|Year : 2022 | Volume
| Issue : 2 | Page : 165-171
Radiological investigation of acute mandibular injury
Department of Radiology, Faculty of Medicine and Health Sciences, Macquarie University, Sydney, NSW, Australia
|Date of Submission||28-Apr-2019|
|Date of Acceptance||09-Jan-2020|
|Date of Web Publication||15-Jul-2022|
Dr. Kevin Sheng
Department of Radiology, Faculty of Medicine and Health Sciences, Macquarie University, Macquarie Park, Sydney, NSW 2109
Source of Support: None, Conflict of Interest: None
| Abstract|| |
This article focuses on the different imaging modalities used to evaluate acute mandibular fractures and explores important concepts relating to their diagnosis, investigation, and treatment. Significant focus will be given to exploring general management principles, considerations regarding first-line imaging, and recent technological advancement. Computed tomography (CT) is the preferred method when attempting to identify acute mandibular fractures, particularly in trauma patients, and has very high specificity and sensitivity. Multidetector CT now represents the standard of care, enabling fast scan times, reduced artifact, accurate reconstructed views, and three-dimensional (3D) reconstructions. Cone-beam CT is a newer advanced imaging modality that is increasingly being used worldwide, particularly in the ambulatory and intraoperative setting. It produces high-resolution images with submillimeter isotropic voxels, 3D and multiplanar reconstruction, and low radiation dose, however is less widely available and more expensive. Ultrasound is a valuable method in identifying a fracture in unstable patients, but is limited in its ability to detect nondisplaced fractures. Magnetic resonance imaging is useful in determining the presence of soft-tissue injury. CT angiography is invaluable in the assessment of potential vascular injury in condylar fracture dislocations.
Keywords: Fracture, imaging, jaw, mandibular, trauma
|How to cite this article:|
Sheng K. Radiological investigation of acute mandibular injury. Natl J Maxillofac Surg 2022;13:165-71
| Introduction|| |
Mandibular fractures represent a common type of facial fracture in maxillofacial trauma, occurring most frequently in young men between the ages of 25 and 34 years., Because of its prominence and mobility, the mandible accounts for up to 75% of all facial fractures., Accordingly, they should be considered in all cases of facial trauma and should be assumed if a patient presents with trismus, fractured teeth, step deformity, or malocclusion. It is the most commonly reduced of all the viscerocranial structures in mandibular dislocations and accounts for up to a quarter of all casualty department presentations for maxillofacial fractures., An epidemiological survey by Haug et al. reported that motor vehicle accidents and assaults alone were responsible for ten times as many cases as all other factors combined. The most common cause of mandibular fractures is motor vehicle accidents, which are mostly due to the ever-growing numbers of vehicles and increasing speed limits. The second most common cause is assault, where fractures of the gonial angle are frequently seen., Mandibular fractures are also shown to happen more often in regions of reduced socioeconomic status secondary to increased alcohol abuse, violence, and assault. They occur most often in the parasymphysis, horizontal ramus, condyle, and gonial angle, with far fewer seen in the ramus (2%–4%) and coronoid process (1%–2%)., Gonial angle injuries are also more likely to be associated with a physical attack.
Imaging studies enable the extent of the fracture to be identified. The optimal end result is normal or near-normal occlusion, while avoiding complications. We will discuss about the various categories of fractures in addition to the diverse range of radiological studies utilized to evaluate this injury. Significant focus will be given to exploring general management principles, considerations regarding first-line imaging, and recent technological advancements.
| Methods|| |
A search was performed of four databases, including PubMed, Medline, Embase, and Scopus, for pertinent articles from January 1990 until December 2018. The reference lists of all relevant studies identified were parsed for further relevant articles. There were no restrictions relating to language. The following terms and their combinations were used as either keywords or MeSH headings: “mandible,” “fracture,” “traumatic,” “imaging,” “computed tomography,” “CT,” “X-ray,” “radiography,” “MRI,” “magnetic resonance imaging,” “US,” and “ultrasound.”
