Key points
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Diagnostic imaging is an essential component for the optimal management of maxillofacial trauma.
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Plain film radiography has a limited role, today, in the diagnostic imaging of the maxillofacial trauma patient.
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Computed tomography (CT) imaging is currently the “gold standard” for imaging of the maxillofacial trauma patient, especially for upper and midface injuries.
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Diagnostic CT imaging can be useful in virtual surgical planning for maxillofacial fracture repair.
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Intraoperative imaging can confirm proper bony reduction and the overall success of surgical reconstruction, reducing the need for postoperative CT imaging and a separate revision surgery.
Introduction
Diagnostic imaging of the patient with maxillofacial trauma is most often an essential component in the proper evaluation and treatment, as history and physical examination alone is typically inadequate. Diagnostic imaging aims to facilitate an accurate diagnosis and assist with treatment, and thus, imaging is essential to optimizing clinical outcomes, both function and esthetics. Further, patients with maxillofacial trauma are a very important subset of patients, as there are almost 500,000 emergency department–related visits per year with a health care cost impact of almost $1 billion dollars. Imaging modalities consist of plain film radiography, computed tomography (CT), MRI, and ultrasound. Advantages and disadvantages exist for all of the available imaging modalities, with the ideal study providing accessible, timely, cost-effective and accurate results, with CT being the “gold standard” and most common imaging study for the patient with maxillofacial trauma, except in the ambulatory mandibular fracture case, when the orthopantomogram (Panorex) is often used.
The purpose of this article is to review historical and contemporary imaging studies available in the evaluation and treatment of the patient with maxillofacial trauma. Specifically, this article highlights the indications, advantages/disadvantages, and application of imaging technologies as a comprehensive update for all clinicians involved in the care of such patients.
Plain radiography
Plain radiographs for jaw imaging were introduced in the early 1900s. Next, the Panorex emerged around the early 1950s and facial/skull plain films in the early 1960s. CT imaging for maxillofacial injuries was first described in the early 1980s. Pertaining to plain radiographs, the anatomic area of concern dictates the imaging studies ordered, which include the following :
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Mandibular Series:
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Posteroanterior—mandibular body and subcondylar fractures ( Fig. 1 ).
Fig. 1 Posteroanterior plain radiograph. Arrow designates left subcondylar fracture. - b.
Oblique—mandibular angle fractures ( Fig. 2 ).
Fig. 2 Oblique plain radiograph. Arrow designates area of mandible fracture. - c.
Lateral—temporomandibular joint dislocation and condylar fractures ( Fig. 3 ).
Fig. 3 Lateral plain radiograph (aka: lateral cephalogram).
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Reverse Towne—condylar fractures ( Fig. 4 ).
Fig. 4 Reverse Towne plain radiograph. - 3.
Orthopantomogram (Panorex)—body, angle, and condylar mandibular fractures ( Fig. 5 ).
Fig. 5 Orthopantomogram (Panorex). Arrow designates right mandibular body fracture. - 4.
Towne—angle and condylar mandibular fractures; skull fractures ( Fig. 6 ).
Fig. 6 Towne plain radiograph. - 5.
Submentovertex—zygomatic arch fractures ( Fig. 7 ).
Fig. 7 Submentovertex plain radiograph. - 6.
Occipitomental/Waters—paranasal sinuses, especially maxillary, and midface fractures ( Fig. 8 ).
Fig. 8 Occipitomental plain radiograph. - 7.
Occipitofrontal/Caldwell—paranasal sinuses, especially frontal and ethmoid, and midface fractures ( Fig. 9 ).
