Disclosures: Facial Trauma ! None

Sara R. Nace, MD American Society of Head & Neck Radiology 50th Annual Meeting Thursday, September 8th, 2016

Objectives Facial

! Briefly review role of facial bones and structural pillars ! Societal importance, perception ! Discuss diagnosis of facial trauma (Multi-detector CT) ! Communication ! Review key points of “simple” midface fractures: nasal , ! Nutrition maxilla/palate, zygoma and ! Housing and protection of proximal airway and organs of special ! Identify complex midface fracture patterns, relevant classification sense systems & commonly associated complications ! “Cushion” for the neurocranium and cervical spine • Le Fort (I, II, & III) • Nasoethmoidal • Zygomaticomaxillary Complex Fractures

Facial Buttresses Facial Buttresses

! Thickened skeletal buttresses evolved in part to distribute vertical & axial (grinding) masticatory forces Sagittal ! Compartmentalize the face and provide attachment points for soft PTERYGO- NASO- • Nasomaxillary (medial) MAXILLARY MAXILLARY tissue structures • Zygomaticomaxillary Sagittal Axial Coronal (lateral) • Pterygomaxillary ZYGOMATICO • Nasomaxillary (medial) • Frontal bar • Anterior plane -MAXILLARY (posterior) • Zygomaticomaxillary • Upper maxillary • Posterior plane • +/- Vertical mandible (lateral) • Lower maxillary VERTICAL • Pterygomaxillary • +/- Skull base MANDIBLE (posterior) • +/- Vertical mandible Facial Buttresses Facial Buttresses

FRONTAL BAR Axial • Frontal bar Coronal • Upper maxillary • UPPER • Anterior plane Lower maxillary MAXILLARY • +/- Skull base • Posterior plane LOWER MAXILLARY

ANTERIOR PLANE POSTERIOR PLANE

Diagnosis in Facial Trauma Diagnosis in Facial Trauma

! Multi-detector CT is imaging of choice ! Clinical examination and routine radiographs are inferior • Clinically, fractures are obscured by soft tissue , altered level of consciousness, and life threatening to remainder of body • Up to 25% patients needed surgical intervention of nasal despite negative plain films* • 43-78% orbital wall fractures could be diagnosed on plain film

Clayton MI, Lesser TH. The role of in the management of nasal fractures. J Laryngol Otol 1986; 100: 797-801.

Diagnosis in Facial Trauma Objectives

! Multi-detector CT is imaging of choice ! Briefly review role of facial bones and structural pillars • Thin section axial bone algorithm images with reformations. • Demonstrates soft tissue injury, hemosinus, foreign bodies ! Discuss diagnosis of facial trauma (Multi-detector CT) • Performed in conjunction with CT head, cervical spine ! Review key points of “simple” midface fractures: nasal bone, maxilla/palate, zygoma and orbit • Three-dimensional images in assessment of complex facial deformities, preoperative planning, and patient consultation ! Identify complex midface fracture patterns, relevant classification • Parmar HA, Ibrahim M, Mukherji SK. Optimizing Craniofacial CT Technique. systems & commonly associated complications Neuroimag Clin N Am 2014; 24: 395-405. • Le Fort (I, II, & III) • Nasoethmoidal • Zygomaticomaxillary Complex Fractures Nasal Bone Fracture Nasal Bone Fracture ! Manifestation dependent on direction and degree of injury force ! The most common central midface fracture, likely • Lateral impact mechanism (2/3rd) > frontal injury underrepresented ! Involvement of bony vs. cartilaginous structures ! Manifestation dependent on direction and degree of injury force • Lateral impact mechanism (2/3rd) > frontal injury • Look for/ report on nasal septal hematoma- potential complications include infection and/or pressure necrosis.

