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Because the radiographic anatomy of the facial skeleton is complex, attempting to identify a fracture simply by looking for discontinuity or deformity of the facial bones is inefficient and may fail to identify the pertinent findings. Facial fractures are best detected by looking for specific injury patterns (tripod fracture, blow-out fracture, isolated zygomatic arch fracture, or LeFort fracture).

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Fracture patterns are best understood by considering the main structural elements of the facial skeleton (Figure 1).

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Figure 1
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Supportive struts of the facial skeleton.

  • Three vertical struts: (A) nasal strut, (B) lateral orbital rim and lateral wall of the maxillary sinus, and (C) pterygoid plate (posterior).

Three horizontal struts: frontal bone (roof of the orbit), zygomatic arch and inferior orbital rim, and hard palate (maxilla).

The walls of the maxillary sinus and orbital floor are cut away in this illustration.

[From: Harris, et al: An approach to mid-face fractures. Crit Rev Diagn Imaging 1984;21:105–132. Copyright CRC Press, Boca Raton, FL.]

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When to Order Facial Radiographs

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Does every patient with a “black eye” need an imaging study? There are no clinical decision rules to guide the ordering of facial radiographs.

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Many facial fractures can be diagnosed clinically, and signs of specific injuries serve as a guide to ordering facial imaging. Such clinical findings include: palpable deformity of the orbital rim or zygomatic arch (can be masked by soft tissue swelling), malar flattening, periorbital subcutaneous emphysema, infraorbital anesthesia, restriction of ocular motion (especially upward gaze), dental malocclusion, mobility of the maxilla (LeFort fractures), enopthalmus, proptosis, sagging of the lateral canthus, and telecanthus (widening of the intercanthal distance). However, patients with nondisplaced fractures may only have nonspecific clinical findings such as swelling or ecchymosis. Radiography is therefore indicated even without definite signs of a fracture. On the other hand, in patients with massive facial injuries that have a dramatic clinical appearance, the serious associated injuries must be given priority over radiography—namely, airway, intracranial, ocular, and cervical injuries.

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In institutions where it is available on an emergency basis, Multidetector CT (MDCT) has supplanted facial radiography. Nonetheless, the anatomical landmarks and patterns of facial injury remain the same.

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Structural Anatomy

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The facial skeleton consists of three horizontal and three vertical supportive struts (Figure 1). Most facial fractures are oriented perpendicular to these supportive struts.

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Facial Radiography

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There are several standard radiographic views of the facial skeleton. These views are usually grouped into two radiographic series—a facial series and an orbital series.

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The facial series includes a Waters view, a Caldwell view, a lateral view, and a submental-vertical view (bucket-handle view). The orbital series includes a Waters view, a Caldwell view, and two oblique orbital views.

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