J Oral Maxdlofac Surg

52:729-733, 1994

Cranial Fractures Associated With Facial Fractures:

A Review of Mechanism, Type, and Severity of Injury

RICHARD H. HAUG, DDS,* JAMES M. ADAMS, DDS,t PHILIP J. CONFORTI, DDS,# AND MATT J. LIKAVEC, MD9

A loo-month retrospective review was undertaken to identify the population characteristics of patients with both facial and cranial fractures and to establish the relationships between them. A 4.4% incidence of cranial fractures was found in the 882 patients with facial fractures. These patients tended to be males (85%) between the ages of 16 and 30 years (54%) who were involved in motor vehicle accidents (64%). Patients with midfacial fractures predominated (70%), and these injuries were most frequently associated with fractures of the frontal (38%), sphenoid (24%) or temporal (22%) bones. No relationship was noted between mandibular fractures and cranial fractures. Midfacial fractures were related to individual cranial bone fractures by sutural attachment. The presence of cranial fractures did not play a role in the development of complications associated with facial fractures.

During a previous investigation that reviewed facial fractures and concomitant injury, it was found that approximately one third of the patients with facial

fractures also had some form of neurologic injury.’ Although it was initially thought that this incidence

was high, a thorough review of the literature indicated that the frequency of neurologic injury associated with

facial fractures was as high as 76%.‘-9 Those publica-

tions, however, described neurologic injury in general terms rather than by specific injury. Further investi- gations by our group evaluated the association of closed-head injury and cervical spine injury with facial fractures.“.” This study completes our series on neu-

rologic injury by focusing on the characteristics of pa-

* Director, Division of Oral and Maxillofacial Surgery MetroHealth Medical Center, and Associate Professor of Surgery. Case Western Reserve University School of Medicine, Cleveland, OH.

t Resident, Division of Oral and Maxillofacial Surgery, Metro- Health Medical Center. Cleveland, OH.

$ In private practice, Hamden. CT: attending. Department ofOral and Maxillofacial Surgery. St Raphael’s Hospital. New Haven, CT.

5 Associate Professor of Neurological Surgery. MetroHealth Med- ical Center. and the Case Western Reserve University School of Medicine. Cleveland. OH.

Address correspondence and reprint requests to Dr Haug: Division of Oral and Maxillofacial Surgery. MetroHealth Medical Center. Cleveland, OH 44 109- 1998.

6 1994 American Association of Oral and Maxillofacial Surgeons

027%2391/94/5207-0010$3.00/0

tients with both cranial and facial fractures and iden- tifying the relationships between them.

Materials and Methods

This investigation was performed at the MetroHealth Medical Center of Cleveland, a level I trauma center

and county facility serving a population of 3.4 million in northeast Ohio. Hospital charts for all patients treated by the Division of Oral and Maxillofacial Sur- gery during the 1 00-month period between March 1984 and July 1992 were reviewed retrospectively. This rep- resented 882 patients, of which 39 were identified as having sustained both facial and cranial fractures, The

charts of these 39 patients were then reviewed for age, sex, mechanism of injury, type of facial fracture(s), type of cranial fracture(s). Brain Injury Index. Glasgow

Coma Score, and the presence of complications asso- ciated with the facial fractures. The types of cranial fractures were classified by anatomic location as frontal, sphenoid. temporal, parietal, and occipital. The types of facial fractures were classified by anatomic location as mandible, maxilla, and zygoma. The maxillary and palatine bones were considered one unit. The Brain Injury Index used was that system described by Bennet and co-authors (grade I, loss of consciousness, to grade IV, brain death).” The Glasgow Coma Scale was the

729

730 CRANIAL FRACTURES ASSOCIATED WITH FACIAL FRACTURES

100

90

pTGiG$-( 8o 70

60

50

40

291

531 il wwd Traume

FIGURE I. Male/female distribution for various populations. The

female population is represented by the white area and the male

population is represented by the stippled area. From 1990 Federal

Census Statistics for Cuyahoga County, 1990-1993 MetroHealth

Medical Center Trauma Registry. Haug RH, Prather J, Indresano

AT: An epidemiologic survey of facial fractures and concomitant

injury. J Oral Maxillofac Surg 48:926. 1990.

system reported by Teasdale and Jennett (15 the best

prognosis, and 3 the wor~t).‘~ The facial fracture com- plications reviewed were nonunion, malocclusion, os- teomyelitis, and infection, as well as functional and

aesthetic deformity.

