the ____ areas.
􏰅 Modified Submentovertex views are useful for ____ fractures.
􏰅 Abdominal views should be considered if missing ____, bone, or restoration fragments cannot otherwise be located.
􏰅 Periapical or occlusal views of the soft tissue can be useful for locating ____ objects.

Answer 2

condylar
zygomatic
tooth
embedded

Question 3

Selection of appropriate radiographs
􏰅 MDCT or CBCT imaging is often used for cases of large scale ____ trauma.
􏰅 MRI can be useful for ____ injuries and also used for depicting displaced or torn discs in ____

Answer 3

dento-alveolar
soft tissue
TMJ

Question 4

Traumatic injuries of the teeth
I 􏰅 Dental ____.
2􏰅 ____:
􏰅 Intrusive subluxation.
􏰅 Extrusive subluxation.
􏰅 Lateral displacement.
􏰅 ____ of teeth:
􏰅 Fractures involving enamel only(Infractions).
􏰅 Fractures involving enamel and dentin.
􏰅 Fractures involving enamel, dentin and pulp.
􏰅 ____. –> where an entire tooth just pops out

Answer 4

concussion
luxation
fractures
avulsion

Question 5

Traumatic injuries of the teeth
— Concussion
• This is a ____ injury to the supporting structures of the teeth. The results are ____ and the immediate radiographic changes may be ____ to discern. A widened ____ space, due to edema, may be noted.
— Over time, the tooth may become ____and an apical inflammatory lesion may develop.
— The pulp chamber may eventually appear to be either ____ or narrowed.

Answer 5

crush
inflammatory
difficult
PDL
non-vital
widened

Question 6

Delayed sequelae to concussion injuries

Here we have some examples of that reads the title
◦ it can develop into an apical rarefying osteitis (red arrow on pic on R)
‣ great descriptive term bec. it is ____ and involves inflammation in the bone
◦ Internal resorption
‣ blue* indicates a normal pulp chamber
‣ red arrow in middle shows the resorption

◦ Calcified pulp chamber
‣ tooth reacted by ____ its chambers due to pulp chamber obliteration as a result of injury

Answer 6

radiolucent

calcifying

Question 7

Traumatic injuries of the teeth
— Luxation:
— Defined as a dislocation of the ____ from it socket with
severing of the periodontal attachment.
— The luxation may be ____, extrusive, or lateral.
— Radiographic evidence includes ____ of the periodontal ligament space. The location of the widening varies with the ____ of the force upon the tooth.

Answer 7

tooth
intrusive
widening
direction

Question 8

Luxation of the teeth

• Here is an example of a ____ PDL and a luxated tooth
• this is tooth #9 and you can see widened PDL here *
• this is a young pt as you can see bec the roots are not as developed

Answer 8

widened

Question 9

Luxation of the teeth

• This is an example on sagittal views of CBCT of luxation of the teeth
• the blow was probably this way (@ anterior teeth)
• So what you have is the teeth outside of the ____. Its
____ luxation
• other pic is just diff view

Answer 9

alveolar bone

intrusive

Question 10

• We have different axial slices:
I ◦ Apically –> luxated outside the ____
2 ◦ mid-coronal –> looks a little ____
3 ◦ coronal –> the crowns have been ____ palatally

Answer 10

arch
closer
intruded

Question 11

Traumatic injuries of the teeth
— Avulsion:

— Defined as the complete ____ of the tooth from the alveolus.
____ are the most common teeth to be traumatically avulsed.
— Unless the avulsed tooth can be located, ____ are necessary to locate the tooth in the surrounding soft tissues, respiratory system, or GI tract.