Categorization and general management principles
The classification of the mandibular fracture is important because it subsequently influences the management approach. General principles include reducing fractures of tooth-bearing segments and those with the least displacement first. There are different treatment strategies depending on the site, displacement, comminution, number of fractures, and whether or not it is unilateral/bilateral. It is particularly important to look for basal wedge fragments at the lower border of the mandible as they are not readily seen intraoperatively, and missing this finding can lead to an inappropriate fixation strategy., Other considerations include the potential risk to important neurovascular structures such as the inferior alveolar nerve and facial nerve, dental status, risk of scarring, baseline level of function and health, and oral hygiene. It is crucial to bear in mind that because of its horseshoe shape, a fracture or dislocation is more likely than not to be accompanied by another fracture or dislocation, often on the opposite side. Thus, over 50% of mandibular fractures can be classified as complex and bilateral. However, because the temporomandibular joint (TMJ) participates in the dissipation of force, it does not exhibit classic fracture patterns' characteristics to other ring-like structures.,
Dingman and Natvig in their classification organized the mandible into seven separate areas (symphysis, body, alveolar process, gonial angle, ramus, condyle process, and coronoid process). The Kazanjian and Converse classification relates to three different types. In a Type I fracture, there are teeth on both bony fragments. If there are teeth on only one bony fragment, then this is a Type II injury. If there are no teeth on either fragment of bone, this is then a Type III injury. A mandibular fracture in the gonial angle and horizontal ramus can also be categorized by how the surrounding musculature acts. Favorable fractures occur when the musculature acts to oppose the fragments together, whereas unfavorable fractures have the opposite effect. Similarly, they can also be staged in accordance with the F0–F4 system, with F0 being an incomplete fracture, F1 a single fracture, F2 a multiple fracture, F3 a comminuted fracture, and F4 a fracture with a bone defect/loss. The higher the score, the higher the chance of inferior alveolar nerve involvement and postoperative sequelae. Condylar fractures can be additionally categorized by the Lindahl classification. In this classification, condylar fractures are divided into condylar head, neck, and caudal fractures, depending on the fracture position. It is important to note that fractures of the condylar head are also intracapsular because the joint capsule extends to the condyle neck, whereas the caudal or subcondylar fracture extends inferiorly from the sigmoid notch. Based on the fracture fragment, condylar fractures are then further categorized into undisplaced, deviated, displaced, or dislocated. The most frequently seen is that of anteromedial condylar head displacement, which occurs in fractures below the lateral pterygoid muscle.
Generally, open reduction and internal fixation (ORIF) will be required for fractures of the gonial angle, body, symphysis, or parasymphysis, given they frequently involve tooth-bearing segments and periodontal ligaments, hence making them open fractures., Although this distinction is generally made clinically, soft-tissue gas is a useful indicator in imaging. The exception is if the fracture line extends into the territory of a third mandibular molar without concomitant gingival break. There is currently no consensus with regard to the management of teeth in the line of mandibular fractures, with more permissive approaches being favored recently with the recognition that the presence of teeth helps with maintaining occlusion.,, However, it is important to look for factors on imaging that favor extraction including associated crown fractures, severe tooth decay, poor periodontal condition, and dislocation.
Another important group are edentulous or atrophic mandibular fractures. A classification by Luhr et al. divides mandibular atrophy into three classes I–III, with III being the most severe and representing a mandibular body height of <10 mm. Classes I and II represent mandibular body heights of 16–20 and 11–15 mm, respectively. These have a higher rate of malunion and nonunion secondary to the reduced area of contact between the injured bone fragments, reduced opposition to antagonist muscles, and poor osteogenic potential. Generally, ORIF will be required to achieve an acceptable outcome in this subgroup of patients. In addition, caudal fractures with unfavorable characteristics including significant shortening and angulation of the ramus have an increased risk of malocclusion and would benefit from ORIF. However, the approach to caudal fractures is generally with maxillomandibular fixation given the high incidence of complications with ORIF, most prominently including facial nerve injury and parotid fistula.
The role of closed reduction and external fixation is diminishing, however there are specific scenarios where it is appropriate, particularly in the emergent trauma setting. For very unwell patients with multiple severe injuries, this technique is appropriate given external fixation can be performed very quickly and can reduce the risk of secondary brain injury from intraoperative hypotension or hypoxia., For grossly comminuted or “defect” fractures, particularly with significant associated soft-tissue loss and infection, external fixation will be required as part of a multistage surgical approach. They are also commonly used in undisplaced closed favorable fractures, however increasingly, condylar fractures are being repaired with an ORIF approach, particularly bilateral condylar fracture and high condylar fractures with associated condylar head displacement and loss of vertical height of the mandibular ramus., Fractures involving the coronoid process are rare, and generally management with observation and physiotherapy is indicated, with removal of the coronoid process indicated for ongoing trismus.