Results

Thirty-nine patients with cranial fractures were identified within the group of 882 patients sustaining facial fractures (4.4%). Males with both cranial and

facial fractures predominated the group by a margin of 6: 1 (Fig 1). The 16- to 30-year age group was most frequently affected (54%) (Fig 2). Motor vehicle acci-

dents were the most common cause of combined cra- nial and facial fractures (64%), and the only cause for

women (100%) (Fig 3). Some of the categories of injury (parietal fractures

and home injuries) contained too few patients to allow an accurate statistical comparison with the Brain Injury

Index and Glasgow Coma Score (Tables l-3). For

9

8

7

LpFiiiG-4:

3

2

I

0

FIGURE 2. Age distribution of the combined cranial/facial fracture

population.

5

0 WA MCA Assault Sports Home

j

FIGURE 3. Distribution of the combined cranial/facial fracture

population by mechanism of injury.

groups that contained enough patients, an analysis of variance was performed. No significant differences were

noted (P < .05) in the Brain Injury Index or Glasgow

Coma Score with any of the mechanism of injury groups, cranial fracture groups, or facial fracture groups. Thus the severity of injury was not related to the mechanism of injury or to the individual cranial

and facial bones fractured. The frontal bone was the cranial bone most fre-

quently fractured (38%) followed by the sphenoid (24%) and temporal bones (22%) (Fig 4). Isolated man-

dible fractures (2 1%) and isolated zygoma fractures

(23%), as well as combination mandible/zygoma frac- tures (2 1%) and maxilla/zygoma fractures (23%), were

found to occur with near equal frequency (Table 4). Zygoma fractures were present in 72% of the patients with both cranial and facial fractures.

No relationship could be identified between isolated mandible fractures and the individual cranial bones fractured (Table 4). Isolated maxillary fractures and isolated zygoma fractures were related by sutural at- tachment to the individual cranial bones fractured (Table 4). Isolated maxillary fractures were associated only with frontal and sphenoid fractures. whereas iso-

lable 1. Mechanism of Injury and Severity of Head Injury (Mean f Standard Deviation)

Mechanism

Brain Injury Glasgow

Index Coma Score

Motor vehicle accidents

(n = 26)

Motorcycle accidents (n = 4)

Assaults (n = 6)

Sports injuries (n = 2)

Home injuries (n = I)

1.58 t 0.85 I 1.78 + 4.5

I.25 k 0.50 13.50 + 2.38

1.33 * 0.81 13.50 k 2.81

I .oo + 0.00 IS.00 k 0.00 1.00 14.00

HAUG ET .41

Table 2. Facial Fractures and Severity of Head Injury (Mean + Standard Deviation)

Facial Bone(s)

Brain Injury Glasgow

Index Coma Score

Mandible (n = 8)

Zygoma (n = 9)

Maxilla In = 3)

Mandible/zygoma (n = 8)

Maxilla/zygoma (n = 9)

Mandible/maxilla/zygoma

(n = 2)

1.50 k 0.76 11.13 2 4.58

1.67 k 1.00 11.78 f 4.76

I .oo I 0.00 14.67 k 0.58

1.38 f 0.74 12.75 + 3.24

I .33 k 0.7 I 11.89 +- 3.86

2.00 ?I 1.41 10.00 2 7.07

lated zygoma fractures only occurred with frontal,

sphenoid, and temporal fractures (Table 4). This as- sociation was also found to occur with combinations of facial fractures (Table 4). When maxillary and zy- goma fractures were grouped together as midfacial

fractures, an interesting trend was noted. Although a 2:l ratio exists between midfacial and mandible frac-

tures in the general facial fracture population,’ in the combined cranial/facial fracture population the op-

posite ratio was found (Fig 5). Thirteen patients (33%) required surgical manage-

ment of their cranial fractures, which included crani-

otomy, craniectomy, and open reduction. These 13 patients, along with one nonsurgical patient. also re- quired medical management of their cranial injuries (36%). The remaining 25 patients (64%) merely re- quired observation of their cranial injuries for signs and symptoms of increased intracranial pressure.

Six patients (15%) sustained complications related

to the treatment of their facial fractures. These com- plications included two nonunions of the mandible. and one patient each who developed epiphora. late in-

ferior rectus entrapment. enophthalmos. and an in- fected orbital floor implant (Table 5). No association was noted between the development of facial fracture

complications and age, race, sex, mechanism of injury, or the cranial bone fractured. These problems were associated with more complicated, combined facial bone fractures, and less severe cranial injuries (Glasgow Coma Score, 14.7: Brain Injury Index, 1.0).

