Facial Bone

Radiography
A five minute guide
to what the
radiologist and
clinician really need.

Facial Bone Radiography

Severe trauma to the facial area usually
proceeds to CT with 2D and possibly 3D
reconstructions.
Facial radiographs remain a useful
screening tool for lesser trauma with the
advantages of lesser cost and radiation.
If you dont perform these often and are
faced with the exam on the night shift
dont despair here is your guide.

 A good facial bone exam is based

primarily on three projections:
Lateral
True Waters
Modified Caldwell
A SMV view is added in some
protocols.
The key to a good exam is to take
the images correctly and produce the
expected view of the anatomy.

THE LATERAL PROJECTION

The lateral view should be taken upright if
possible. A cross table lateral without turning
the head is the next best choice.
Turning the patients head is not a good plan
with acute trauma but, more importantly, a
rotated projection can mask clues to a basilar
skull fracture and doesnt allow a correct view
of the cervical/cranial junction.
Right and Left laterals are not as important as a
patient with a suspected skull Fx will get a CT.

 This lateral view

was taken with the
head turned to the
side on the table.
An air-fluid level in
the sphenoid sinus
is a clue to a
possible basilar
skull fracture which
would be missed as
the fluid would
spread out in the
dependant portion
of the sinus.

 This correctly
positioned lateral
displays well the
relationship of the
skull base to the
cervical spine.
An air fluid level in
the sinuses would
be evident.

Another good lateral. Did you note the air-fluid

levels in the maxillary sinuses? These can be due
to sinusitis but in the setting of acute trauma may
be a clue to bleeding and an orbital floor fracture.

THE WATERS VIEW

A waters view by definition should show the
entire maxillary sinuses. Faces are different! A
common mistake is to plug in a standard angle
which ends up being too shallow. If a standard
angle does not show the entire sinuses, it
should be repeated. This view shows the
anterior orbital rims (not the orbital floor) and
gives the radiologist a good view of the
zygomatic arches, zygomas and orbital roofs.
Differentiation between an orbital rim Fx and
an orbital floor Fx is important to the clinician.

Correctly positioned Waters.

Z=zygoma, OR=orbital rim, ZA=
zygomatic arch and ms=maxillary
sinus. Note that the entire
maxillary sinus is displayed.

THE CALDWELL PROJECTION

The Caldwell view is the only
projection to visualize the true orbital
floor where blowout fractures and
sometimes entrapment of the
extraocular muscle occurs. The
standard Caldwell will not show the
orbital floor well and a modified
Caldwell with steeper angle is
needed. In most patients, this is
around 22 degrees. The ideal

This standard, 15
degree Caldwell
shows the petrous
ridges (PR) above
the lower orbit and
obscures detail of
the true orbital
floor. It should be
repeated with
additional angle of
around 8 degrees.

This is the anatomic

view you want to
produce for a good
modified Caldwell.
A lesser angle
obscures the
orbital floor and a
steeper angle
approaches a
Waters and shows
the orbital rim
instead of the floor.

Modified Caldwell

If an orbital floor fracture is found, patients

should proceed to CT to evaluate possible
muscle entrapment and fragment position.
This CT coronal image shows a left orbital floor
depressed fracture with entrapment of the
inferior rectus muscle. The patient went to
surgery to relieve the entrapment and diplopia.

A case can be made for a facial bone protocol using just the previous
three well positioned images. Our present protocol also includes a
submental vertex view which gives the radiologist an additional look
at the zygomatic arches.

GOOD POSITIONING
MAKES EVERYONE HAPPY!