Answer 11

displacement
maxillary central incisors
radiographs

Question 12

Avulsion

• An axial slice of avulsion, you can see that there is a missing tooth over here, where do you think the missing tooth is?
• Note the avulsed tooth in the ____ of the lip (red arrow) ◦ tooth was avulsed and got embedded into the lips of the pt

Answer 12

soft tissue

Question 13

Classification of tooth fractures
(
Bennet’s classification)

— Class 1 —
Traumatized teeth without ____ or root fx —
a. Tooth ____ in alveolus
— b. Tooth ____ in alveolus

Class II
Coronal fracture without ____ exposure 2b — a. Involving ____
— b. Involving enamel and ____

Class III
Coronal fracture with ____ exposure

Class IV
____ fracture
— a. Without ____ fracture —
b. With ____ fracture

Class 5
____ of tooth

Answer 13

coronal
firm
subluxated

pulp
enamel
dentin

pulpal

root
coronal
coronal

avulsion

Question 14

Vertical root fracture
— Can be ____-standing pain.
— Pain may be elicited using ____ on the teeth.
— Difficult to obtain radiographic evidence unless plane of fracture is ____ to the radiograph and ____ to the x-ray beam.
—____ maybe seen. Thesuspected tooth should be ____ tested.
— 2D imaging is not of much help. ____ imaging may be needed.

Answer 14

long
pressure
perpendicular
parallel
apical rarefying osteitis
vitality
3D

Question 15

Vertical root fracture - CBCT

• Here, we can focus in on the axial view
◦ can you appreciate where the vertical fractures are ◦ its pretty hyper -dense going all the way around
◦ lines over here are vertical fracture (yellow
arrows)
• nowadays, you have a ____ where you can go up and down the tooth and you can see the vertical fracture

Answer 15

CBCT

Question 16

Alveolar fractures

1. Definition:
   Fractures of the ____-bearing part of the mandible and maxilla.
2. Diagnosis:
   ____ evidence of fracture.
   Evidence of fracture from ____ - plain radiographs. Disruption of the dental ____.
   Tooth ____.
   3. Aims of Treatment:
      Initial treatment to restore and maintain ____.
      Arrest hemorrhage.
      Restoration and preservation of pre-trauma occlusion and teeth. Restoration of function ____ & mastication.
      Relief of pain.
      Prevent development of infection.
      Avoid delayed or non-union of ____.

Answer 16

tooth
clinical
imaging
occlusion
displacement

airway
speech
fracture

Question 17

Alveolar fractures

• Here is an example of a fracture that is within the alveolar bone. The pt has been fixated w/ wire
• just apical to the lower incisor –> can see the fracture
• thats an example of an ____ fracture (blue arrow)

Answer 17

alveolar

Question 18

Trauma to the jaws

— Fractures of the maxilla: — Fractures of the ____. —
____ I, II and III.

— Fractures of the mandible:
— Fractures involving the ____. —
Fractures involving the ramus:
— ____ process. — ____.

Answer 18

zygoma
lefort
body/angle
coronoid
condyle

Question 19

Radiographic signs of facial fx’s

Direct Signs
— Non-anatomic ____ lucencies.
— Cortical defect or diastatic (separated) sutures.
— Bone fragments overlapping causing a “____ density”.
— Asymmetry of face.

Indirect Signs
— Soft tissue \_\_\_\_.
— Periorbital or intracranial
air.
— Fluid in the \_\_\_\_.

Answer 19

linear
double
swelling
paranasal sinuses

Question 20

Prevalence of maxillary fractures

• In terms of prevalence of max. fracture, the ____ fracture (also known as tripod) is the most prevalent –> occurs 40%
• Followed by leFort I, II, III w/ LeFort I being the most ____ one of the 3
• reads the remaining fracture types

Answer 20

zygomatico-max

common

Question 21

Lines of McGrigor and Campbell (1950)

Line 1: follows from one ____ suture along the superior orbital margin and across the glabella to the superior ____ and the
zygomatico-frontal suture of the opposite side.
Line 2: Courses from the superior aspect of the ____ and zygoma to the zygomatico-frontal suture, along the infraorbital margin, across the frontal process of the maxilla, along the lateral wall of the nose, through the septum and then onto the like course on the opposite side.
Line 3: from the ____ across the sigmoid nothc and the tip of the coronoid process to the lateral and medial antral walls at the level of the ____ and on to a similar course on the opposite side.
Line 4: The fourth line traces the ____ of the upper and lower teeth or if the patient is edentulous, the crest of the alveolar ridges in order to detect
any discrepancy.
Line 5: The lower border of the ____ and the posterior aspect of the ____.

