Multidetector and three-dimensional CT evaluation of the patient with maxillofacial injury

Enhancing Cranio-Maxillofacial Fracture Care in Low- and Middle-Income Countries: A Systematic Review

Background: Cranio-maxillofacial (CMF) injuries represent a significant challenge in low- and middle-income countries (LMICs), exacerbated by inadequate infrastructure, resources, and training. This systematic review aims to evaluate the current strategies and solutions proposed in the literature to improve CMF fracture care in LMICs, focusing on education, patient transfer, and off-label solutions. Methods: A comprehensive literature search was conducted using PubMed/Medline from January 2000 to June 2023. Studies were selected based on the Preferred Reporting Items for Systematic Review and Meta-analysis Statement (PRISMA). Solutions were categorized into three main areas: education (digital and on-site teaching, fellowships abroad), patient transfer to specialized clinics, and off-label/non-operative solutions. Results: Twenty-three articles were included in the review, revealing a consensus on the necessity for enhanced education and training for local surgeons as the cornerstone for sustainable improvements in CMF care in LMICs. Digital platforms and on-site teaching were identified as key methods for delivering educational content. Furthermore, patient transfer to specialized national clinics and innovative off-label techniques were discussed as immediate solutions to provide quality care despite resource constraints. Conclusions: Effective CMF fracture care in LMICs requires a multifaceted approach, prioritizing the education and training of local healthcare professionals, facilitated patient transfer to specialized centers, and the adoption of off-label solutions to leverage available resources. Collaborative efforts between international organizations, local healthcare providers, and educational institutions are essential to implement these solutions effectively and improve patient outcomes in LMICs.

Morphometric and volumetric analysis of lacrimal glands in patients with thyroid eye disease

Assessment of morphometric and volumetric changes in lacrimal glands in thyroid eye disease, its clinical manifestations in relation of disease progression. Retrospective volumetric analysis included both genders and was performed on total of 183 patients - 91 patients with diagnosed Grave's disease and thyroid eye disease and 92 patients without Grave's disease and thyroid eye disease who underwent multidetector computed tomography (MDCT) examination in routine daily work according to other medical indications. In the group of females, there was statistical significance between patients with thyroid eye disease and controls who were smoking and had body weight gain. We found statistical significance in volumetric enlargements for both orbits in both genders for the patients group when compared to controls. There was also statistical significance in morphometric characteristics for the lacrimal gland diameters measured. Determination planimetric morphometric parameters of importance were coronary height of lacrimal gland of the right eye, coronary height of lacrimal gland of the left eye and coronary width of lacrimal gland of the left eye for the group of males. In a group of females the established determination parameters of importance were the coronary height of lacrimal gland of the left eye, the axial width of lacrimal gland of the left eye, volume of lacrimal gland of the right eye and the volume of lacrimal gland of the left eye. When we compared the displaced lacrimal gland coming forward (proptosis) in time progressing disease between group of patients and controls, we also found statistical significant connection. Evaluation of lacrimal gland volumetric and morphometric data may increase validity of defining this anatomical substrate and its morphology disruption as liable tool for thyroid eye disease progression follow up and treatment planning and outcome.

Facial fractures: The "bottom-up" approach

Given the demands of a busy high-volume trauma center, trauma radiologists are expected to evaluate an enormous number of images covering a multitude of facial bones in a short period of time in severely traumatized patients. Therefore, a comprehensive checklist, search pattern, and practical approach become indispensable for evaluation. Moreover, fracture complex classification conveys abundant information in a succinct shorthand fashion, which can be a large asset in a busy high-volume trauma center: reliably helping clinicians communicate urgent findings, make early treatment decisions, and effectively plan surgical approaches. Traditionally, radiologists' approach the CT axial dataset in top-down fashion: navigating their descent craniocaudal. However, a bottom-up approach may be advantageous, especially when it comes to facial fracture complex classification. Four key anatomic landmarks of the face, when evaluated sequentially in bottom-up fashion, are favorable to rapid single-sweep facial fracture characterization: the mandible, the pterygoid plates, the zygoma, and the bony orbits. That is, when done in succession: 1. Clearing the mandible rules out a panfacial smash fracture. 2. Clearing the pterygoid plates effectively rules out a Le Fort I, II, and III fracture. 3. Clearing the zygoma effectively rules out a zygomaticomaxillary complex (ZMC) type fracture. 4. Clearing the bony orbits effectively rules out a naso-orbital-ethmoid (NOE) fracture. Following this process of exclusion and elimination; as one ascends through the face, fracture characterization becomes more manageable and straightforward. Besides identifying all of the fractures and using the appropriate classification system, the radiologist also needs to recognize key clinically relevant soft tissue injuries that may be associated with facial fractures and thus should address these in the report.

