Section VII. Facial Radiology

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).

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

When to Order Facial Radiographs

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

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.

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.

Structural Anatomy

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

Facial Radiography

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.

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.

The ...