Table 3. Cranial Fractures and Severity of Head Injury (Mean 2 Standard Deviation)

Cranial Bones

Brain Injury

Index

Glasgow

Coma Score

Frontal f n = i 5) 1.13 i 0.35 14.00 ? I .77

Sphenoid (n = 7) I .43 f 0.79 12.00 +- 4.93

Temporal (n = 7) I .57 + 0.98 I I .43 * 4.89

Parietal (n = I) 1 .oo 15.00 Occipital (n = 1) I .oo * 0.00 15.00 * 0.00

Combinations (n = 7) 1.71 + 0.95 I 1 .oo I? 4.90

18

16

14

pGzz-,12 10

8

6

4

2

0

FIGURE 4. Distribution of cranial fractures.

Discussion

It is interesting to note the male predilection for the combination of facial fractures and neurologic injury.

Information for the year 1990, provided by the Federal Census Bureau for the county in which this study was

performed, indicated that 47% of the general popula- tion was male (Fig 1). During the years 1990 to 1993. the MetroHealth Trauma Registry indicated that 7 1% of trauma admissions were male. During the period from March 1984 to January 1990, at this same insti-

tution, 79% of the patients treated with facial fractures were male.’ Our current study indicated that 85% of the patients with both cranial and facial fractures were male. This finding was similar in other studies per- formed by our group. During the period between

March 1984 and August 1990.88% ofthe patients suf- fering more severe forms of closed head injury along with facial fractures were male.“’ During the 78-month

period between March 1984 and August 1990.9 1% of the patients surviving both cervical spine injury and facial fractures were male.” Although we have iden- tified a trend that the more severe the neurologic injury

associated with facial fractures the higher the predilec- tion for males, we can offer no explanation for this phenomenon.

Patients between the ages of 16 and 30 years were the most frequently affected in our study (Fig 2). This pattern is similar to our other demographic studies identifying the relationships between facial fractures and concomitant neurologic injury. ‘,‘“.’ ’ Motor vehicle

accidents were the most frequent cause of combined cranial and facial fractures (64%) and the only cause

for women (100%). Although this finding was similar to our investigation on closed head (64%) and cervical spine injury (9 I%), it differed from our study on facial fractures alone (43%).‘.“.” This confirms observations that motor vehicle accidents are responsible for more cases of polytrauma than any other mechanism of in-

jury. Frontal (38%) sphenoid (24%), and temporal (22%)

fractures were the most frequently encountered cranial

732 CRANIAL FRACTURES ASSOCIATED WITH FACIAL FRACTURES

Table 4. Facial Fracture Types Associated With Cranial Fracture Types

Mandible Zygoma Maxilla Mandible/Zygoma Maxilla/Zygoma Mandible/Maxilla/Zygoma Total

Frontal

Sphenoid

Temporal

Parietal

Occipital

Frontal/parietal

Frontal/temporal

Frontal/sphenoid

Occipital/sphenoid

Temporal/parietal

Total

1 5 2 5 ? - 15

2 - I I 2 I 7 I 3 - 2 I 7

- - I - I

2 - - - 3

I - I 2 - - - I I

- I - I 2 - - - I 1

I - - - I 8 9 3 8 9 2 3’)

fractures (Fig 4). This was primarily due to the prox- imity of the facial bones fractured. Isolated zygoma fractures were found in association with fractures of cranial bones joined by sutural attachment (frontal,

sphenoid, and temporal) (Table 4). Similarly, isolated maxillary fractures were associated with sphenoid and frontal fractures. Analogous observations were made with combined facial fractures. No relationship could

be found, however, between mandible fractures and the type of cranial fracture. Combining maxillary and

zygoma fractures into one group showed that patients with middle third facial fractures had more than twice the chance of sustaining cranial fractures than patients

with mandible fractures (Fig 5). This finding and ratio were similar to those in our study associating closed- head injury and facial fractures.” This tends to refute

theories that the midface is designed to absorb impacts and protect the cranial structures.‘4 In fact, the facial bones appear to transmit forces directly to the cranium.

The Brain Injury Index and Glasgow Coma Scale

are the most common measures used to quantify the severity of head injury.“,‘3 No relationship could be identified between the severity of cranial injury and

60

pG-,'O 50

40

30

20

IO

0 Mandible

FIGURE 5. Relationship between mandible fractures and middle The demographic material contained in this study

third facial fractures for both the general facial fracture population has practical application for patient assessment and and the combined/facial fracture population. treatment planning by the clinician treating maxillo-

either the mechanism of injury, the cranial bone(s)

fractured, or the facial bone(s) fractured.