Application Value of the CT Scan 3D Reconstruction Technique in Maxillofacial Fracture Patients

Purpose The aim of the study was to explore the application value of computerized tomography (CT) scan 3D reconstruction technology in maxillofacial fracture patients. Methods A total of 80 maxillofacial fracture patients who underwent surgical treatment in Shijiazhuang People's Hospital from January 2019 to January 2020 were enrolled. All of them received 128-slice spiral CT  scans before surgery, and the images were subjected to multiplanar reconstruction (MRP) and volume reconstruction (VR). Results A total of 181 fractures were found in 80 patients with maxillofacial fractures. The detection rates of axial CT, MRP, and VR were 77.90% (141/181), 93.92% (170/181), and 97.79% (177/181), respectively. The detection rates of the four inspection methods were statistically different. Taking the findings of surgical anatomy as the gold standard, the sensitivity of MRP and VR for the diagnosis of maxillofacial fractures was 90.06% (163/170) and 95.56% (174/177), with no significant difference. Conclusion CT scan 3D reconstruction technology has a high application value in the clinical diagnosis and treatment of maxillofacial fracture patients.

ACR Appropriateness Criteria® Imaging of Facial Trauma Following Primary Survey

Maxillofacial trauma patients comprise a significant subset of patients presenting to emergency departments. Before evaluating for facial trauma, an emergency or trauma physician must perform a primary survey to ensure patient stabilization. Following this primary survey, this document discusses the following clinical scenarios for facial trauma: tenderness to palpation or contusion or edema over frontal bone (suspected frontal bone injury); pain with upper jaw manipulation or pain overlying zygoma or zygomatic deformity or facial elongation or malocclusion or infraorbital nerve paresthesia (suspected midface injury); visible nasal deformity or palpable nasal deformity or tenderness to palpation of the nose or epistaxis (suspected nasal bone injury); and trismus or malocclusion or gingival hemorrhage or mucosal hemorrhage or loose teeth or fractured teeth or displaced teeth (suspected mandibular injury). The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Mandibular Fractures: Diagnosis and Management

Accurate evaluation, diagnosis, and management of mandibular fractures is essential to effectively restore an individual's facial esthetics and function. Understanding of surgical anatomy, fracture fixation principles, and the nuances of specific fractures with respect to various patient populations can aid in adequately avoiding complications such as malocclusion, non-union, paresthesia, and revision procedures. This article reviews comprehensive mandibular fracture assessment, mandibular surgical anatomy, fracture fixation principles, management considerations, and commonly encountered complications. In addition, this article reviews emerging literature examining 3-dimensional printing and intraoperative imaging.

Global Research on Maxillofacial Fracture Over the Last 40 Years: A Bibliometric Study

ABSTRACT

Maxillofacial injuries are widely investigated worldwide as it consists a significant portion of trauma patients. Many researchers from various regions have reported the clinical and statistical analyses of maxillofacial fractures (MFFs) as the statistical data of MMFs are of great importance for both effective control and prevention of these cases. The number of studies concerning the diagnosis and treatment modalities of MFFs has significantly increased over the years. The bibliometric method was used to analyze publication outputs, countries, journals, most citations, and trends. In this study, the bibliometric analysis method was used in the publications related to MFFs published between 1980 and 2019, which were Science Citation Index Expanded indexed in the Web of Science database. Bibliometric analysis is applied to evaluate existing data in an evidence-based manner. The highest number of scientific articles on MFFs came from the USA, which was also the most cited country among others. When the distribution of the words in abstracts and titles by years was examined, it was seen that there was a significant change in the words "navigation," "computer," and "technology" between 2009 and 2012. The authors predict that our study would provide a novel perspective to the studies about MFFs and contribute to the researchers about the limits of the topic, and being aware of the active journals that publish the papers on this issue would facilitate the work of the researchers.