| Discussion and Review of Literature|| |
The potential for mandibular fracture should be recognized quickly because of the risk of complications with subsequent dysfunction. These include non- and mal-union, TMJ dysfunction, traumatic arthritis, and ankylosis., In addition, rapid identification of flail mandible, particularly trifocal, bilateral gonial angle, and bilateral body fractures, should be made due to the threat of airway compromise from associated complications. Failure to recognize this has the potential to lead to significant morbidity and mortality. Most patients with suspected mandibular fractures in the trauma setting have computed tomography (CT) imaging to look for other injuries, for example intracranial hemorrhage, organ rupture, or cervical spine fracture. For multiple trauma cases, scanning of the facial bones and orbit can be readily added to whole-body CT-based trauma imaging protocols., Attempting to elicit the severity of a fracture clinically in this setting is impractical given the presence of distracting injuries and potentially altered level of consciousness. Concurrent injuries are fairly typical in mandibular fracture patients, specifically in the intracranial region. They can be present in up to 20% of mandibular fractures, hence the need for additional imaging of the head if there is a suspicion of head injury. Cervical spine injuries can also occur concurrently and must be ruled out in people with reduced Glasgow Coma Scale or have come from a high-speed motor vehicle accident with distracting injuries. It is interesting to note that the presence of multiple mandibular fractures has a negative association with cervical vertebrae injury, perhaps secondary to a force dissipation mechanism. On the whole due to the high risk of concurrent injuries, CT of these regions is generally carried out together.
Treatment decisions and pathways are now progressively reliant on multidetector CT, particularly in preoperative assessment., This is because if the extent and type of the fracture pattern, together with associated injuries, is not identified, then potentially inappropriate fixation or selection of a nonoptimal surgical plan and strategy may result.,, A study by Wilson et al. compared a cohort of 42 consecutive patients with mandibular fractures who received both CT and panoramic tomography imaging. The sensitivity of CT for the detection of mandibular fractures compared to panoramic tomography was higher (100% vs. 86%), with the surgical management being changed in six patients. Similarly, Roth et al. showed greater sensitivity for CT (100% vs. 86%), with superior interobserver agreement. Multidetector CT has been shown to have better sensitivity, particularly for fractures of the gonial angle, ramus, or condyle., Increasingly, surgical evidence and protocols support the use of ORIF to facilitate faster recovery and re-establishment of structure and function., Hence, in patients with a high pretest probability, multidetector CT is increasingly playing the dual role of the initial modality of choice for making the diagnosis together with facilitating planning of the surgical approach.
By and large, multidetector CT now represents the first-line imaging modality of choice if it can be achieved in patients with suspected fractures of maxillofacial trauma and is generally considered to represent the standard of care. Health-care cost containment and lack of availability represent the main factors that limit adoption, however the changed medicolegal environment is gradually tilting the scale to increasing utilization. Multidetector CT is relatively weaker for the characterization of concomitant dental trauma, which is important, for example, when considering symphyseal and body fractures (which generally always cross the tooth row) and gonial angle fractures (which generally involve the mandibular third molar). When there is concern regarding the status of the mandibular third molar or other dental structures, further panoramic tomography imaging can be sought. However, this is proving increasingly unnecessary, with further improvements in technology allowing for increasingly high-resolution multiplanar reformatting and three-dimensional (3D) reconstruction with acceptable levels of artifact.
Multiplanar formatting allows coronal and sagittal views to be reconstructed from the axial plane, hence permitting for projections where there is minimal superimposition. Accordingly, condylar and symphyseal fractures are seen well in contrast to plain radiography. Furthermore, this overcomes the issues relating to an immobilized trauma patient. CT also allows for a 3D reconstruction of the mandible which affords a number of advantages for the surgeon, particularly with regard to preoperative planning. It is useful in determining the categorization and severity of the fracture and favorable/nonfavorable status and allows for better analysis of displacement, including location, direction, and magnitude. However, this can represent a potential pitfall as 3D volumetric reconstruction is associated with a partial volume averaging artifact, therefore smaller structures are best reviewed with high-resolution reconstructed axial, sagittal, and coronal slices. The overall sensitivity for CT in detecting mandibular fracture is higher than that for plain radiography. Furthermore, the decreased sensitivity of plain radiography is also contributed to by the fact that nondisplaced fractures may not be apparent for up to 10 days with this modality, and hence is frequently not seen initially. There is a greater level of sensitivity in analyzing a fracture with CT, however this comes at the cost of increased radiation dose (around 2 mSv, in comparison to a plain radiograph at 0.010 mSv). However, low-dose CT applications with dose-reduction programs are increasingly being performed, with doses of <1 mSv in maxillofacial CT being achieved in new multidetector CT scanners. Previously, weaknesses of CT included lengthier scan times with the potential for the production of artifact, particularly metallic artifact and motion blur in multiplanar and 3D volumetric reconstructed views. However, modern multidetector CT scanners, particularly higher slice systems, have very fast scan times with significant improvement in z-axis spatial resolution, allowing for coronal and sagittal views to be reconstructed quickly. In addition, the development of iterative metal artifact reduction algorithms and dual-energy multidetector CT techniques has helped to overcome artifact from beam hardening.,
Cone-beam CT is a newer advanced imaging modality that is increasingly being used worldwide, particularly in the ambulatory and intraoperative setting., It involves the use of a cone-shaped beam and a flat panel detector which captures all the images in a single rotation without patient movement, with most scanners requiring a seated posture., Cone-beam CT can generate isotropic voxels to as small as 0.075 mm3 and can afford multiplanar reconstruction and 3D volumetric reconstruction. It has significantly reduced radiation dose up to twenty-five times lower when compared to multidetector CT and is less susceptible to beam-hardening artifact., Multidetector CT, however, has superior soft-tissue contrast and is better able to characterize the fracture fragments and their relationship to surrounding musculature, the extent of hemorrhage, and the presence of foreign bodies. In the acute emergency setting, dedicated cone-beam CT imaging is generally impractical or unavailable when compared to multidetector CT imaging., In the ambulatory setting, it affords high-quality information both for diagnosis and surgical planning compared to plain radiography but is less available and more expensive. This is demonstrated in a study by Kaeppler et al. where follow-up cone-beam CT was performed in 164 patients with equivocal radiographic findings, resulting in an altered management plan for 9.52% of patients.
