Facial Fracture Patterns Research Articles

Multidetector Computed Tomography of Maxillofacial Fractures: The Key to High-Impact Radiological Reporting

Maxillofacial fractures are very common. Recognizing patterns of facial fractures is helpful in assessing maxillofacial injury and accurately characterizing all fractures that may be present. Facial fractures are grouped into the following categories: nasal bone, naso-orbito-ethmoid, orbital, zygomatic, maxillary (including Le Fort-type fractures), mandibular, and frontal sinus fractures. Within each subgroup of facial fractures, there are key findings, whether of the fracture itself or of potential associated injuries, that are important factors in determining whether the patient is managed conservatively or with surgery. This article highlights the features of facial fractures that are the most important to the surgeons and provides a framework for effective radiological reporting.

Trends in the Pattern of Facial Fractures in Different Countries of the World

El objetivo del estudio fue examinar los cambios en el patron de las fracturas maxilofaciales entre los paises desarrollados y en vias de desarrollo en dos periodos de tiempo (1987-1999) y (2000-2007). Una busqueda exhaustiva de la literatura en PubMed se llevo a cabo entre las publicaciones de lesiones maxilofaciales publicados durante los ultimos 20 anos. Solo 45 articulos cumplieron con los criterios de inclusion, y los textos completos de estos articulos fueron examinados a fondo. En cada uno de los estudios incluidos se registraron diferentes parametros. Se calculo el porcentaje de peso de cada parametro a traves del numero total de pacientes. La mandibula fue el hueso facial mas fracturado (57%). En todo el periodo evaluado, la media de edad de los pacientes con fracturas faciales fue de 24,4 anos y la incidencia de las fracturas faciales fue mayor en hombres (81,3%) que en mujeres. La razon hombre-mujer de los pacientes con fracturas faciales fue mayor en los paises en vias de desarrollo (5,1:1,0) que en los paises desarrollados (3,7:1,0) en todo el periodo. Las lesiones relacionadas con accidentes de transito disminuyeron considerablemente en los paises desarrollados, mientras que aumento en los paises en vias de desarrollo durante los dos periodos. Sin embargo, las lesiones faciales relacionadas con asaltos aumentaron considerablemente en los paises desarrollados y disminuyo en los paises en vias de desarrollo durante los dos periodos. El cuerpo de la mandibula fue el sitio de fractura mas comun (27,2%). Se concluyo que las fracturas mandibulares son las lesiones mas comunes en el tercio medio del esqueleto facial. La mayoria de los pacientes afectados por fracturas faciales en los diferentes paises fueron hombres jovenes.

Mandibular fracture scoring system: for prediction of complications

Mandibular fractures are one of the most commonly encountered injuries in trauma clinics. Although several widely accepted classification systems exist, these are mostly region specific, differ in the classification criteria used, and are sometimes only correlated with specific treatment modalities, thereby making it impossible to uniformly and comprehensively document facial fracture patterns. In this study, we developed a modified scoring system for mandibular fractures and analyzed the relationship between scoring of fractures that were treated and the incidence of complications after surgical treatment. To evaluate the suitability of the proposed scoring system, a prospective study on a series of 116 patients was performed. All the fractures were classified using the proposed scoring system. The scoring was based on clinical and radiological evaluation of each fracture. Patients were followed up postoperatively for presence of complications. A good correlation between the proposed scoring system and the incidence of complications was detected. This scoring system for mandibular fractures facilitates an objective and standardized assessment of the degree of severity of a fracture, thereby allowing for systematic evaluation of facial fracture outcomes, including assessment of complications. However, it is our understanding that a multicenter study should be performed before the effectiveness of the proposed classification can be clearly stated.

Retrospective study of prevalence of face fractures in southern Brazil

Trauma has been an important public health problem worldwide. Facial injuries are among the most common types of trauma treated at emergency departments, associated or not with injuries in other anatomic sites. The patterns of facial fractures are usually affected by geography and socioeconomic conditions. To investigate the prevalence of facial fractures in Lages, state of Santa Catarina, southern Brazil, from September 2003 to August 2008. Cross-sectional, retrospective, epidemiological study. Data on patients' gender, age, etiological agent, and facial region affected by fracture were collected from the charts of patients treated with facial fractures. Qualitative variables were expressed as absolute and relative frequencies, and quantitative variables as means and standard deviation. The Chi-square test was used to evaluate the association between gender, traffic accidents and facial region affected. The association between etiological agents and facial region affected was assessed using the chi-square test and the adjusted residuals analysis. 492 patients presented with oral and maxillofacial trauma, with 988 facial fractures; 80.9% of the patients were men, and the most frequent age group was 21-30 years (29.5%). The most frequent causes of fractures were: Traffic accidents in 27.9%, physical assault in 14.9%, and bicycle falls in 10.5%; several other causes scored below 10%. Regular publication of epidemiological data is extremely important for the implementation of prevention campaigns and for an increased awareness of the etiology of fractures affecting the face and other anatomic sites.