Nasal Bone Fracture Fracture of Maxilla/Palate • Look for/ report on nasal septal hematoma- potential complications include infection and/or pressure necrosis. ! Alveolar fracture is the most common isolated maxillary fracture • Mechanism = blow to mandible, pushing teeth upward/outward • Associated displacement / devitalization of teeth Anterior Posterolateral

* Hendrickson M, Clark N, Manson PN, et al. Palatal fractures: classification, patterns and treatment. Plast AXIAL Reconstr Surg 1998; 101 (2): 319-332.

Fracture of Maxilla/Palate Fracture of Maxilla/Palate

! Palatal Fracture Classification* Type I- Alveolar • Type I- Alveolar (anterior, posterolateral) Anterior • Type II- Sagittal • Type III- Parasagittal • Type IV- Para-alveolar • Type V- Complex • Type VI- Transverse

* Hendrickson M, Clark N, Manson PN, et al. Palatal fractures: classification, patterns and treatment. Plast Reconstr Surg 1998; 101 (2): 319-332. CORONAL SAGITTAL AXIAL MIP

Fracture of Maxilla/Palate Fracture of Maxilla/Palate

! Sagittal palatal fractures ! Parasagittal & para-alveolar palatal fractures • Fracture pattern primarily in pediatric population • Fracture extension along thinner bone, lateral to the vomerine attachment to the maxilla • Palatal suture ossifies between the second and third decade • Association with more complex Le Fort type injury patterns Type II- Sagittal Type III- Parasagittal Type IV- Para-alveolar

Fracture of Maxilla/Palate Fracture of Maxilla/Palate

Type III- Parasagittal Type III- Parasagittal

CORONAL AXIAL AXIAL MIP SAGITTAL AXIAL AXIAL MIP

Fracture of Maxilla/Palate Fracture of Zygomatic Arch

Type V- Complex Type VI- Transverse ! Isolated fractures • Typically 2 fractures segments with medial/ inferior displacement • Potential impingement on temporalis musculature or coronoid process

AXIAL AXIAL Orbital Fracture Orbital Checklist

! “Blow-out” and “Blow-in” fractures (pure vs. impure) ! Mechanisms: Hydraulic and bone conduction theories of orbital blow-out fractures*

• Blow too large to enter orbit, resulting in forces transmitted to bony and soft Intraocular tissue structures. Hemorrhage Globe Rupture ! Globe is typically undamaged

• Checklist: anterior chamber, position of the lens, posterior globe segment, Foreign Bodies orbital apex and foreign bodies Retrobulbar Waterhouse N, Lyne J, Urdang M, et al. An investigation into the mechanism of orbital blowout fractures Br J Plast Hematoma Surg 1999; 52: 607-12. Lens Injury (Fracture-)

Orbital “Blow-out” Fracture Orbital Blow-Out Fracture

! Orbital Floor ! Mechanisms: Hydraulic and bone conduction • Fractures in middle third, near infra-orbital canal • Blow too large to enter orbit, resulting in forces transmitted to bony and soft tissue structures. • Trapdoor, hinged ! Medial Wall • Fractures less predictable due to reinforcement by ethmoid sinus • Emphysema, adjacent fat effacement is helpful to distinguish acute injury

Hydraulic Theory Bone Conduction Theory

Orbital Blow-Out Fracture Orbital Blow-Out Fracture

! Mechanisms: Hydraulic and bone conduction • Blow too large to enter orbit, resulting in forces transmitted to bony and soft tissue structures. 2 Fracture types: 1. Small fracture, involving the anterior to mid medial floor of the orbit. Herniation of contents is unusual.

AXIAL

Waterhouse N, Lyne J, Urdang M, et al. An investigation into the mechanism of orbital blowout fractures Br J Plast Surg 1999; 52: 607-12. Bone Conduction Theory CORONAL SAGITTAL Orbital Blow-Out Fracture Orbital Blow-Out Fracture

AXIAL

AXIAL CORONAL SAGITTAL

Orbital Blow-Out Fracture Orbital Blow-Out Fracture

! Mechanisms: Hydraulic and bone conduction • Blow too large to enter orbit, resulting in forces transmitted to bony and soft tissue structures. 2 Fracture types:

