7. Maxillofacial and Dentoalveolar Trauma Flashcards
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.
difficult two right resolution periapical occlusal
• 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.
condylar
zygomatic
tooth
embedded
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 ____
dento-alveolar
soft tissue
TMJ
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
concussion
luxation
fractures
avulsion
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.
crush inflammatory difficult PDL non-vital widened
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
radiolucent
calcifying
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.
tooth
intrusive
widening
direction
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
widened
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
alveolar bone
intrusive
• We have different axial slices:
I ◦ Apically –> luxated outside the ____
2 ◦ mid-coronal –> looks a little ____
3 ◦ coronal –> the crowns have been ____ palatally
arch
closer
intruded
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.
displacement
maxillary central incisors
radiographs
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
soft tissue
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
coronal
firm
subluxated
pulp
enamel
dentin
pulpal
root
coronal
coronal
avulsion
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.
long pressure perpendicular parallel apical rarefying osteitis vitality 3D
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
CBCT
Alveolar fractures
- Definition:
Fractures of the ____-bearing part of the mandible and maxilla. - Diagnosis:
____ evidence of fracture.
Evidence of fracture from ____ - plain radiographs. Disruption of the dental ____.
Tooth ____.- 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 ____.
- Aims of Treatment:
tooth clinical imaging occlusion displacement
airway
speech
fracture
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)
alveolar
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. ____.
zygoma lefort body/angle coronoid condyle
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 \_\_\_\_.
linear
double
swelling
paranasal sinuses
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
zygomatico-max
common
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 ____.
zygomatico-frontal
orbital margin
zygomatic arch
mandibular condyle
nasal floor
occlusal plane
mandible
rami
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)
orbital
zygomatic
maxillary
waters
CBCT
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.
zygoma frontal frontal zygomatico-temporal zygomatico-maxillary displaced
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
black eye
swelling
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)
dose
whitens
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)
larger
max
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)
corticated
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 ____.
horiztonal midface teeth pterygoid bilateral
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.
pyramidal nasal frontal zygomatico-maxillary maxillary pterygomaxillary
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 ____
displaced
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.
craniofacial middle nasal zygomatico-frontal dish open bite
• this is an example of LeFort III ◦ basically complete
displacement of ____ of the face from the ____
lower third
cranium
Fractures of the nasal bone
• Fractures of the ____ bone
◦ reddened in skull pic below
bec of ____
nasal
fracture
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
symmetry
splinting
lateral
radiation
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
body
angle
condyle
opposite
symphsis
alveolar
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
occlusion
open
Mandibular fracture
these are different areas you can have a fracture, commonly in the ____
body
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)
diagonal
- 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)
step deformity
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
occlusal
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
condylar
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.
fracture
deformation
discontinuity
green stick
• 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
condyle
mandible
CT evaluation of mandibular fractures
• here is just a CT of an obvious ____ fracture as seen in the soft tissue and bone windows
mandibular
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
moved
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)
incomplete
lucency
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 ____
close
downward
backward