Answer 21

zygomatico-frontal
orbital margin

zygomatic arch

mandibular condyle
nasal floor

occlusal plane
mandible
rami

Question 22

Lines of Dolan
and
Elephants of Rogers

• There are another guidelines and they consist of just 3 lines ◦ 1 –> ____ line
◦ 2 –> ____ line
◦ 3 –> ____ line
• the shape below looks like an elephant - thats why they are called elephant of Rogers

• So you can appreciate it when you have the ____ view (right) and ____ (left)

Answer 22

orbital
zygomatic
maxillary

waters
CBCT

Question 23

Tripod fractures

This fracture usually occurs due to a direct blow to the body of the ____.
The separation of the ____ process of the zygoma from the ____ bone usually occurs in the form of a diastasis of the zygomatico-frontal suture. This occurs along with separations at the ____ and ____ sutures. Hence, it is called the tripod fracture.
Zygomatic arch fractures are usually well-supported by the temporalis and masseter muscles and hence rarely ____ upwards or downwards.

Answer 23

zygoma
frontal
frontal
zygomatico-temporal
zygomatico-maxillary
displaced

Question 24

Tripod fracture of the zygoma

• So really its a ____
◦ will have peri-orbital ____
◦ when you see black eye = tripod fracture diagnosis

• this is a CBCT reconstruction; can appreciate the zygoma being displaced here
• basically have to fixate it and pt will heal nicely

Answer 24

black eye

swelling

Question 25

Submento-vertex projection

• We talked about submento-vertex projection before where you have the pt back and when you lower the radiation ____, it ____ everything out, and you appreciate the highlights of the fracture (see arrows on Left)

Answer 25

dose

whitens

Question 26

Mechanism of blowout fractures

• You have a blunt object ____ than the orbit, traumatizing the orbit
◦ the orbit has muscles and fluid and they have no place to go ◦ ..so what happens, these bones collapse and that why its
called blowout fractures and all fluid from orbit leaks into the ____. sinus (black arrows)

Answer 26

larger

max

Question 27

blow out fracture

• Here we can see to on a Waters view
◦ you have this is intact on the right
◦ the blow was at the orbit on the left ; it is not as well
____ as the orbit on the R and you can see contents of orbit sagging into the sinus (see red arrow)

Answer 27

corticated

Question 28

Le Fort I
— ____ fracture of the body of the maxilla resulting in the detachment of the alveolar process from the ____.

The fracture line passes above the ____, below the zygomatic process, and through the maxillary sinuses and tuberosities to the inferior portion of the ____ plates. May be unilateral or ____.

Answer 28

horiztonal
midface
teeth
pterygoid
bilateral

Question 29

Le Fort II
____ FRACTURES
— The maxilla is separated from the base of the skull because of fractures of the ____ bones and ____ process of the maxilla.

The fracture extends laterally through the lacrimal bones and the floors of the orbits and inferiorly through the ____ sutures. The fracture extends through the ____ sinus.

Posteriorly, it extends up to the pterygoid plates across the ____ fissure.

Answer 29

pyramidal
nasal
frontal
zygomatico-maxillary
maxillary
pterygomaxillary

Question 30

Tomographic view of multiple facial fractures Le Fort II

• Here is a tomographic view of Le Fort II fracture
◦ See white arrows for the fractures
◦ this area could be ____

Answer 30

displaced

Question 31

Le Fort III

____ DISJUNCTION

— Complete separation of the ____ third of the facial skeleton from the cranium.

The fracture line extends through ____ bones, frontal process of the maxilla, across the floors of the orbits and through the ethmoid and sphenoid sinuses and the ____ sutures.
— ____ face deformity and anterior ____ are clinically evident.

