|Year : 2018 | Volume
| Issue : 2 | Page : 21-25
Reliability of multidetector computed tomography in rational analysis of midface fractures
Noha Abdelfattah Ahmed Madkour
Department of Radiodiagnosis, Kasr Alainy Hospital, Cairo University, Cairo, Egypt
|Date of Web Publication||13-Aug-2018|
Noha Abdelfattah Ahmed Madkour
Department of Radiodiagnosis, Kasr Alainy Hospital, Cairo University, Cairo
Source of Support: None, Conflict of Interest: None
Background: Motor vehicle accidents (MVAs) are the main causes of midfacial fractures in developing countries. Multidetector computed tomography (MDCT) is the principle diagnostic imaging tool in maxillofacial trauma. Multiplanar reformatted (MPR) and three-dimensional (3D)-reconstructed images provide a detailed analysis for midfacial fractures and assessment of their severity. Aim: To identify, outline, and quantify different patterns of midfacial and orbital fractures evaluated by MDCT using MPR and 3D-reconstructed images. Subjects and Methods: A total of 35 patients with midfacial and orbital trauma were included in this study referred to the Emergency Unit of Kasr Alainy University Hospital. All patients were subjected to MDCT in axial sections. MPR and 3D volume-rendering images were obtained. Statistics: A prospective descriptive study. Results: Majority (65.7%) of midfacial fractures were due to MVAs. Men represent 91% of cases. In this study, the most common facial fracture was orbital fractures (34%), followed by maxillary fractures (31%). Fifteen cases with midfacial injuries were associated with head trauma. Conclusion: MDCT with its expedient imaging capabilities provides a comprehensive analysis of midfacial fractures. MPR and 3D-reconstructed images exhibit high informative value in elucidation of midfacial and orbital fractures needed for prompt surgical management.
Keywords: Imaging, maxillofacial trauma, midfacial fractures, multidetector computed tomography
|How to cite this article:|
Ahmed Madkour NA. Reliability of multidetector computed tomography in rational analysis of midface fractures. J Oral Maxillofac Radiol 2018;6:21-5
|How to cite this URL:|
Ahmed Madkour NA. Reliability of multidetector computed tomography in rational analysis of midface fractures. J Oral Maxillofac Radiol [serial online] 2018 [cited 2019 Dec 7];6:21-5. Available from: http://www.joomr.org/text.asp?2018/6/2/21/238928
| Introduction|| |
Demographics, prevalence, and mode of midfacial trauma vary between different countries according to the socioeconomic status and exposure risk. Nevertheless, motor vehicle accidents (MVAs) are the main causes of maxillofacial fractures in developing countries.,, Majority of road traffic accidents lead to craniofacial trauma.,,,
Multidetector computed tomography (MDCT) is the principle diagnostic imaging tool in maxillofacial trauma., MDCT with high spatial resolution has renovated the imaging capabilities in evaluation and classification of maxillofacial fractures. Multiplanar reformatted (MPR) images provide a detailed analysis for midfacial fractures and assessment of their severity.,,, Three-dimensional (3D)-reconstructed images allow accurate localization of fractures and displacements in maxillofacial trauma.,
Aims and objectives
This study aims to identify, outline, and quantify different patterns of midfacial and orbital fractures evaluated by MDCT using MPR and 3D-reconstructed images.
| Subjects and Methods|| |
The study is a prospective descriptive study. The study included 35 patients (32 males and 3 females), with the mean age of 31 years ranging from 18 to 69 years, with midfacial trauma due to MVAs, fall from a height, and direct assault. The study population was referred to the Emergency Unit of Kasr Alainy University Hospital during the period from March 2016 to September 2017. All patients were subjected to MDCT maxillofacial in axial sections using 16-row multislice CT scanner. MPR in coronal and sagittal planes and 3D reconstruction were obtained.
All 35 patients were scanned by a 16-row multislice CT (BrightSpeed; GE Healthcare, Milwaukee, Wisconsin, USA) with 16 mm × 1.25 mm collimation, matrix 512 × 512, pitch 1.75, table feed 7.5 mm/s, rotation time 1.00 s/HE, tube current 340 mA, voltage 120 kV, and a total exposure time of approximately 15 s.