The association of Le Fort midfacial fractures with frontobasal injuries: a 17-year review of 125 cases, reflections on biomechanics, classifications and treatment

The frequency of midface and frontobasal fractures has increased over the past 40 years despite the improvement and stringent regulation implemented on modern safety equipment (belts, helmets…). This observation might be correlated with the progress of radiodiagnosis tools. Literature was reviewed according to Prisma guidelines. We searched for reviewed articles, published between January 2000 and December 2017, through Medline (Pubmed) online databases and ScienceDirect, using the following MeSH Keywords: "Le Fort classification", "Le Fort fracture", "Frontobasal fracture", "skull base fracture", "Midface Fractures". Among 652 patients with frontobasal fractures, 125 (19.1%) were associated with a Le Fort fracture. 59 (9%) were associated with Le Fort III fracture, 51 (7.8%) with Le Fort II fracture and 15 (2.3%) with Le Fort I fracture. When frontobasal fractures were associated with midfacial fractures, we found 18 cerebrospinal fluid leaks (11.8 %) and 19 cases of meningitis (12.5 %). When only the frontobasal area was involved, there were 6 cerebrospinal fluid leaks (4.3 %) and 6 meningitis (4.3 %). Our results highlight a regular association between Le Fort fractures and frontobasal fractures for stages II and stage III of Le Fort fractures and also found a higher rate of neuro-septic complication. Further research shall investigate treatment and monitoring recommendations fitting modern epidemiology of craniofacial traumatology.

Epidemiology of facial fractures: incidence, prevalence and years lived with disability estimates from the Global Burden of Disease 2017 study

BACKGROUND

The Global Burden of Disease Study (GBD) has historically produced estimates of causes of injury such as falls but not the resulting types of injuries that occur. The objective of this study was to estimate the global incidence, prevalence and years lived with disability (YLDs) due to facial fractures and to estimate the leading injurious causes of facial fracture.

METHODS

We obtained results from GBD 2017. First, the study estimated the incidence from each injury cause (eg, falls), and then the proportion of each cause that would result in facial fracture being the most disabling injury. Incidence, prevalence and YLDs of facial fractures are then calculated across causes.

RESULTS

Globally, in 2017, there were 7 538 663 (95% uncertainty interval 6 116 489 to 9 493 113) new cases, 1 819 732 (1 609 419 to 2 091 618) prevalent cases, and 117 402 (73 266 to 169 689) YLDs due to facial fractures. In terms of age-standardised incidence, prevalence and YLDs, the global rates were 98 (80 to 123) per 100 000, 23 (20 to 27) per 100 000, and 2 (1 to 2) per 100 000, respectively. Facial fractures were most concentrated in Central Europe. Falls were the predominant cause in most regions.

CONCLUSIONS

Facial fractures are predominantly caused by falls and occur worldwide. Healthcare systems and public health agencies should investigate methods of all injury prevention. It is important for healthcare systems in every part of the world to ensure access to treatment resources.