2. Large fracture, involving the floor and medial orbital wall. Herniation of contents is frequent. Hydraulic Theory CORONAL SAGITTAL

Orbital Blow-Out Fracture Orbital “Blow-out” Fracture

! Clinically: • Upward gaze palsy due to extraocular muscle entrapment • Herniation of fat alone leads to muscle entrapment due to fibrous attachments to adjacent musculature! • (hemorrhage, edema, emphysema) • Reduced visual acuity (globe injury, hematoma, emphysema, optic nerve injury)

• Injury to maxillary division of trigeminal nerve (V2)

CORONAL AXIAL Orbital “Blow-out” Fracture Orbital Blow-Out Fracture

! Indications for surgery: • Chronic is related to sizeable fracture defect with fat herniation. Identify prospectively! • Muscle entrapment and acute enophthalmos (fracture fragments > 1 cm in size) • Proptosis resulting in posterior globe tenting is an ophthalmologic emergency • Chronic enophthalmos is related to sizeable fracture defect with fat herniation. Identify prospectively! ! Alloplasts reconstruct orbital floor

CORONAL AXIAL AXIAL

Orbital Blow-Out Fracture Orbital Blow-In Fracture ! Orbital Floor • Rare. Fracture fragments may impinge on extraocular musculature or globe • Risk of globe laceration

CORONAL AXIAL AXIAL

CORONAL CORONAL

Orbital Blow-in Fracture Orbital Roof & Frontal Sinus Fracture

! Orbital Roof • Mechanism: Direct blow to forehead, with fracture fragments displaced inward • Association with skull (70%) and frontal sinus (55%) fractures, IC hemorrhage • Depressed fracture +/- subperiosteal hematoma can impinge on upper globe, clinically mimicking upward gaze palsy. CORONAL • Unique complications: dural tear with CSF leak or cephalocele, extension of fracture into orbital apex

AXIAL CORONAL Orbital Roof & Frontal Sinus Fracture Frontal Sinus Fracture

! 5-15% maxillofacial trauma ! Mechanism: Direct trauma versus extension from calvarium; requires 800-2200 lbs of force! ! Treatment: ! Non-displaced are treated conservatively ! Anterior table fractures are treated with reduction/ stabilization (2/3rds) ! Frontal recess obstruction is treated with sinus obliteration ! Comminuted/ displaced anterior- posterior fractures (CSF leakage!) treated by frontal sinus cranialization. CORONAL AXIAL

Orbital Roof & Frontal Sinus Fracture Complex Orbital Fracture

AXIAL CORONAL

Orbital Apex Fracture Extension Orbital Apex Fracture Extension

! May extend through the optic canal and/or superior orbital fissure, resulting in clinical syndromes:

• Superior orbital fissure (SOF) syndrome: injury to CN III, IV, V1 and VI, resulting in ophthalmoplegia, diplopia and ptosis

CORONAL CORONAL Orbital Apex Fracture Extension Objectives

! May extend through the optic canal and/or superior orbital fissure, ! Briefly review role of facial bones and structural pillars resulting in clinical syndromes: ! Discuss diagnosis of facial trauma (Multi-detector CT) • Superior orbital fissure (SOF) syndrome: injury to CN III, IV, V1 and VI, resulting in ophthalmoplegia, diplopia and ptosis ! Review key points of “simple” midface fractures: nasal bone, maxilla/palate, zygoma and orbit • Orbital apex syndrome: SOF syndrome + monocular vision loss Emergency prompting high dose steroid therapy or surgical decompression ! Identify complex midface fracture patterns, relevant classification systems & commonly associated complications • Le Fort (I, II, & III) • Nasoethmoidal • Zygomaticomaxillary Complex Fractures

Le Fort Fractures Le Fort Fractures

! René Le Fort- French army surgeon described “lines of least ! René Le Fort- French army surgeon described “lines of least resistance” through which midface fractures occur. resistance” through which midface fractures occur. • Though the 3 types of complex fractures patterns were originally characterized separately and symmetrically across the midface, any 3 fracture types can exist in Le Fort III Le Fort II combination with another, either on the ipsilateral or contralateral side • Disruption of the pterygomaxillary junction is the commonality shared by the 3 patterns, and must be present to characterize a fracture pattern as a Le Fort type fracture Le Fort I