The main utility of plain radiography as a first-line imaging modality is triaging for simple fractures in the ambulatory setting where CT imaging is unavailable., The advantages are the cheaper cost, more widespread accessibility, and decreased radiation dose., Panoramic radiography can be combined with the standard series of X-ray views or used as a strategy in isolation, with studies showing similar or superior sensitivity for the identification of simple fractures when assessed against standard radiographs. They display the whole mandible in a single plane and are the most helpful radiograph in identifying a mandibular fracture, with a higher sensitivity (92% vs. 66%). They show fractures in the horizontal ramus well and also permit superior assessment of any type of comminution or displacement. Weaknesses include poor visualization of condyloid process fractures and artifacts secondary to poor technique. In addition, minimally displaced anterior fractures can be misinterpreted where there is superimposition of the cervical spine. For patients needing to stay supine with a collar on, only anteroposterior/lateral/oblique views are attainable, with the main limitation here being that the condylar region is poorly visualized and displacement is difficult to assess., An orthopantomogram, Clementscitsch, and posteroanterior views are unfeasible in this case given the person is unable to stand or move his/her neck; hence, in these patients, CT is the preferred modality by default.
Ultrasound has been shown to be helpful in finding displaced fractures, with very high sensitivities seen., It is particularly useful for the recognition of fractures with bony step-off, but it is limited in its ability with respect to nondisplaced fractures., However, resolution can be improved to 0.01-cm displacement with high-resolution ultrasonography, with the trade-off being a reduced field of view. A systematic review by Adeyemo and Akadiri on ultrasonography in maxillofacial fractures showed that ultrasound performed less well in the detection of intracapsular condylar fractures due to the superimposition of the zygomatic arch. The main benefits of ultrasonography are that it is a rapid imaging strategy, is reasonably economical, and has no ionizing radiation. This would be specifically valuable in trauma where the patient is too unstable or in cases where the patient declines CT scanning due to radiation, for example pregnancy. Unfortunately, ultrasonography supplies limited information relating to the extent and classification of the fracture because of technical limitations such as the number of views and spatial resolution attainable. It also has the additional significant weakness of being operator dependent.,
Magnetic resonance imaging (MRI) is generally not used in the acute stages for patients with maxillofacial trauma as CT is faster and superior in assessing for suspected bony injury and also has the advantage of being a round-the-clock service. However, in stabilized patients with suspected soft-tissue injury, MRI does play a significant role and has the advantage of not using ionizing radiation. Acute traumatic TMJ disc displacement and perforation/rupture of the retrodiscal tissue is significantly associated with TMJ ankylosis and other sequelae, with MRI representing the sole imaging modality that can dependably and adequately assess the anatomical structures for this. Significant morbidity can result, however, unfortunately, a number of factors including cost and availability prevent the widespread imaging of condylar fractures for soft-tissue injury. At this stage, more focus is placed on detecting the patterns of injury on CT that might be prognostic of further soft-tissue complications and that may profit from ORIF. High condylar fractures with associated condylar head displacement and loss of vertical height of the mandibular ramus have been shown to have an association with higher rates of disc displacement and perforation/rupture of the retrodiscal tissue. These are factors that eventually lead to the development of TMJ ankylosis, poor functional and anatomical outcomes, and the potential need for future joint replacement.