Dynamic changes of facial skeletal fractures with time

To investigate the characteristics of imaging changes with time of facial fractures, patients with facial fractures who had computed tomographic scan were enrolled including 500 patients who were divided into six groups based on the time of scanning: super early (<3 d), early (4–7 d), early-to-medium (8–14 d), medium (15–21d), medium-to-late (22d–2 months) and late stage (>2 months). The data were compared and analyzed. Forty two patients with frontal bone fractures had high-energy impact as the reason of fractures. The fracture line was clear and sharp within one week but blunt and sclerotic due to bone absorption at 2–3 weeks, and might exist for a long time. All patients had soft tissue swelling and paranasal sinus effusion at 1–2 weeks after injury. Air might gather in the adjacent soft tissues and/or intracranially within 3 days of injury if the fracture involved the frontal or other sinuses. Twelve of the 42 patients (28.6%) had intracranial hematoma, and five (11.9%) had epidural effusion. Subarachnoid hemorrhage was mostly absorbed within one week while epidural hematoma was completely absorbed over 3 weeks. Significant changes (P < 0.05) in the fracture lines, effusion of paranasal sinuses, soft tissue swelling and pneumocephalus were observed during the study period. For patients with medial orbital wall fractures, the fracture line was sharp and clear at early stages with concurrent sphenoid sinus effusion, and the fracture line became depressed 3 weeks later with disappearance of sphenoid sinus effusion. Significant changes (P < 0.05) were observed in the sharp fracture line, soft tissue swelling, sphenoid sinus effusion and smooth depression at fracture sites. For nasal fractures, the fracture line was sharp and clear at early stages with concurrent soft tissue swelling which disappeared one week later. The fracture line became smooth three weeks later. A significant (P < 0.05) difference was demonstrated in the changes of fracture line and soft tissue swelling with time. In conclusion, facial fractures have some dynamic alterations with time and identification of these characteristics may help reaching a correct clinical diagnosis with regard to fracture severity and time.

Postoperative CT of the Mandible Following Trauma: Review of Normal Appearances and Common Complications

RATIONALE AND OBJECTIVES

Surgeons aim to restore occlusion and jaw function to baseline status for patients with mandibular fractures using either closed treatment or reduction and fixation.

MATERIALS AND METHODS

Occlusion is defined as the relationship between the maxillary and mandibular teeth as they approach each other.

RESULTS

Radiologists should be familiar with the goals of repair to help identify which treatment is adequate as well as to diagnose potential complications. Some of the more common complications encountered are infection, nonunion or malunion, and malocclusion.

CONCLUSION

We provide a comprehensive review of both the desired and untoward CT findings after surgical repair of traumatic mandibular injuries.

Postoperative CT of the Midfacial Skeleton After Trauma: Review of Normal Appearances and Common Complications

OBJECTIVE

The objective of this article is to describe the CT appearance of the midfacial skeleton after surgical repair of posttraumatic Le Fort, nasoorbitoethmoidal (NOE), and frontal sinus fractures. Several of the more commonly encountered complications will also be described.

CONCLUSION

Surgery after midfacial trauma is aimed at restoring both form and function. Knowledge of the principal tenets of Le Fort, NOE, and frontal sinus fracture repair is vital for radiologists to accurately assess the adequacy of treatment on postoperative CT and provide meaningful reports for the surgeon.

Simultaneous head and facial computed tomography scans for assessing facial fractures in patients with traumatic brain injury

INTRODUCTION

Patients with traumatic brain injury (TBI) may have concomitant facial fractures. While most head injury patients receive head computed tomography (CT) scans for initial evaluation, the objective of our study was to investigate the value of simultaneous facial CT scans in assessing facial fractures in patients with TBI.

METHODS

From January 1, 2015 to December 31, 2015, 1649 consecutive patients presenting to our emergency department (ED) with a TBI who received CT scans using the protocol for head and facial bones were enrolled. The clinical data and CT images were reviewed via a standardized format.

RESULTS

In our cohort, 200 patients (12.1%) had at least one facial fracture shown on the CT scans. Patients with facial fractures were more likely to have initial loss of consciousness (ILOC; p<0.001), a Glasgow coma scale of 8 or less (p<0.001), moderate or severe degrees of head injury severity scale (p<0.001), positive physical examination findings (p<0.001), and positive CT cranial abnormalities (p<0.001). A total of 166 (83.0%) patients with facial fractures required further facial CT scans instead of conventional head CT scans alone. Surgical intervention was mandatory in 73 (44.0%) of the 166 patients, who more frequently exhibited fractures of the lower third of the face (p<0.001) and orbital fractures (p=0.019).

CONCLUSIONS

TBI patients with risk factors may have a higher probability of concomitant facial fractures. Fractures of the lower third of the face and orbit are easily overlooked in routine head CT scans but often require surgical intervention. Therefore, simultaneous head and facial CT scans are suggested in selected TBI patients.

