Comparative evaluation of MRI-based bone-targeted sequences and computed tomography for preoperative assessment of midfacial trauma

Abstract

This prospective study aimed to compare computed tomography (CT) and magnetic resonance imaging (MRI) in the preoperative assessment of acute midfacial trauma. Twenty patients received posttraumatic CT and MRI scans using a 3T scanner with a dedicated 15-channel dentomaxillofacial coil. Five MRI protocols were evaluated: UTE, DESS, Dark Bone, StarVIBE, and STIR. Three observers qualitatively assessed fracture detection, image quality, fracture line visibility, cortical delineation, and bone-to-soft-tissue contrast using a five-point scale. Descriptive statistics and inter-observer reliability (Krippendorff's α) were calculated. Forty-two fractures were analyzed. CT achieved excellent fracture detection (98% of fractures detected; α = 1.0) with the fastest evaluation times (30-82 s vs. 42-145 s). Among MRI protocols, UTE and StarVIBE performed best, detecting 88-89% of fractures, with excellent image quality and high inter-observer reliability (α = 0.80-0.91). Darkbone, DESS, and STIR consistently showed lower detection rates (up to 43%). UTE and StarVIBE were particularly effective for orbital, zygomaticomaxillary, and nasal bone fractures. Optimized gradient-echo-based MRI protocols provide radiation-free, CT-like imaging of midfacial fractures with superior soft-tissue contrast. While CT remains essential for emergency situations, a patient-, protocol-, and pathology-specific MR-based diagnostic approach offers a clinically feasible preoperative alternative in trauma management.Trial registration number: Swiss National Clinical Trials Portal: SNCTP000006343, ClinicalTrials.gov ID: NCT07012850 (trial registration date: May 9, 2025).

Keywords: CT-like MRI; Computed tomography; Magnetic resonance imaging; Maxillofacial surgery; Midfacial fractures; Trauma.

Fig. 1

Frequency distribution of visual grading scores (5 = most favorable, and 1 = least favorable outcome) from qualitative assessments of technical image quality, fracture line visibility, cortical border delineation, and bone-to-soft-tissue contrast for each MR-protocol is presented. UTE, 3D ultrashort echo time; DESS, 3D double-echo steady-state; Dark bone, 3D T1-weighted Gradient Echo (GRE) “Dark Bone” protocol; StarVIBE, 3D T1-GRE stack-of-stars volume interpolated breath-hold examination; STIR, 3D fast spin echo short-tau inversion recovery.

Fig. 2

Frequency distribution of visual grading scores for fracture line visibility (1 = least favorable; 5 = most favorable) is presented for each midfacial trauma subtype, along with the corresponding Krippendorf’s alpha for inter-observer agreement for each MR protocol. UTE, 3D ultrashort echo time; DESS, 3D double-echo steady-state; Dark bone, 3D T1-weighted Gradient Echo (GRE) “Dark Bone” protocol; StarVIBE, 3D T1-GRE stack-of-stars volume interpolated breath-hold examination; STIR, 3D fast spin echo short-tau inversion recovery.

Fig. 3

(A and B: CT; C–G MRI) Pronounced left-sided depressed fracture of the maxillary process with a depressed nasal bone fracture (arrow in A) with hemorrhage in adjacent soft tissues. Concurrent fracture of the nasal septum (lower arrow in B) with associated septal hematoma (middle arrow in B). For nasal fractures, the StarVIBE sequence (F and L) provides superior visualization, enabling the detection of even the smallest fracture fragments. (H–M; H CT; I-M MRI) Axial reconstructions demonstrate a comminuted fracture of the nasal bone. UTE, 3D ultrashort echo time; DESS, 3D double-echo steady-state; Dark bone, 3D T1-weighted Gradient Echo (GRE) “Dark Bone” protocol; StarVIBE, 3D T1-GRE stack-of-stars volume interpolated breath-hold examination; STIR, 3D fast spin echo short-tau inversion recovery.

Fig. 4

A 31-year-old patient with a fracture of the left medial orbital wall following a blow to the eye sustained during interpersonal violence. The fracture was initially diagnosed on computed tomography (CT) (A–C). Subsequent magnetic resonance imaging (MRI) employed five protocols: (UTE (D–F), DESS (G–I), Dark Bone (J–L), StarVIBE (M–O), and STIR (P–R)), visualizing the fracture in axial (first vertical column), coronal (middle vertical column), and sagittal (third vertical column) planes. UTE, 3D ultrashort echo time; DESS, 3D double-echo steady-state; Dark Bone, 3D T1-weighted Gradient Echo (GRE) “Dark Bone” protocol; StarVIBE, 3D T1-GRE stack-of-stars volume interpolated breath-hold examination; STIR, 3D fast spin echo short-tau inversion recovery.

Fig. 5

Comminuted midfacial fracture of the frontal bone, displaced dorsocaudally, involving the frontal sinus, orbital roof, and medial orbital wall, with periorbital soft tissue swelling and subcutaneous emphysema (arrows in A–C), in a 25-year-old man resulting from a sports-related injury. Imaging modalities and protocols: CT (A, B), UTE (C, D), DESS (E, F), Darkone (G, H), StarVIBE (I, J), and STIR (K, L). UTE and StarVIBE MRI not only allow excellent visualization of soft tissue involvement, including potential dural or frontonasal duct injury, but may also help predict possible obliteration of the sinus. UTE, 3D ultrashort echo time; DESS, 3D double-echo steady-state; Dark Bone, 3D T1-weighted Gradient Echo (GRE) “Dark Bone” protocol; StarVIBE, 3D T1-GRE stack-of-stars volume interpolated breath-hold examination; STIR, 3D fast spin echo short-tau inversion recovery.

Fig. 6

Axial reconstructions demonstrating a displaced fracture of the left zygomatic bone and the maxillary sinus wall in a 27-year-old man following a traffic accident. Imaging modalities and protocols: CT (A, B), UTE (C, D), DESS (E, F), Dark Bone (G, H), StarVIBE (I, J), and STIR (K, L). Both UTE and StarVIBE sequences provide superior simultaneous visualization of osseous fracture lines and associated soft tissue involvement. UTE, 3D ultrashort echo time; DESS, 3D double-echo steady-state; Dark bone, 3D T1-weighted Gradient Echo (GRE) “Dark Bone” protocol; StarVIBE, 3D T1-GRE stack-of-stars volume interpolated breath-hold examination; STIR, 3D fast spin echo short-tau inversion recovery.