CT angiography is important to perform for condylar fractures with associated dislocation. This is done to look specifically for vascular complications, most prominently including dissection, particularly of the internal carotid artery, active hemorrhage, pseudoaneurysms, arteriovenous fistula, and aneurysms. A high index of suspicion and early detection is paramount, as early surgical intervention or endovascular therapy can limit subsequent morbidity., Pseudoaneurysms and dissections, particularly those involving major vessels, represent fairly uncommon but potential serious complications, however an increasing number of cases are being reported in literature.,,,,,, This may be reflective of the increased access to imaging modalities and technological advancements., Other important nonvascular complications associated with condylar fracture dislocations include fractures of the tympanic plate and mandibular fossa, associated dislocation into the external auditory canal and middle cranial fossa, abnormal bony development, and cranial nerve injury.
This article has examined the different imaging modalities used to evaluate acute mandibular fractures and explored important principles underpinning diagnosis and management and recent technological advances. Plain radiographs have traditionally been used to identify mandibular fractures in stable ambulatory patients. CT is the preferred method when attempting to identify acute mandibular fractures, with very high specificity and sensitivity. Multidetector CT now represents the de facto technological standard of care, enabling fast scan times, reduced artifact, and accurate multiplanar and 3D reconstructions. Cone-beam CT is a newer advanced imaging modality that is being used predominantly in the ambulatory and intraoperative setting, allowing for high-resolution images with submillimeter isotropic voxels, 3D and multiplanar reconstructions, and lower radiation doses. Ultrasound is a useful modality for identifying fractures in grossly unstable patients but is limited in its ability to detect nondisplaced fractures. MRI is valuable in the assessment of soft-tissue injury. CT angiography is invaluable in the assessment of potential vascular injury in condylar fracture dislocations.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Haug RH, Prather J, Indresano AT. An epidemiologic survey of facial fractures and concomitant injuries. J Oral Maxillofac Surg 1990;48:926-32.
Ogundare BO, Bonnick A, Bayley N. Pattern of mandibular fractures in an urban major trauma center. J Oral Maxillofac Surg 2003;61:713-8.
Hogg NJ, Stewart TC, Armstrong JE, Girotti MJ. Epidemiology of maxillofacial injuries at trauma hospitals in Ontario, Canada, between 1992 and 1997. J Trauma 2000;49:425-32.
Morrow BT, Samson TD, Schubert W, Mackay DR. Evidence-based medicine: Mandible fractures. Plast Reconstr Surg 2014;134:1381-90.
Gutta R, Tracy K, Johnson C, James LE, Krishnan DG, Marciani RD. Outcomes of mandible fracture treatment at an academic tertiary hospital: A 5-year analysis. J Oral Maxillofac Surg 2014;72:550-8.
Vyas A, Mazumdar U, Khan F, Mehra M, Parihar L, Purohit C. A study of mandibular fractures over a 5-year period of time: A retrospective study. Contemp Clin Dent 2014;5:452-5.
] [Full text]
Munante-Cardenas JL, Facchina Nunes PH, Passeri LA. Etiology, treatment, and complications of mandibular fractures. J Craniofac Surg 2015;26:611-5.
Fridrich KL, Pena-Velasco G, Olson RA. Changing trends with mandibular fractures: A review of 1,067 cases. J Oral Maxillofac Surg 1992;50:586-9.
Gadicherla S, Sasikumar P, Gill SS, Bhagania M, Kamath AT, Pentapati KC. Mandibular Fractures and Associated Factors at a Tertiary Care Hospital. Arch Trauma Res 2016;5:e30574.
Goodday RH. Management of fractures of the mandibular body and symphysis. Oral Maxillofac Surg Clin North Am 2013;25:601-16.
Abreu ME, Viegas VN, Ibrahim D, Valiati R, Heitz C, Pagnoncelli RM, et al
. Treatment of comminuted mandibular fractures: A critical review. Med Oral Patol Oral Cir Bucal 2009;14:E247-51.
Ellis E 3rd
, Muniz O, Anand K. Treatment considerations for comminuted mandibular fractures. J Oral Maxillofac Surg 2003;61:861-70.
Koshy JC, Feldman EM, Chike-Obi CJ, Bullocks JM. Pearls of mandibular trauma management. Semin Plast Surg 2010;24:357-74.
Natu SS, Pradhan H, Gupta H, Alam S, Gupta S, Pradhan R, et al
. An epidemiological study on pattern and incidence of mandibular fractures. Plast Surg Int 2012;2012:834364.
Escott EJ, Branstetter BF. Incidence and characterization of unifocal mandible fractures on CT. AJNR Am J Neuroradiol 2008;29:890-4.
Cillo JE Jr., Ellis E 3rd
. Treatment of patients with double unilateral fractures of the mandible. J Oral Maxillofac Surg 2007;65:1461-9.