Fractures of the posterolateral maxillary sinus: a masticator space blowout injury?

BACKGROUND AND PURPOSE

Segmental, depressed fractures of the posterolateral maxillary sinus may occur as a result of trauma to the masticator space, previously described in association with mandibular fractures. The authors hypothesize that the fracture is due to a transient increase in pressure in the masticator space (blow out) and therefore should be seen in association with other regional fractures.

MATERIALS AND METHODS

Injuries of the masticator space were retrospectively identified by searching the imaging database from January 2014 to November 2014 for keywords that would identify regional trauma. The images were reviewed for segmental depressed fractures in the posterolateral aspect of the maxillary sinus accompanied by herniation of a variable amount of masticator space fat and/or muscle into the adjacent sinus. Three neuroradiologists reviewed the images and agreed by consensus on the presence or absence of a masticator space blowout fracture.

RESULTS

Forty-three zygomaticomaxillary complex (ZMC) fractures, 89 mandibular fractures, and 49 isolated zygomatic arch fractures were identified. While all of the ZMC fractures had a maxillary component, 3 of 43 (7.0 %) additional fractures met our fracture definition. Five of 89 (5.6 %) of the mandibular fractures and 6 of 49 (12.2 %) zygomatic arch fractures had an associated posterolateral maxillary fracture.

CONCLUSIONS

Segmental depressed fracture of the posterolateral maxillary sinus is relatively common, occurring in conjunction with other regional injuries. The authors hypothesize that it is due to a transient increase in pressure in the masticator space and is a separate entity from other fractures of the region that may occur concurrently.

Reevaluating the Utility of Maxillary Sinus Opacification as a Screening Tool for Facial Bone Fracture a Decade After Its Original Analysis

In 1997, Lambert and colleagues demonstrated that the absence of sinus fluid on head CT essentially excludes a fracture involving the sinus walls. Our purpose is to reevaluate this association utilizing the current standard of imaging technology. With improved image resolution, we aim to reassess whether the sensitivity and specificity of the “clear sinus sign” are improved or worsened. Furthermore, the current standard of care is to obtain a CT of the facial bones along with a head CT when facial trauma is suspected, so we also analyzed the association of the "clear sinus sign" with nasal bone and mandible fractures. We identified 629 facial bone CT scans performed on adult patients in the emergency department between July 2012 and May 2013. They were retrospectively analyzed by three reviewers for the presence of facial bone fracture and/or fluid opacification of at least one paranasal sinus (as defined by either complete sinus opacification or an air-fluid level - circumferential mucosal thickening was considered the absence of fluid). We found that sinus opacification was 98.8% specific for facial bone fracture but only 44.7% sensitive. However, for complex facial fractures, such as zygomaticomaxillary complex, orbital, and sinus fractures, the lack of sinus fluid is significantly more sensitive at 91%. Therefore, our results for complex facial fractures are congruent with those of the previous studies conducted by Lambert, et al. and Lewandowski, et al. However, we also demonstrate that sinus opacification is not specific for nasal bone or mandibular fractures.  

Does Training Background Influence Decision-Making in the Management of Zygomaticomaxillary Complex Fractures?

PURPOSE

Management of zygomaticomaxillary complex (ZMC) fractures should be based on injury patterns and not on training background. This study assessed management decisions for ZMC injuries among surgeons with different training backgrounds.

MATERIALS AND METHODS

This was a cross-sectional study of surgeons who evaluated 5 ZMC injury cases. The primary predictor variable was training background: plastic and reconstructive surgeons (PRSs), craniofacial PRSs (c-PRSs), and oral and maxillofacial surgeons (OMSs). Other variables were years in practice, fellowship training, practice scope, and comfort with managing facial injuries. The primary outcome variable was management of the ZMC and orbital floor (operative vs nonoperative). Secondary outcome measurements were related to surgical approaches and fixation. Descriptive, bivariate, and regression statistics were computed.