Le Fort Type I Fracture Le Fort Type I Fracture

! “Floating Palate” ! Pterygoid plate involvement • Mechanism: Blow to upper lip/ maxilla • Detaches the upper jaw from the maxillary sinuses and lower nasal septum- maxilloalveolar dissociation ! Involves all walls of in axial plane ! “Unique feature” is involvement of the lateral margin of the nasal fossa and inferior nasal septum*

* Rhea J, Novelline R. How to simplify the CT diagnosis of Le Fort fractures. AJR Am J Roentgenol 2005; 184: CORONAL AXIAL 1700-1705. Le Fort Type I Fracture Le Fort Type I Fracture

! Nasal septum= type I injury

CORONAL AXIAL AXIAL

Le Fort Type I Fracture Le Fort Type II Fracture

! Pyramidal • Mechanism: Blow to high central midface ! Further classification: • Wassmund I- nasal bone sparing • Wassmund II- nasal bone extension ! “Unique feature” is involvement of the inferior orbital rim*

! High (80%) rate of V2 nerve injury

AXIAL * Rhea J, Novelline R. How to simplify the CT diagnosis of Le Fort fractures. AJR Am J Roentgenol 2005; 184: 1700-1705.

Le Fort Type II Fracture Le Fort Type I Fracture (Right)

AXIAL CORONAL AXIAL Bilateral Le Fort Type II Fractures

CORONAL AXIAL CORONAL CORONAL

Sphenotemporal Buttress Fracture Blunt Cerebrovascular Injury

AXIAL AXIAL AXIAL SAGITTAL

Blunt Cerebrovascular Injury Blunt Cerebrovascular Injury

% of Patients with Fracture Types ! Craniofacial fractures have been repeatedly implicated as a cause of BCVI in numerous retrospective studies, though the association has been poorly characterized. • Retrospective series of 4398 patients with blunt mechanism facial fractures* Results: Complex facial fractures, including all LeFort injuries AXIAL DWI AXIAL DWI Bilateral fractures of any “facial third” complex Subcondylar mandibular fractures (esp. w/ skull base)

* Mundinger, GS, Dorafshar AH, Gilson MM, et al. Blunt-mechanism facial fracture patterns associated with ADC ADC internal carotid artery injuries: recommendations for additional screening criteria based on analysis of 4,398 patients. J Oral Maxillofac Surg 2013;71(12):2092-100

Blunt Cerebrovascular Injury Blunt Cerebrovascular Injury

% of Patients with Fracture Types ! ! Craniofacial fractures have been repeatedly implicated as a cause of Retrospective series of 1882 patients with craniocervical trauma * BCVI in numerous retrospective studies, though the association has Fracture With CVI No CVI Risk Type (n=99) (n=1783) Ratio been poorly characterized. Mandible 18.1 13.4 1.4 ! Western and Eastern Trauma Associations currently recommend Midface 54.5 43.4 1.3 screening all patients with Le Fort II or III facial fractures for the - Sphenotemporal Buttress 31.3 8.1 3.9 presence of BCVI. - Orbital Roof/Rim 29.3 10.6 2.8 - Le Fort 1-3 12.0 6.6 1.8

- NFE / NMB 11.1 8.3 1.3 Carotid Canal Fx (Displaced > 2 mm) 75.5 13.3 5.7

* Alsheik N, Gentry LR, Smoker WRK, et al. Comprehensive diagnostic evaluation of traumatic vascular injury in head trauma. Chicago (IL): RSNA; 2007.