Using a sagittal scout with field of view of 220–290 mm, helical MDCT scan was performed from head vertex to chin in axial planes. From thin-sectioned axial source images of 1.25 mm in thickness, MPR coronal and sagittal planes were performed in all cases, as well as 3D volume-rendering reconstruction images.
In this study, the midfacial fractures were classified according to location into nasal, orbital, zygomatic, frontal sinus, and maxillary. Complex fractures include naso–orbito–ethmoidal, zygomaticomaxillary complex (ZMC), and Le Fort fractures. Midfacial fractures include central and lateral midface fractures. Consequent soft-tissue injuries were estimated. Associated skull fractures were evaluated.
| Results|| |
The study included 35 patients admitted for midface fractures (32 males and 3 females) with the mean age of 31 years ranging from 18 to 69 years. Majority (65.7%) of cases were due to MVAs, 25.7% were due to fall from a height, and 8.5% were due to physical assault.
In the present study, 35 cases with midfacial trauma with a total of 129 fractures were evaluated for midfacial fractures using MDCT, MPR, and 3D-reconstructed images. In this study, the most common facial fracture was orbital fractures (34%), followed by maxillary fractures (31%) [Table 1]. Orbital apex has the least incidence of fractures [Table 2]. In general, central midface fractures (68%) were more common than lateral (32%) ones [Graph 1].
Coronal and axial images provide comparable results in detection of frontal sinus fractures. In this study, four frontal sinus fractures were encountered that included three anterior table and two posterior table fractures which were associated with anterior cranial fossa injury and pneumocephalus [Figure 1].
|Figure 1: (a) Coronal, (b) axial multidetector computed tomography of face in a male patient. (a and b) Fracture anterior table of the left frontal sinus with hemosinus. Fracture posterior tables of both frontal sinuses with pneumocephalus|
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MPR images allow detailed specifications of midface fractures. Complex midface fractures including Le Fort [Figure 2] and ZMC fractures [Figure 3] were better estimated in 3D-reconstructed images as main components of the fractures involving facial buttresses were displayed.
|Figure 2: Multidetector computed tomography face in a patient with Le Fort I. (a-c) Coronal. Fracture pterygoids, bilateral lateral nasal walls, subcutaneous emphysema, and bilateral maxillary hemosinus. (d) Three-dimensional reconstruction. Le Fort I, fracture right maxilla and right palatoalveolar margin|
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|Figure 3: Multidetector computed tomography face in a patient with left zygomaticomaxillary complex fracture. (a) Coronal. Left lateral orbital fracture. (b) Axial. Left zygomatic fracture and left proptosis. (c) Coronal. Fracture posterolateral wall left maxilla with hemosinus. (d) Three-dimensional reconstruction. Displaced left zygomaticomaxillary complex fracture|
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Almost all cases sustain soft-tissue injuries. Associated soft-tissue injuries and orbital complications included orbital and preseptal edema, proptosis, subcutaneous emphysema, cerebrospinal fluid rhinorrhea, enophthalmos, exophthalmos, and vitreous hemorrhage in two cases, and herniated orbital fat was noted in four cases with orbital floor fractures. Hemosinus was noted in 17 cases.
In the current study, 15 cases with midfacial injuries were associated with head trauma. Concomitant skull bone fractures were 10 frontal and 5 temporal bone fractures complicated with brain contusions, extradural and subdural hematoma, intracranial hemorrhage, and pneumocephalus.
| Discussion|| |
MVA has widely prevailed as the major cause of maxillofacial injuries. The current study revealed that 65.7% of midface fractures were due to MVA, with a male: female ratio of 9:1 as conformed to many studies.,,
In this study, 42.8% of cases with midfacial fractures were associated with head injuries. A prospective study done by Abdul Razak et al., who found a substantial association between traumatic brain injuries and facial trauma, revealed similar results as the current study. Moreover, comparable results were noted in a retrospective study obtained by Sigaroudi et al. who evaluated different mechanisms involved in craniofacial trauma.,
The most common midfacial fracture in the current study was orbital fractures followed by maxillary fractures. Similar results were obtained by Whitesell et al. who conducted a cohort study that focused on the severity of clinical conditions of polytrauma patients including facial fractures.