RESULTS

Twenty-one surgeons (7 PRSs, 7 c-PRSs, and 7 OMSs) with an average of 14.4 ± 12.6 years of experience provided a total of 105 treatment plans. There was significant agreement between c-PRSs and OMSs for management of ZMC and orbital floor injuries (rs = 0.70 and 0.76, respectively; P ≤ .001). PRSs did not have substantial agreement with c-PRSs or OMSs with regard to ZMC fractures (rs = 0.39 and 0.49, respectively; P ≤ .06), but significant agreement with regard to orbital floor injuries (rs = 0.70 and 0.76, respectively; P < .001). In a regression model, injury pattern was the only factor associated with operative management (P ≤ .001).

CONCLUSIONS

There is substantial agreement between OMSs and c-PRSs regarding the management of ZMC fractures and associated orbital floor injuries.

Assessment of Emergency Department Eye Examinations in Patients Presenting with Mid-Face Injury

BACKGROUND

One-fifth of patients with severe facial trauma suffer ophthalmic injury. Currently, patients presenting with mid-face injury to the emergency department (ED) undergo visual examination and then further assessment by ophthalmologists and with computed tomography (CT) scanning. The utility of the initial visual examination in the ED, performed by nonophthalmologists, remains unclear.

OBJECTIVE

We aimed to objectively identify whether a more thorough initial visual assessment, performed by nonophthalmologists in the ED, was associated with improved ophthalmic outcomes.

METHODS

Patients (n = 100) were retrospectively recruited from a tertiary craniomaxillofacial center. Visual examinations performed in the ED were scored objectively and measured against defined management and prognostic outcomes.

RESULTS

There was no significant difference between more thorough initial visual examination and reduced time to ophthalmology assessment or reduced visual complications. There was no correlation between more comprehensive examination and incidence of CT scanning.

CONCLUSIONS

We identified no significant difference between a comprehensive visual examination performed by nonophthalmologists in the ED, and improved ophthalmic outcomes. Physicians assessing patients with mid-face trauma in the ED should rule out eye emergencies, including retrobulbar hemorrhage and penetrating globe injury, and initiate expeditious CT scan and assessment by specialist ophthalmologists.

Virtual Surgical Planning for Orbital Reconstruction

The advent of computer-assisted technology has revolutionized planning for complex craniofacial operations, including orbital reconstruction. Orbital reconstruction is ideally suited for virtual planning, as it allows the surgeon to assess the bony anatomy and critical neurovascular structures within the orbit, and plan osteotomies, fracture reductions, and orbital implant placement with efficiency and predictability. In this article, we review the use of virtual surgical planning for orbital decompression, posttraumatic midface reconstruction, reconstruction of a two-wall orbital defect, and reconstruction of a large orbital floor defect with a custom implant. The surgeon managing orbital pathology and posttraumatic orbital deformities can benefit immensely from utilizing virtual planning for various types of orbital pathology.

Significance of post-traumatic maxillary sinus fluid, or lack of fluid, in a level II trauma population

Our goal was to test the predictive value of high-attenuation material within the maxillary sinus for adjacent facial bone fracture. After IRB approval, all blunt trauma facial CTs performed over a 5-month period at a level II trauma center were reviewed in consensus by three radiologists for the presence of facial fractures or high attenuation maxillary sinus opacity (≥30HU, ≥40HU, or ≥50HU). Three classes of fractures were analyzed: any fracture, any fracture contiguous with the maxillary sinus, and only fractures not contiguous with the maxillary sinus. Statistics were calculated using two-by-two tables. A total of 844 cases were reviewed with 273 patients having any fracture. There were 402 hemi-faces with any fracture and 62 hemi-faces with fracture contiguous with the maxillary sinus. Sensitivity, specificity, positive predictive value, and negative predictive value for any fracture (using the ≥40HU threshold) were 13, 99, 85, and 78 % respectively; for fracture contiguous with the sinus, these were 71, 99, 72, and 99 % respectively; and for only non-contiguous fractures, these were 2.3, 96, 13, and 80 %, respectively. We conclude that in this level II trauma population, lack of high attenuation maxillary sinus material nearly ruled out fractures in contiguity with the sinus. High-attenuation sinus material is only moderately predictive of a fracture contiguous with the maxillary sinus. Therefore, if after careful review a fracture is not identified, the radiologist should not be overly concerned that a fracture is being missed. High-attenuation sinus material is a poor marker for fractures not contiguous with the maxillary sinus.