Le Fort Type III Fracture Le Fort Type III Fracture

! Craniofacial separation • Centrolateral midface fractures ! Further classification: • Wassmund III- nasal bone sparing (separation at suture) • Wassmund IV- nasal bone extension ! “Unique feature” is involvement of the lateral orbital rim and zygomatic arch*

* Rhea J, Novelline R. How to simplify the CT diagnosis of Le Fort fractures. AJR Am J Roentgenol 2005; 184: 1700-1705. CORONAL

Bilateral Le Fort Type I Fractures Bilateral Le Fort Type II Fractures

CORONAL CORONAL CORONAL

CORONAL AXIAL Bilateral Le Fort Type III Fractures Bilateral Le Fort Type III Fractures

CORONAL AXIAL AXIAL

AXIAL CORONAL

Bilateral Le Fort Type I, II and III Fractures Nasoethmoidal Fracture

! “Nasoorbitoethmoid”(NOE) / “Nasofrontoethmoid” (NFE) / Nasomaxillary Buttress • Mechanism: Blow to nasal region with transmission through the nasal cavity, medial orbital walls and ethmoid sinuses.

Nasoethmoidal Fracture Nasoethmoidal Fracture

! Imaging ! “Nasoorbitoethmoid”(NOE) / “Nasofrontoethmoid” (NFE) / Nasomaxillary Buttress ! The medial canthal tendon and “central” bony fragment it inserts on are the critical factors in the diagnosis and treatment of nasoethmoidal orbital fractures. • Mechanism: Blow to nasal region with transmission through the nasal cavity, medial orbital walls and ethmoid sinuses. ! Clinical ! Damage to nasolacrimal apparatus and medial canthal tendon (telecanthus) ! Frontal sinus outflow tract injury (frontal recess) ! High association with severe nonfacial injuries (Intracranial hemorrhage, CSF rhinorrhea) Nasoethmoidal Fracture Nasoethmoidal Fracture

! Imaging Type I ! The medial canthal tendon has anterior and superior insertions along the frontal ! Markowitz and Manson classification: process of the maxilla and roof of the lacrimal crest. • Type I: Medial canthal structures insert on bony fragment large enough to be fixed to adjacent bone

Nasoethmoidal Fracture Nasoethmoidal Fracture

Type I I Type III ! Markowitz and Manson classification: ! Markowitz and Manson classification: • Type I: Medial canthal structures insert on bony • Type I: Medial canthal structures insert on bony fragment large enough to be fixed to adjacent fragment large enough to be fixed to adjacent bone bone • Type II: Comminuted fracture with medial • Type II: Comminuted fracture with medial canthal structure attachment to central fragment canthal structure attachment to central fragment • Type III: Severely comminuted fracture with avulsion of medial canthal tendon from bone.

Nasoethmoidal Fracture Nasoethmoidal Fracture

Type I Type II Type III

AXIAL AXIAL Nasoethmoidal Fracture Nasoethmoidal Fracture

AXIAL CORONAL CORONAL 3D SURFACE CORONAL

Nasoethmoidal Fracture Nasoethmoidal Fracture

CORONAL CORONAL SAGITTAL

Nasoethmoidal Fracture Zygomaticomaxillary Fracture

! “Trimalar,” “tripod” (misnomer) ! 2nd most common midface fracture after nasal bone • Mechanism: Direct traumatic blow to malar eminence • Centrolateral midface fractures resulting in disruption of the 4 sutures that attach the zygoma to the remaining face and calvarium • Includes maxillary segment ! Intraorbital volume can be increased or decreased depending on direction and rotation of fracture fragments.

SAGITTAL Zygomaticomaxillary Fracture Zygomaticomaxillary Fracture

! Disruption of: ! Disruption of:

! Lateral orbital wall/rim ZYGOMATICO- ! Lateral orbital wall/rim FRONTAL SUTURE ! Zygomatic arch ! Zygomatic arch ! Inferior orbital wall/rim ! Inferior orbital wall/rim ! Zygomaticomaxillary buttress ! Zygomaticomaxillary buttress ZYGOMATICO- SPHENOID SUTURE

ZYGOMATICO- TEMPORAL SUTURE ZYGOMATICO- MAXILLARY SUTURE

Zygomaticomaxillary Complex Fracture Zygomaticomaxillary Complex Fracture

AXIAL CORONAL CORONAL CORONAL

Zygomaticomaxillary Complex Fracture Key Points

Nasal bone: Look for/ report on nasal septal hematoma. Orbit: • Mechanisms of blow-out injury and associated fracture types • Herniation of orbital fat alone leads to muscle entrapment due to fibrous attachments to adjacent musculature • Evaluate orbital apex Frontal sinus: Assess frontal recess and posterior table involvement

AXIAL CORONAL Key Points THANK YOU!