A cross-sectional study involving young adults done by Rajandram et al. found a significant link between traumatic brain injury and midfacial fractures with dominance of orbital fractures which was consistent with the present study and other concurrent retrospective studies.,
In agreement with many previous studies, lateral orbital wall was the most common fracture site in orbital trauma in this study which could be due to peripheral location.,,,
Several studies emphasized the reliability of coronal reformatted images in evaluation of orbital floor, lateral orbital wall, inferior orbital rim, and pterygoid plate fractures as well as assessment of complex fractures including Le Fort and ZMC fractures.,
Many studies are in accordance with the results obtained in this study regarding that ZMC fractures were the most common complex fracture type., Being appreciated in complex fractures, valuable 3D-reconstructed images provide a better definition of fracture lines along vertical and horizontal facial buttresses roaming through arbitrary planes.,,
As similar to many studies, this study indicates that majority of midfacial fractures were central midface, which in agreement with other longitudinal and regional studies.,,,
Limitations of the study were small sample size and limited prognostic data of the patients. Nevertheless, the current study addressed the main aspects of midfacial trauma and defined diagnostic precession integrated by advanced MDCT technology.
This study focused on the ability of MDCT to identify, classify, and quantify midfacial fractures. MDCT with its expedient capabilities in MPR and 3D-reconstructed images provide comprehensive analysis of midfacial and orbital fractures. MPR images are of high informative value about location of facial fractures, displacements, and associated soft-tissue injuries. 3D images allow precipitous elucidation and offer overall epitomized evaluation of the bony components constituting maxillofacial fractures.
Refinements in the current MDCT technology could provide further insights supporting patterns and underlying mechanisms of maxillofacial trauma and development of advanced perspective guidance for preoperative evaluation.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Erol B, Tanrikulu R, Görgün B. Maxillofacial fractures. Analysis of demographic distribution and treatment in 2901 patients (25-year experience). J Craniomaxillofac Surg 2004;32:308-13.
Chrcanovic BR. Factors influencing the incidence of maxillofacial fractures. Oral Maxillofac Surg 2012;16:3-17.
Zaleckas L, Pečiulienė V, Gendvilienė I, Pūrienė A, Rimkuvienė J. Prevalence and etiology of midfacial fractures: A study of 799 cases. Medicina (Kaunas) 2015;51:222-7.
Gassner R, Tuli T, Hächl O, Rudisch A, Ulmer H. Cranio-maxillofacial trauma: A 10 year review of 9,543 cases with 21,067 injuries. J Craniomaxillofac Surg 2003;31:51-61.
Choonthar MM, Raghothaman A, Prasad R, Pradeep S, Pandya K. Head injury- A maxillofacial surgeon's perspective. J Clin Diagn Res 2016;10:ZE01-6.
Obimakinde OS, Ogundipe KO, Rabiu TB, Okoje VN. Maxillofacial fractures in a budding teaching hospital: A study of pattern of presentation and care. Pan Afr Med J 2017;26:218.
Kaur J, Chopra R. Three dimensional CT reconstruction for the evaluation and surgical planning of mid face fractures: A 100 case study. J Maxillofac Oral Surg 2010;9:323-8.
Patil S, Melkundi SS. Maxillofacial and orbital injuries evaluation by three dimensional MDCT. J Evol Med Dent Sci 2015;4:12470-8.
Peltola EM, Koivikko MP, Koskinen SK. The spectrum of facial fractures in motor vehicle accidents: An MDCT study of 374 patients. Emerg Radiol 2014;21:165-71.
Turner BG, Rhea JT, Thrall JH, Small AB, Novelline RA. Trends in the use of CT and radiography in the evaluation of facial trauma, 1992-2002: Implications for current costs. AJR Am J Roentgenol 2004;183:751-4.
Santos DT, Oliveira JX, Vannier MW, Cavalcanti MG. Computed tomography imaging strategies and perspectives in orbital fractures. J Appl Oral Sci 2007;15:135-9.