Dingman RO, Natvig P. Surgery of facial fractures. Philadelphia: W.B. Saunders; 1964.
Kazanjian VH, Converse JM. Kazanjian and Converse's Surgical Treatment of Facial Injuries. Vol. 1. New York: Williams & Wilkins; 1974.
Pickrell BB, Hollier LH Jr., Evidence-based medicine: Mandible fractures. Plast Reconstr Surg 2017;140:192e-200.
Carinci F, Arduin L, Pagliaro F, Zollino I, Brunelli G, Cenzi R. Scoring mandibular fractures: A tool for staging diagnosis, planning treatment, and predicting prognosis. J Trauma 2009;66:215-9.
Powers DB. Classification of mandibular condylar fractures. Atlas Oral Maxillofac Surg Clin North Am 2017;25:1-0.
Neff A, Cornelius CP, Rasse M, Torre DD, Audigé L. The comprehensive AOCMF classification system: Condylar process fractures-Level 3 tutorial. Craniomaxillofac Trauma Reconstr 2014;7:S044-58.
Scheinfeld MH, Shifteh K, Avery LL, Dym H, Dym RJ. Teeth: What radiologists should know. Radiographics 2012;32:1927-44.
Mehta N, Butala P, Bernstein MP. The imaging of maxillofacial trauma and its pertinence to surgical intervention. Radiol Clin North Am 2012;50:43-57.
Taysi M, Yildirim S. Should the teeth in the line of jaw fractures be extracted? J Istanb Univ Fac Dent 2015;49:61-5.
Kamboozia AH, Punnia-Moorthy A. The fate of teeth in mandibular fracture lines. A clinical and radiographic follow-up study. Int J Oral Maxillofac Surg 1993;22:97-101.
Arosarena O, Ducic Y, Tollefson TT. Mandible fractures: Discussion and debate. Facial Plast Surg Clin North Am 2012;20:347-63.
Ellis E 3rd
, Miles BA. Fractures of the mandible: A technical perspective. Plast Reconstr Surg 2007;120:76S-89S.
Luhr HG, Reidick T, Merten HA. Results of treatment of fractures of the atrophic edentulous mandible by compression plating: A retrospective evaluation of 84 consecutive cases. J Oral Maxillofac Surg 1996;54:250-4.
De Feudis F, De Benedittis M, Antonicelli V, Pittore P, Cortelazzi R. Decision-making algorithm in treatment of the atrophic mandible fractures. G Chir 2014;35:94-100.
Kisnisci R. Management of fractures of the condyle, condylar neck, and coronoid process. Oral Maxillofac Surg Clin North Am 2013;25:573-90.
O'Brien PJ. Fracture fixation in patients having multiple injuries. Can J Surg 2003;46:124-8.
Chrcanovic BR. Open versus closed reduction: Comminuted mandibular fractures. Oral Maxillofac Surg 2013;17:95-104.
Choi KY, Yang JD, Chung HY, Cho BC. Current concepts in the mandibular condyle fracture management Part II: Open reduction versus closed reduction. Arch Plast Surg 2012;39:301-8.
Valiati R, Ibrahim D, Abreu ME, Heitz C, de Oliveira RB, Pagnoncelli RM, et al
. The treatment of condylar fractures: To open or not to open? A critical review of this controversy. Int J Med Sci 2008;5:313-8.
Shen L, Li J, Li P, Long J, Tian W, Tang W. Mandibular coronoid fractures: Treatment options. Int J Oral Maxillofac Surg 2013;42:721-6.
Teichgraeber JF, Rappaport NH, Harris JH Jr., The radiology of upper airway obstruction in maxillofacial trauma. Ann Plast Surg 1991;27:103-9.
Romeo A, Pinto A, Cappabianca S, Scaglione M, Brunese L. Role of multidetector row computed tomography in the management of mandible traumatic lesions. Semin Ultrasound CT MR 2009;30:174-80.
Dreizin D, Munera F. Blunt polytrauma: Evaluation with 64-section whole-body CT angiography. Radiographics 2012;32:609-31.
Czerwinski M, Parker WL, Williams HB. Algorithm for head computed tomography imaging in patients with mandible fractures. J Oral Maxillofac Surg 2008;66:2093-7.
Roccia F, Cassarino E, Boccaletti R, Stura G. Cervical spine fractures associated with maxillofacial trauma: An 11-year review. J Craniofac Surg 2007;18:1259-63.
Chu MW, Soleimani T, Evans TA, Fernandez SI, Spera L, Klene C, et al
. C-spine injury and mandibular fractures: Lifesaver broken in two spots. J Surg Res 2016;206:386-90.