Le Fort: Systematic approach “Unique features” I: Lateral margin of nasal fossa and inferior nasal septum II: Inferior orbital rim III: Lateral orbital rim and zygomatic arch ZMC: Involvement of 4 sutures attaching the zygoma to the face and calvarium Nasoethmoidal: Attachment site of medial canthal tendon

References References

1. Stanley RB Jr, Nowak GM. Midfacial fractures: importance of angle of impact to horizontal craniofacial buttresses. Otolaryngol Head 14. Martello JY, Vasconez HC. Supraorbital roof fractures: a formidable entity with which to contend. Ann Plast Surg 1997; 38: 223-227. Neck Surg 1985; 93: 186-192. 15. Girotto JA, Davidson J, Wheatly M, et al. Blindness as a complication of Le Fort osteotomies: role of atypical fracture patterns and 2. Slupchynskyj OS, Berkower AS, Byrne DW, Cayten CG. Association of skull base and facial fractures. Laryngoscope 1992; 102: distortion of the optic canal. Plast Reconstr Surg 1998; 102 (5): 1409-1421 1247-1250. 16. al-Qurainy IA, Dutton GN, Hankovan V, et al. Midfacial fractures and the eye: the development of a system for detecting patients at risk 3. Clayton MI, Lesser TH. The role of radiography in the management of nasal fractures. J Laryngol Otol 1986; 100: 797-801. of eye injury. Br. J. Oral Maxillofac. Surg. 1991; 29: 363-367. 4. Bell RB, Dierks EJ, Homer L, Potter BE. Management of cerebrospinal fluid leak associated with craniomaxillofacial trauma. J Oral 17. Holt GR, Jolt JE. Incidence of eye injuries in facial fractures: An analysis of 727 cases. Otolaryngol. Head Neck Surg. 1983; 91: 276. Maxillofac Surg 2004; 62: 676-684. 18. al-Qurainy IA, Stassen LF, Dutton GN, et al. Diplopia following midfacial fractures. Br. J. Oral Maxillofac. Surg 1991; 29: 302-307. 5. Stranc MF. The pattern of lacrimal injuries in naso-ethmoid fractures. Br J Plast Surg 1970; 23: 339-346. 19. Winegar BA, Gutierrez JE. Imaging of orbital trauma and emergent non-traumatic conditions. Neuroimag Clin N Am 2015; 25: 6. Stranc MF. Primary treatment of naso-ethmoid injuries with increased intercanthal distance. Br J Plast Surg 1970; 23: 8-25. 439-456 7. Cooter RD, Dunaway DJ, David DJ. The influence of maxillary dentures on mid-facial fracture patterns. Br J Plast Surg 1996; 49: 20. Waterhouse N, Lyne J, Urdang M, et al. An investigation into the mechanism of orbital blowout fractures Br J Plast Surg 1999; 52: 379-382. 607-612. 8. Rowe NL. Maxillofacial injuries- current trends and techniques. Injury 1985; 16: 513-525. 21. Ellis E, Reddy L. Status of the internal orbit after reduction of zygomaticomaxillary complex fractures. J oral Maxillofac Surg 2004; 62: 9. al- Qurainy IA, Stassen LF, Dutton GN, et al. The characteristics of midfacial fractures and the association with ocular injury: a 275-283. prospective study. Br J Oral Maxillofac Surg 1991; 29: 291-301. 22.Markowitz B, Manson P, Sargent L et al. Management of the medial canthal tendon in nasoethmoid orbital fractures: the importance of 10. Smith PH. Blow out fracture of the floor of the orbit. Aust N Z J Surg 1967; 36: 319-322. the central fragment in classification and treatment. Plast Reconstr Surg 1991; 87: 843-853. 11. Burm JS, Chung CH, Oh SJ. Pure : new concepts and importance of medial orbital blout fracture. Plast 23. Rhea J, Novelline R. How to simplify the CT diagnosis of Le Fort fractures. AJR Am J Roentgenol 2005; 184: 1700-1705. Reconstr Surg 1999: 103: 1839-1849 24. Unger J. Orbital apex fractures: the contribution of computed tomography. Radiology 1984; 150: 713-717. 12. Nolasco FP, Mathog RH. Medial orbital wall fractures: classification and clinical profile. Otolaryngol Head Neck Surg 1995; 112: 549- 25. Kubal WS. Imaging of orbital trauma. RadioGraphics 2008; 28: 1729-1739. 556. 26. Bord SP, Linden J. Trauma to the globe and orbit. Emerg Med Clin North Am 2008; 26: 97-123 13. Lee HJ, Jilani M, Frohman L, Baker S. CT of orbital trauma. Emerg Radiol 2004; 10: 168-172. 27. Kuhn F, Morris R, Mester V, et al. Epidemiology and socioeconomics. Ophthalmol Clin North Am 2002; 15: 145-151