Hardt N, Kuttenberger J. Classification of craniofacial fractures. In: Craniofacial Trauma. Berlin, Heidelberg: Springer; 2010. p. 31-54.
Chouinard AF, Troulis MJ, Lahey ET. The acute management of facial fractures. Curr Trauma Rep 2016;2:55-65.
Yamamoto K, Matsusue Y, Horita S, Murakami K, Sugiura T, Kirita T, et al.
Clinical analysis of midfacial fractures. Mater Sociomed 2014;26:21-5.
Sivalingam J, Kumar A, Yennabathina K, Rajasekhar KV. Evaluation of maxillofacial injuries using multislice computed tomography. IOSR J Dent Med Sci 2016;15:49-57.
Joshi UM, Ramdurg S, Saikar S, Patil S, Shah K. Brain injuries and facial fractures: a prospective study of incidence of head injury associated with maxillofacial trauma. J Maxillofac Oral Surg 2018;8:1-7. doi: 10.1007/s12663-017-1078-8.
Hwang K, You SH. Analysis of facial bone fractures: An 11-year study of 2,094 patients. Indian J Plast Surg 2010;43:42-8.
] [Full text]
Abdul Razak N, Nordin R, Abd Rahman N, Ramli R. A retrospective analysis of the relationship between facial injury and mild traumatic brain injury. Dent Traumatol 2017;33:400-5.
Sigaroudi AK, Saberi BV, Chabok SY. The relationship between mid-face fractures and brain injuries. J Dent Shiraz Univ Med Sci 2012;13:18-22.
Whitesell RT, Steenburg SD, Shen C, Lin H. Facial fracture in the setting of whole-body CT for trauma: Incidence and clinical predictors. AJR Am J Roentgenol 2015;205:W4-10.
Rajandram RK, Syed Omar SN, Rashdi MF, Abdul Jabar MN. Maxillofacial injuries and traumatic brain injury – A pilot study. Dent Traumatol 2014;30:128-32.
Halsey JN, Hoppe IC, Granick MS, Lee ES. A single-center review of radiologically diagnosed maxillofacial fractures: Etiology and distribution. Craniomaxillofac Trauma Reconstr 2017;10:44-7.
Sohns JM, Staab W, Sohns C, Schwarz A, Streit U, Hosseini AS, et al.
Current perspective of multidetector computed tomography (MDCT) in patients after midface and craniofacial trauma. Clin Imaging 2013;37:728-33.
Shah S, Uppal SK, Mittal RK, Garg R, Saggar K, Dhawan R, et al.
Diagnostic tools in maxillofacial fractures: Is there really a need of three-dimensional computed tomography? Indian J Plast Surg 2016;49:225-33.
] [Full text]
Smith H, Peek-Asa C, Nesheim D, Nish A, Normandin P, Sahr S, et al.
Etiology, diagnosis, and characteristics of facial fracture at a Midwestern level I trauma center. J Trauma Nurs 2012;19:57-65.
Muass QH, Ibrahim S. Gataa: The diagnostic value of computed tomography in evaluation of maxillofacial Trauma: Kufa Med J 2009;12:251-255.
Prokop M. MDCT: Technical principles and future trends. In: Multidetector-Row Computed Tomography. Milan: Springer; 2005. p. 5-12.
Salonen EM, Koivikko MP, Koskinen SK. Acute facial trauma in falling accidents: MDCT analysis of 500 patients. Emergency radiology. 2008;15:241-7.
Tomich G, Baigorria P, Orlando N, Méjico M, Costamagna C, Villavicencio R. Frequency and types of fractures in maxillofacial traumas. Assessment using multi-slice computed tomography with multiplanar and three-dimensional reconstructions. Rev Argent Radiol 2011;75:305-17.
Raju NS, Ishwar P, Banerjee R. Role of multislice computed tomography and three-dimensional rendering in the evaluation of maxillofacial injuries. J Oral Maxillofac Radiol 2017;5:67. [Full text]
Kumar V, Das B, Venkatesha MP. Multi detector computed tomography evaluation of spectrum of facial fractures in motor vehicle accidents. Int J Anat Radiol Surg 20165:RO24-30.
[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2]