1. 外傷及感染之放射線影像檢查 Radiographic Interpretation of Trauma and Infection

2. 內容綱要
顎顏面外傷之影像檢查 技術
顎顏面外傷分類 判讀
感染的影像檢查
軟硬組織感染

3. 影像檢查在顎顏面外傷的應用 Plays a critical role
Identify the location and orientation of fractures
Indicate the degree of separation or displacement

4. 顎顏面外傷常用 放射線影像檢查技術 -I Routine view bones 2. Lateral view of facial bone
1. Posterior-anterior (PA) view of facial
bones
2. Lateral view of facial bone
3. Panorex
4. Water’s ( Occipitomental )
Suspect mid-face fracture

5. 顎顏面外傷常用 放射線影像檢查技術-II 5. Periapical view 6. Occlusal view
Occlusal view of nasal bone
Occlusal view of mandible
7. Submental-vertex view
8. Lateral view of nasal bone

6. 顎顏面外傷常用 放射線影像檢查技術-III
9. Tomography
10. Towne’s view
11. PA view of mandible
12. Oblique view of mandible

7. 1. PA view
Skull
Jaws

8. 2. Lateral view
Skull
Jaws
Neck

9. Mandible, maxilla, dentition,
3. Panex
Mandible, maxilla, dentition,
70 % of mid-face fracture

10. 4. Water’ view (Occipito-mental )
Maxillary fracture
Orbital fracture
Frontal bone / sinus

11. 5. Periapical view
Tooth and alveolar injury

12. 6. Occlusal view - Mandible
Fracture line , direction
Axial section

13. 6. Occlusal view - Maxilla

14. 7. Submental vertex view
Zygomatic arch fracture
Coronoid fracture

15. 8. Lateral nasal view

16. 9. Tomography
Blow –out fracture
TMJ fracture
185
180

17. 175
170

18. 165
160

19. 10. Modified Town’s view
Condylar fracture
Mandibular angle fracture

20. 11.PA symphysis view

21. 12. Oblique lateral view Was replaced by Panoex
Used when patient can not sit or stand

22. CT scan

23. Reconstructive 3-D CT scan

24. 顎顏面外傷之影像檢查判讀 General interpretation of fracture line
Condyle and other mandibular fracture
Middle facial fracture
Cavity: sinus, orbital
Dento-alveolar fracture

25. General interpretation of fracture line
Displacement ( deviation, dislocation )
Step, gap, overlapping
Discontinuity
Asymmetry
Comminuted
Malocclusion
Cavity: (air-fluid level )
*** Degree and direction

26. Mandibular fracture

27. Angle and symphysis fracture
Malocclusion
Step
Angle and symphysis fracture

28. Condyle and symphysis fracture
Overlap , discontinuity and
displacement
Asymmetry
Comminuted

29. Coronoid and ramus fracture
Gap, Discontinuity
Step , Displacement

30. Condyle Deviation Displacement Dislocation Displacement Undisplaced

31. condyle fracture
Displacement

32. Bilateral condyle fracture
Dislocation

33. Bone gap

34. Split fracture
Coronoid fracture

35. Chin horizontal fracture

36. Mid-facial trauma Cavity: sinus, hernia of orbital soft tissue
Tomography of orbital fracture CT
Air-emphysema
Middle fracture ( Le Fort I, II, III )
ZMC fracture
Basilar skull fracture: air-fluid level in sphenoid sinus

37. Le fort I fracture

38. Air-fluid level

40. Le Fort II fracture

41. Le Fort III fracture

42. Blow-out fracture

44. Zygomatic arch fracture

45. Zygomatico-maxillary complex ( ZMC) fracture

46. Classification of dentoalveolar injuries
A. Tooth structures
B. Supporting structures
1. Crown craze or crack
2. Crown fracture
1) Enamel
2) Enamel-Dentin
3) Enamel-Dentin- Pulp
3. Crown and root fracture
1) Pulp involvement
2) No pulp involvement

47. Classification of dentoalveolar injuries
4. Root fracture
1) Apical third
2) Middle third
3) Cervical third
Shift to another angle

48. B. Supporting Structure
1. Sensitivity ( concussion )
* percussion pain
* no displacement
* no mobility
* Image  widening of PDL space
2. Subluxation
* loosening, no displacement,
* Image  portion of PDL widening

49. Classification of dentoalveolar injuries
3. Tooth displacement
1) Intrusion
2) Extrusion
3) Labial displacement
4) Lingual displacement
5) Lateral displacement
4. Avulsion
5. Alveolar process fracture

50. 感染的影像檢查技術 Plain film radiography CT scan MRI Nuclear bone scans
Tomography
Ultrasonography

51. 齒源性感染的常用影像檢查 Plain film radiography 根尖片 : 對於根尖及早期病變的顯示最佳
咬合片 : (Axial) Garrie’s osteomyelitis
全口片 (panoex)
有張口困難的病人,
同時對牙齒的情況做,骨頭的破壞檢查,

52. CT Scan Space infection Neck: Air way, pharynx Sinus Orbit
Intracranial abscess
Soft tissue

53. MRI
Noninvasion, no radiation, high soft tissue resolution﹐high sensitivity and specificity
對骨的細部變化
space infection, presence of pus, cavitation
TMJ abscess

54. 選擇的要領 Plain film : 一般診斷及治療反應後的追蹤
CT / MRI : Extension into soft tissue ,
air way
Bone scan: Response to treatment

55. Image finding and Bone changes
Difficult to visualize by conventional techniques in early stage
Until substantial mineral removed %
After infection :5 -14 days

56. 感染部位與描述名稱 Margin: well or poor demarcation / defined
Lesion: radiolucent / radiopaque
Periapical changes: PDL , trabeculae .
Cavity (sinus) : cloudy, air-fluid level…
Osteomyelitis: periosteal reaction﹐moth eaten , rarefaction, ….
Sinus tract ( fistula )

57. 1. Periapical Infection ( acute / chronic ) Widening of PDL
Lamina dura discontinuity
Trabeculae destruction
Chronic
Periapical abscess
Periapical granuloma
Fistula
Root resorption

58. 2. Osteomyelitis (骨髓炎 ) Acute suppurative osteomyelitis
Trabeculae: fuzzy, diffuse destruction﹐
Radiolucent area
Poor demarcation
Irregular border

59. Chronic suppurative osteomyelitis
Necrotic Bone
Moth eaten*
Radiolucent area
with poor demarcation
Necrotic bone
Sequestrum
Radiopaque with
peripheral
rediolucent area
Rarefaction

60. Moth eaten

62. Sequestrum
Radiopaque with
peripheral radiolucent area

64. Pathologic fracture

65. Expansion
Rarefaction

66. Sclerosing Osteomyelitis
Focal type
Increasing density ( disposition of the bone ) rarefaction
Periapical area
Thickening of PDL
Bone scar

67. Sclerosing Osteomyelitis
Diffuse type
Border between normal and sclerosis .. poor defined
Cotton wool appearance。

69. Garre’s proliferative periostitis (Osteomyelitis)
Subperiosteal reaction: onion skinning﹐
Duplication of the cortical layer of bone

70. ORN ( Osteo-Radio Necrosis )
No remodeling

72. Bone necrosis due to Arsenic
Tooth germ, nerve damage…

73. 軟組織感染 Infections involving soft tissues are not readily
Demonstrated by many imaging techniques
Gas producing organism

74. Infratemporal space
Submasseteric space

75. Air way

77. MRI of TMJ space abscess

78. Sinusitis
Cloudy
Air-Fluid level

79. 下 課