All patients with severe head injuries (a score of less than 8 on the Glasgow Coma Scale) or major skull

fractures (open, depressed, compound, or basilar) re- quire early intervention by a neurological surgeon.” Neurosurgical intervention is directed toward cosmetic

improvement in depressed fractures, debridement and control of infection in open or compound fractures, and removal of space-occupying lesions caused by de- pressed fractures or those that interrupt arteries. the meninges, or dura.15 Medical management is directed toward the prevention of cerebral edema and improve-

ment of cerebral perfusion. ‘5.‘6 Only 13 patients in our study required surgical intervention. These surgical patients and one nonsurgical patient required medical management. Thus, 64% of the patients in this study, in spite of the presence of cranial fractures, required

no deviation from routine treatment addressing only the facial fractures. Modifications in the management of patients with head injury has been the focus of an- other study. I6

Kaufman and coinvestigators in 1984 stated that neurologically injured patients have a higher compli- cation rate than the non-neurologically injured facial

fracture population.” Our study did not support that statement. Fifteen percent of the patients in our current investigation developed problems. This was well within the range of reported complications for both mandib- ular and midfacial fractures in similar populations.‘8.‘y Facial fracture complications in our investigation de- veloped in patients with less severe cranial injuries (a

mean Glasgow Coma Score of 14.7, and Brain Injury Index of 1.0). There was no association between the individual cranial bones affected and the development of problems with facial fractures. Complications were, however, associated with more complex, combination facial injuries.

HAUC; ET 4L 733

Table 5. Facial Fracture Complications

Facial Fracture Complication Sex Age Race Facial Bone Injured

Cranial

Fractures

Glasgow Brain

Mechanrsm Coma Injury

of Injury Score Index

Nonunton of mandihlc M 32 W Mandible/maxilla/zygoma Sphenoid MVA I5 I Infected orbital floor implant M 2 W Maxilla/zygoma Sphenoid MV4 I5 I Late inferior rectus entrapment M 23 B Maxilla/zygoma Frontal Assault 13 I Enophthalmus F 12 B Maxilla/zygoma Temporal MVA 15 1

Epiphora M 18 W Maxilla/zygoma Frontal Assault I5 I Nonunion of mandible F 40 W Mandible/maxilla/zygoma Frontal MVA I5 I

Abhrcviations: MVA. motor vehicle accident: B. blach: W. white: M. male: F. female

facial trauma. Additionally, the observations in our

study have direct application for research and design

in the crash helmet industry. Our information tends to refute theories that the facial bones act as a cushion to protect the cranium and its contents.14 In fact. it

appeared as if the midfacial bones transmit the force of impacts directly to the cranium. This observation would support the design of crash helmets that provide

full face protection.

References

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3. Morgan BDG. Maden DK, Bergerot JPC: Fractures of the middle third of the face: A review of 300 cases. Br J Plast Sum 25: 147. 1972

4. Adekeye EO: The pattern of fractures of the facial skeleton in Kaduna. Nigeria. Oral Surg Oral Med Oral Pathol 49:49 I. 1980

5. Turvey TA: Midfacial fractures: A retrospective analysis of 593 cases. J Oral Surg 35:887. 1977

6. Murray JF. Hall HC: Fractures ofthe mandible in motor vehicle accidents. Clin Plast Surg 2: 13 I, I975

7. Schultz RC: Facial injuries from automobile accidents: A study of 400 consecutive cases. Plast Reconstr Surg 40:4 15. 1967

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I I Haug RH. Wible RT. Likavec MJ. et al: Cervical spine fractures and maxillofacial trauma. J Oral Maxillofac Surg 49:7X. I99 1

12. Youman JR (ed): Neurological Surgery. Philadelphia. PA. Saun- ders. 1986 pg 2016.

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14. Lee KF. Wagner LK. Lee YE. et al: The impact-absorbing effects of facial fractures in closed-head injury. J Neurosurg 66:542. I987

15. White RJ. Likavec MJ: The diagnosis and initial management of head injury. N Engl J Med 377: 1507. 1991

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17. Kaufman MS, Marciani RD. Thomson SF. et al: Treatment of facial fractures in neurologically injured patients. J Oral Max- illofac Surg 42250. 1984

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19. Haug RH, Prather J. Bradrick JP. et al: The morbidity associated with fifty maxillary fractures treated by closed reduction. Oral Surg Oral Med Oral Path01 73:659. 1992