Answer 31

craniofacial
middle
nasal
zygomatico-frontal
dish
open bite

Question 32

• this is an example of LeFort III ◦ basically complete

displacement of ____ of the face from the ____

Answer 32

lower third

cranium

Question 33

Fractures of the nasal bone

• Fractures of the ____ bone
◦ reddened in skull pic below
bec of ____

Answer 33

nasal

fracture

Question 34

Nasal fracture before and after

• Here is a pt. You can see the ____ (vertical white line) if off here bec of the nasal fracture
• this is just treated by ____ them and you can achieve symmetry

• you diagnose it w/
____ film
• similar to the modified submittal- vertex, you can lower the ____ and enhance the small thinner bones of the nasal bones to note the fracture

Answer 34

symmetry
splinting
lateral
radiation

Question 35

Prevalence of mandibular fractures

• Prevalent most commonly in the ____ of the mandible, secondly the ____ and then the ____
• Whats interesting is: if you get hit on one side (points to R side of jaw) bec our jaws are mobile, you may get a fracture on the ____ (L) condyle

• ____, ramus, ____ and coronoid process fractures are less
common

Answer 35

body
angle
condyle

opposite

symphsis
alveolar

Question 36

Clinical evidence of mandibular fracture

• So what is the clinical evidence of mandibular fracture in this pt?
ans: his ____ is off and there is a bit of an ____ bite- his occlusion is not as it used to be

Answer 36

occlusion

open

Question 37

Mandibular fracture

these are different areas you can have a fracture, commonly in the ____

Answer 37

body

Question 38

Mandibular fracture

Here we have a panoramic and here is a mandibular fracture can anyone tell me whether its on the L or R?
ans: yes, pt’s left!
Do we see another line ? yes we see 2 lines (blue arrows) but these are not different fractures; the same fracture
‣ she goes to explain that by saying that imagine that the fracture is ____ so when you look at it with a radiograph you see the two lines like this (the dotted green lines indicate the 2 lines shown below)

Answer 38

diagonal

Question 39

• Where do we see the fracture here, on the L or the R? ◦ ans: def on the L
• Line 5 (according to mcgrigor Campell ) you follow the inferior border of the mandible and you see if its corticated. Here you see a ____ so obviously there is a fracture there (green arrow)

Answer 39

step deformity

Question 40

Mandibular fracture

• Here ____ views are useful for symphysial fractures
◦ So you can appreciate the fracture here (blue arrow)
• You got hit right in the chin to get a symphysial fracture

Occlusal views are useful for symphyseal fractures

Answer 40

occlusal

Question 41

Condylar fractures

• Another thing that can happen if you get hit in the chin is you get a
____ fractures
• She said this is not a very good quality pano but this highlights a bilateral condylar fracture (black arrows) condyle going backwards due to a blow to the chin

Answer 41

condylar

Question 42

Radiographic features of mandibular fractures

Radiographic evidence of fractures: —
A demonstrable ____ line/lines.
— Displacement of adjacent bony segments.
— ____ of normal bone shape and contour. — Symphyseal fractures are hard to diagnose.
— Cortical ____ sign.
— Discontinuity of mandibular canal.
____ fractures.

Answer 42

fracture
deformation
discontinuity
green stick

Question 43

• what we have here is a fracture of the ____ (black arrow) and this was caused by a blow occurring here (blue arrow)
◦ pt was most likely was not hit in the condyle but hit in the ____ and we see the definite fracture here (blue arrow) ..And from the impact of that you get a fracture of the condyle
◦ Thats a contrecoup fracture

Answer 43

condyle

mandible

Question 44

CT evaluation of mandibular fractures

• here is just a CT of an obvious ____ fracture as seen in the soft tissue and bone windows

Answer 44

mandibular

Question 45

Artifacts mimicking fractures

• Finally, here are artifacts mimicking fractures
◦ you do not want to diagnose a fracture that looks like normal anatomy
Top Pano:
◦ It might seem that there is a step deformity (yellow
arrow)
◦ ..but when you look at the arch nothing really strange
going on
◦ probably the pt ____ while the pano was going

Answer 45

moved

Question 46

Incomplete fracture of the mandible

•
Can anyone find the ____ fracture of the mandible here (the green stick)?
◦ its on the L; its a green stick fracture
◦ you follow the inferior border and everything looks
really well corticated and there is a little ____ here
(yellow arrow)

Answer 46

incomplete

lucency

Question 47

Acute dislocation of the condyle

• this is an acute dislocation of the condyle
• pt presents to you and they cannot ____ their mouth and what you do is you have to use your knowledge of anatomy and push ____ and ____

Answer 47

close
downward
backward