Sun JK, LeMay DR. Imaging of facial trauma. Neuroimaging Clin N Am 2002;12:295-309.
Kommers SC, Boffano P, Forouzanfar T. Consensus or controversy? The classification and treatment decision-making by 491 maxillofacial surgeons from around the world in three cases of a unilateral mandibular condyle fracture. J Craniomaxillofac Surg 2015;43:1952-60.
Wilson IF, Lokeh A, Benjamin CI, Hilger PA, Hamlar DD, Ondrey FG, et al
. Contribution of conventional axial computed tomography (nonhelical), in conjunction with panoramic tomography (zonography), in evaluating mandibular fractures. Ann Plast Surg 2000;45:415-21.
Roth FS, Kokoska MS, Awwad EE, Martin DS, Olson GT, Hollier LH, et al
. The identification of mandible fractures by helical computed tomography and panorex tomography. J Craniofac Surg 2005;16:394-9.
Dreizin D, Nam AJ, Tirada N, Levin MD, Stein DM, Bodanapally UK, et al
. Multidetector CT of Mandibular Fractures, Reductions, and Complications: A Clinically Relevant Primer for the Radiologist. Radiographics 2016;36:1539-64.
Scarfe WC. Imaging of maxillofacial trauma: Evolutions and emerging revolutions. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2005;100:S75-96.
Huang G, Zheng J, Zhang S, Yang C. The value of panoramic radiograph, CT and MRI for the diagnosis of condylar fracture. Zhonghua Kou Qiang Yi Xue Za Zhi 2014;49:434-9.
Cevidanes LH, Bailey LJ, Tucker SF, Styner MA, Mol A, Phillips CL, et al
. Three-dimensional cone-beam computed tomography for assessment of mandibular changes after orthognathic surgery. Am J Orthod Dentofacial Orthop 2007;131:44-50.
Barrett JF, Keat N. Artifacts in CT: Recognition and avoidance. Radiographics 2004;24:1679-91.
Ceallaigh PO, Ekanaykaee K, Beirne CJ, Patton DW. Diagnosis and management of common maxillofacial injuries in the emergency department. Part 2: Mandibular fractures. Emerg Med J 2006;23:927-8.
Ngan DC, Kharbanda OP, Geenty JP, Darendeliler MA. Comparison of radiation levels from computed tomography and conventional dental radiographs. Aust Orthod J 2003;19:67-75.
Jeong DK, Lee SC, Huh KH, Yi WJ, Heo MS, Lee SS, et al
. Comparison of effective dose for imaging of mandible between multi-detector CT and cone-beam CT. Imaging Sci Dent 2012;42:65-70.
Napolitano G, Sodano A, Califano L, Grassi R, Brunese L. Multidetector row computed tomography with multiplanar and 3D images in the evaluation of posttreatment mandibular fractures. Semin Ultrasound CT MR 2009;30:181-7.
Horton KM, Sheth S, Corl F, Fishman EK. Multidetector row CT: Principles and clinical applications. Crit Rev Comput Tomogr 2002;43:143-81.
Weiß J, Schabel C, Bongers M, Raupach R, Clasen S, Notohamiprodjo M, et al
. Impact of iterative metal artifact reduction on diagnostic image quality in patients with dental hardware. Acta Radiol 2017;58:279-85.
Roele ED, Timmer VCML, Vaassen LAA, van Kroonenburgh AMJL, Postma AA. Dual-Energy CT in Head and Neck Imaging. Curr Radiol Rep 2017;5:19.
Boeddinghaus R, Whyte A. Current concepts in maxillofacial imaging. Eur J Radiol 2008;66:396-418.
Klatt JC, Heiland M, Marx S, Hanken H, Schmelzle R, Pohlenz P. Clinical indication for intraoperative 3D imaging during open reduction of fractures of the mandibular angle. J Craniomaxillofac Surg 2013;41:e87-90.
Venkatesh E, Elluru SV. Cone beam computed tomography: Basics and applications in dentistry. J Istanb Univ Fac Dent 2017;51:S102-S121.
Ogura I, Kaneda T, Mori S, Sekiya K, Ogawa H, Tsukioka T. Characterization of mandibular fractures using 64-slice multidetector CT. Dentomaxillofac Radiol 2012;41:392-5.
Kaeppler G, Cornelius CP, Ehrenfeld M, Mast G. Diagnostic efficacy of cone-beam computed tomography for mandibular fractures. Oral Surg Oral Med Oral Pathol Oral Radiol 2013;116:98-104.
Naeem A, Gemal H, Reed D. Imaging in traumatic mandibular fractures. Quant Imaging Med Surg 2017;7:469-79.