Facial Fracture in the Setting of Whole-Body CT for Trauma: Incidence and Clinical Predictors

OBJECTIVE

The objective of our study was to identify the incidence and clinical predictors of facial fracture in the setting of whole-body MDCT for trauma.

MATERIALS AND METHODS

The clinical data from the electronic medical records, including the final radiology reports, of 486 consecutive patients who underwent MDCT for trauma (head, cervical spine, chest, abdomen, and pelvis examinations) with dedicated maxillofacial reconstructions from October 1, 2011, to July 31, 2013, were studied. The clinical variables were compared between cohorts of patients with and those without facial fracture. The two-sample t test was used to compare continuous variables, and the Fisher exact test was used to compare categoric variables.

RESULTS

Two hundred sixteen (44.4%) patients had at least one fracture on the dedicated maxillofacial CT examinations, 215 of whom had facial physical examination findings (sensitivity = 99.5%). Of the 28 patients without documented physical examination findings, 27 did not have a facial fracture (negative predictive value = 96.4%). Statistically significant differences were found between positive and negative cases of facial fracture in patients with a Glasgow coma scale (GCS) score of 8 or less (p < 0.0001), an injury severity score of 16 or greater (p < 0.0001), acute alcohol intoxication according to blood alcohol concentration (BAC) (p = 0.0387), intubation at presentation (p < 0.0001), positive physical examination findings (p < 0.0001), and loss of consciousness (p = 0.0364). Falls from a height greater than standing height and open-vehicle collisions had the highest fracture rates (80.0% and 58.3%, respectively).

CONCLUSION

A negative finding at facial physical examination reliably excluded fracture. Clinical variables positively associated with facial fracture included the following: GCS score of 8 or less, ISS of 16 or greater, alcohol intoxication according to BAC, intubation at presentation, loss of consciousness, and the presence of abnormal facial findings at physical examination.

The First AO Classification System for Fractures of the Craniomaxillofacial Skeleton: Rationale, Methodological Background, Developmental Process, and Objectives

Validated trauma classification systems are the sole means to provide the basis for reliable documentation and evaluation of patient care, which will open the gateway to evidence-based procedures and healthcare in the coming years. With the support of AO Investigation and Documentation, a classification group was established to develop and evaluate a comprehensive classification system for craniomaxillofacial (CMF) fractures. Blueprints for fracture classification in the major constituents of the human skull were drafted and then evaluated by a multispecialty group of experienced CMF surgeons and a radiologist in a structured process during iterative agreement sessions. At each session, surgeons independently classified the radiological imaging of up to 150 consecutive cases with CMF fractures. During subsequent review meetings, all discrepancies in the classification outcome were critically appraised for clarification and improvement until consensus was reached. The resulting CMF classification system is structured in a hierarchical fashion with three levels of increasing complexity. The most elementary level 1 simply distinguishes four fracture locations within the skull: mandible (code 91), midface (code 92), skull base (code 93), and cranial vault (code 94). Levels 2 and 3 focus on further defining the fracture locations and for fracture morphology, achieving an almost individual mapping of the fracture pattern. This introductory article describes the rationale for the comprehensive AO CMF classification system, discusses the methodological framework, and provides insight into the experiences and interactions during the evaluation process within the core groups. The details of this system in terms of anatomy and levels are presented in a series of focused tutorials illustrated with case examples in this special issue of the Journal.

The Comprehensive AOCMF Classification System: Radiological Issues and Systematic Approach

The AOCMF Classification Group developed a hierarchical three-level craniomaxillofacial (CMF) classification system with increasing level of complexity and details. The basic level 1 system differentiates fracture location in the mandible (code 91), midface (code 92), skull base (code 93), and cranial vault (code 94); the levels 2 and 3 focus on defining fracture location and morphology within more detailed regions and subregions. Correct imaging acquisition, systematic analysis, and interpretation according to the anatomic and surgical relevant structures in the CMF regions are essential for an accurate, reproducible, and comprehensive diagnosis of CMF fractures using that system. Basic principles for radiographic diagnosis are based on conventional plain films, multidetector computed tomography, and magnetic resonance imaging. In this tutorial, the radiological issues according to each level of the classification are described.