References References

28. Bellamy JL, Mundiger GS, Reddy SK, et al. Le Fort II Fractures are associated with death: a comparison of simple and complex midface 39. Mundinger, GS, Dorafshar AH, Gilson MM, et al. Blunt-mechanism facial fracture patterns associated with internal carotid artery fractures. J Oral Maxillofac Surg 2013; 71: 1556-1562. injuries: recommendations for additional screening criteria based on analysis of 4,398 patients. J Oral Maxillofac Surg 2013;71(12): 29. Som PM, Curtin HD, eds. Head and neck imaging. St. Louis, Mo.: Mosby Elsevier, 2011:491-524. 2092-100 30. Uzelac A, Gean AD. Orbital and facial fractures. Neuroimag Clin N Am 2014; 24: 407-242. 40. Alsheik N, Gentry LR, Smoker WRK, et al. Comprehensive diagnostic evaluation of traumatic vascular injury in head trauma. Chicago 31. Nace SR, Gentry LR. Cerebrovascular Trauma. Neuroimag Clin N Am 2014; 24: 487-511. (IL): RSNA; 2007. 32. Plaisier BR, Punjabi AP, Super DM, Haug RH. The relationship between facial fractures and death from neurologic injury. J Oral Maxillofac Surg 2000;58: 708. 33. Mithani SK, St- Hilaire H, Brooke BS, etal. Predicatable patterns of intracranial and cervical spine injury in craniomaxillofacial strauma: analysis of 4786 patients. Past Reconstr Surg 2009; 123: 1293. 34. Gentry LR, Manor WF, Turski PA, Strother CM. High-resolution CT analysis of facial struts in trauma: 1. Normal anatomy. AJR Am J Roentgenol 1983; 140: 523-532. 35. Gentry LR, Manor WF, Turski PA, Strother CM. High-resolution CT analysis of facial struts in trauma: 2. Osseous and soft-tissue complications. AJR Am J Roentgenol 1983; 140: 533- 541. 36. Hendrickson M, Clark N, Manson PN, et al. Palatal fractures: classification, patterns and treatment. Plast Reconstr Surg 1998; 101 (2): 319-332. 37. Leipziger LS and Manson PN. Nasoethmoid Orbital Fractures. Nasoethmoid Orbital Fractures. Clinics in Plastic Surgery. 1992; 19(1): 167-193. 38. Andreasen JO, Lauridsen E, Gerds TA, et al. guide: a source of evidence-based treatment guidelines for dental trauma. Dent Traumatol 2012; 28 (2): 142-147.