Braasch DC, Abubaker AO. Management of mandibular angle fracture. Oral Maxillofac Surg Clin North Am 2013;25:591-600.
Schuknecht B, Graetz K. Radiologic assessment of maxillofacial, mandibular, and skull base trauma. Eur Radiol 2005;15:560-8.
Chayra GA, Meador LR, Laskin DM. Comparison of panoramic and standard radiographs for the diagnosis of mandibular fractures. J Oral Maxillofac Surg 1986;44:677-9.
Nair MK, Nair UP. Imaging of mandibular trauma: ROC analysis. Acad Emerg Med 2001;8:689-95.
Freimanis AK. Fractures of the facial bones. Radiol Clin North Am 1966;4:341-63.
Guss DA, Clark RF, Peitz T, Taub M. Pantomography vs mandibular series for the detection of mandibular fractures. Acad Emerg Med 2000;7:141-5.
Singh KS, Jayachandran S. A comparative study on the diagnostic utility of ultrasonography with conventional radiography and computed tomography scan in detection of zygomatic arch and mandibular fractures. Contemp Clin Dent 2014;5:166-9.
] [Full text]
Mandava R, Sreeram MP, Elengkumaran, Ravindran C, Venkata S. Ultrasound - An imaging tool for mandibular fracture. MedPulse – Int J Radiol 2018;6: 21-3.
Rama Mohan K, Koteswara Rao N, Leela Krishna G, Santosh Kumar V, Ranganath N, Vijaya Lakshmi U. Role of ultrasonography in oral and maxillofacial surgery: A review of literature. J Maxillofac Oral Surg 2015;14:162-70.
Hirai T, Manders EK, Nagamoto K, Saggers GC. Ultrasonic observation of facial bone fractures: Report of cases. J Oral Maxillofac Surg 1996;54:776-9.
Adeyemo WL, Akadiri OA. A systematic review of the diagnostic role of ultrasonography in maxillofacial fractures. Int J Oral Maxillofac Surg 2011;40:655-61.
Boffano P, Benech R, Gallesio C, Arcuri F, Benech A. Current opinions on surgical treatment of fractures of the condylar head. Craniomaxillofac Trauma Reconstr 2014;7:92-100.
Dwivedi AN, Tripathi R, Gupta PK, Tripathi S, Garg S. Magnetic resonance imaging evaluation of temporomandibular joint and associated soft tissue changes following acute condylar injury. J Oral Maxillofac Surg 2012;70:2829-34.
Schneidereit NP, Simons R, Nicolaou S, Graeb D, Brown DR, Kirkpatrick A, et al
. Utility of screening for blunt vascular neck injuries with computed tomographic angiography. J Trauma 2006;60:209-15.
Alonso N, de Oliveira Bastos E, Massenburg BB. Pseudoaneurysm of the internal maxillary artery: A case report of facial trauma and recurrent bleeding. Int J Surg Case Rep 2016;21:63-6.
Chakrabarty S, Majumdar SK, Ghatak A, Bansal A. Management of pseudoaneurysm of internal maxillary artery resulting from trauma. J Maxillofac Oral Surg 2015;14:203-8.
Ribeiro Ribeiro AL, Brasil da Silva W, Alves-Junior Sde M, de Jesus Viana Pinheiro J. Giant life-threatening external carotid artery pseudoaneurysm caused by a mandibular condylar fracture. Oral Surg Oral Med Oral Pathol Oral Radiol 2015;119:e95-100.
Mohanty S, Gulati U, Kathuria S. Pseudoaneurysm of the internal maxillary artery: A rare complication of condylar fracture. Craniomaxillofac Trauma Reconstr 2013;6:271-4.
Moro A, Todaro M, Pedicelli A, Alexandre A, Pelo S, Doneddu P, et al
. Pseudoaneurysm of the internal maxillary artery secondary to subcondylar fracture: Case report and literature review. J Surg Case Rep 2018;2018:rjy080.
Nastro Siniscalchi E, Catalfamo L, Pitrone A, Papa R, Famà F, Lo Giudice G, et al
. Traumatic pseudoaneurysm of the internal maxillary artery: A rare life-threatening hemorrhage as a complication of maxillofacial fractures. Case Rep Med 2016;2016:9168429.
Tveita IA, Madsen MR, Nielsen EW. Dissection of the internal carotid artery and stroke after mandibular fractures: A case report and review of the literature. J Med Case Rep 2017;11:148.
Long X, Cheng Y, Li X, Li H, Hu S. Arteriovenous fistula after mandibular condylar fracture. J Oral Maxillofac Surg 2004;62:1557-8.