Emergency radiology: Maxillofacial and skull-base trauma

Craniofacial trauma is common following road-traffic accidents, assaults and falls and may occur in isolation or associated with other body injuries. Due to the complexity of the maxillofacial and skull-base region, initial diagnosis may be inaccurate or delayed, leading to significant morbidity. Multidetector computed tomography is the modality of choice following high-energy blunt or penetrating trauma. It allows accurate evaluation of the fracture patterns and associated soft tissue complications and aids the appropriate medical and surgical treatment. In this article, we review and classify the most common traumatic injuries to the maxillofacial and skull-base region and outline the role of imaging in establishing complications and prognosis.

Spectrum of critical imaging findings in complex facial skeletal trauma

Multidetector computed tomography (CT) is the modality of choice for the evaluation of facial trauma because it helps accurately identify and characterize fractures and associated complications, thereby aiding timely clinical management and surgical planning. In particular, CT clearly depicts clinically relevant fractures in the eight osseous struts or buttresses that function as an underlying scaffold for facial structures. Information about the involvement of specific facial buttresses in a complex fracture is helpful for determining the type of fracture present and for identifying associated soft-tissue injuries that may require urgent care or surgery. Various kinds of complications can be expected to occur in Le Fort fractures, which affect the full thickness of the pterygoid plates, with resultant dissociation of part or all of the maxilla from the skull base; naso-orbitoethmoid complex fractures, which involve the medial orbital wall, nasal bone, ethmoid sinuses, and, often, the attachment site of the medial canthal tendon; zygomaticomaxillary complex fractures, which disrupt all four zygomatic sutures and may lead to enophthalmos due to increased orbital volume because of angulation of the lateral orbital wall; orbital "blowout" fractures, which may result in extraocular muscle herniation or entrapment and injuries to the globe or the infraorbital nerve; and fractures of the alveolar process, which are treated as open fractures because of their extension through the gingiva to the oral cavity and their resultant vulnerability to infection. Similarly, extension of a frontal sinus fracture through the posterior sinus wall creates a portal to the anterior cranial fossa and may lead to cerebrospinal fluid leakage, intracranial hemorrhage, or intracranial infection.

Multimodality imaging of the orbit

The role of imaging is well established in the evaluation of orbital diseases. Ultrasonography, Computed tomography and Magnetic resonance imaging are complementary modalities, which allow direct visualization of regional anatomy, accurate localization and help to characterize lesions to make a reliable radiological diagnosis. The purpose of this pictorial essay is to highlight the imaging features of commonly encountered pathologies which involve the orbit.

Multidetector computed tomography of maxillofacial fractures: the key to high-impact radiological reporting

Maxillofacial fractures are very common. Recognizing patterns of facial fractures is helpful in assessing maxillofacial injury and accurately characterizing all fractures that may be present. Facial fractures are grouped into the following categories: nasal bone, naso-orbito-ethmoid, orbital, zygomatic, maxillary (including Le Fort-type fractures), mandibular, and frontal sinus fractures. Within each subgroup of facial fractures, there are key findings, whether of the fracture itself or of potential associated injuries, that are important factors in determining whether the patient is managed conservatively or with surgery. This article highlights the features of facial fractures that are the most important to the surgeons and provides a framework for effective radiological reporting.

CT angiography for surgical planning in face transplantation candidates

SUMMARY

Facial allotransplantation replaces missing facial structures with anatomically identical tissues, providing desired functional, esthetic, and psychosocial benefits far superior to those of conventional methods. On the basis of very encouraging initial results, it is likely that more procedures will be performed in the near future. Typical candidates have extremely complex vascular anatomy due to severe injury and/or multiple prior reconstructive attempts; thus, each procedure is uniquely determined by the defects and vascular anatomy of the candidate. We detail CT angiography vascular mapping, noting the clinical relevance of the imaging, the angiosome concept and noninvasive delineation of the key vessels, and current controversies related to the vascular anastomoses.