Ocular Injury, Visual Impairment, and Blindness Associated with Facial Fractures

Injuries to the face can potentially lead to destruction of vital structures, with devastating sequelae to the patient. Facial fractures, especially of the midface, are often complicated by ocular injuries. The purpose of this study was to systematically review the literature to better understand specific fracture patterns associated with ocular injuries, including visual impairment and blindness. The PubMed, EMBASE, and Cochrane databases from January of 2004 to April of 2010 were systematically reviewed to identify relevant studies. Only those that investigated facial fractures with concomitant ocular injuries, visual impairment, and/or blindness were included. Studies that described nonfacial fractures or those that only focused on the function of extraocular muscles were excluded. Case reports, nonsystematic reviews, and studies with fewer than 10 patients were also excluded. Eleven articles met study criteria and were included for analysis. There were a total of 14,535 patients, with an average of 1211 patients (range, 39 to 4426) per study. Level of evidence included levels II (n = 1 study), III (n = 1), and IV (n = 9). The mean reported rate of acute visual loss was 1.7 percent. Periorbital and orbital blowout fractures were more often complicated by ocular injuries compared with other facial fracture patterns. High-impact zygomatic fractures were most commonly associated with blindness. Existing studies exploring ocular injuries, visual impairment, and blindness associated with facial fractures offer conflicting data. Specifically directed studies are required so that significant correlations between specific fracture patterns and specific ocular injuries can be drawn. Risk, IV.

Computerized tomography assessment of cranial and mid-facial fractures in patients following road traffic accident in South-West Nigeria

Globally, the most common cause of cranio-facial fractures is road traffic accident (RTA) with computerized tomography (CT) scan as the gold standard in the diagnosis of patients with cranial and facial fractures. The purpose of this study is to assess the pattern of cranial and facial fractures on CT in head injured patients following RTA. Using CT, detailed analyses of 236 patients with head injury following RTA were performed between 2006 and 2008, Data recorded included cause of injury, age and gender distribution, cranial and mid-facial fractures sustained, associated intracranial and soft tissue injury and the types of vehicular accident. The peak age of the patients was between 30 and 39 years. RTA was more common in males than females. Motor-vehicle was the most common cause of RTA in the present study (66.9%). More passengers were involved in the motor vehicle (87.3%) and motorcycle (52.0%) accidents than their corresponding drivers, and they were predominantly males. Majority of the patients involved in pedestrian road traffic accident (PRTA) were motor vehicle victims (93.3%). There were more patients with cranial (59.8%) than mid-facial fractures (40.2%). Majority of the patients had temporal bone cranial fracture (31.1%) and combined or mixed type of mid-facial fractures (41.3%). Intracranial bleeding (31.7%) was the most common associated intracranial finding. RTAs continue to be a menace and are the main cause of craniofacial injury in Nigeria. This pattern of etiologic factors is in accordance with data from most developing countries. Special attention should be paid to reinforcement of legislation and enactment of laws aimed at the reduction of head injury and provision for easy access to CT for the head injured patient.

A New System for Severity Scoring of Facial Fractures

Facial fractures are often the result of high-velocity trauma, causing skeletal disruption affecting multiple anatomic sites to varying degrees. Although several widely accepted classification systems exist, these are mostly region-specific and differ in the classification criteria used, making it impossible to uniformly and comprehensively document facial fracture patterns. Furthermore, a widely accepted system that is able to provide a final summary measure of fracture severity does not exist, making it difficult to investigate the epidemiologic data surrounding facial fracture severity. In this study, a comprehensive method for panfacial fracture documentation and severity measurement is proposed and validated through a retrospective analysis of 63 patients operated on for acute facial fracture. The severity scale was validated through statistical analysis of correlation with surrogate markers of severity (operating room procedure time and number of implants). Spearman correlation coefficients were calculated, and a statistically significant correlation was found between severity score and both number of implants and operating room procedure time (R = 0.92790 and R = 0.68157, respectively). Intraclass correlation coefficients were calculated to assess intrarater and interrater reliabilities of the severity scale and were found to be high (0.97 and 0.99, respectively). This severity scale provides a valuable, validated research tool for the investigation of facial fracture severity across patient populations, allowing for systematic evaluation of facial fracture outcomes, cost-benefit analysis, and objective analysis of the effect of specific interventions.

Predictable Patterns of Intracranial and Cervical Spine Injury in Craniomaxillofacial Trauma: Analysis of 4786 Patients

Patients presenting with traumatic craniomaxillofacial fractures often have occult concomitant injuries. This study was designed to determine whether facial fracture patterns are associated with a particular constellation of concomitant head and neck injuries. A retrospective review of 4786 consecutive patients diagnosed with maxillofacial fractures at a dedicated urban trauma center from 1998 to 2005 was conducted; maxillofacial fractures and cervical spine injuries were grouped by dividing the craniomaxillofacial skeleton and cervical spine into thirds. Univariate and multivariate logistic regression analyses were used to identify associations between facial fractures and other traumatic injuries. Among all patients with facial fractures, 461 (9.7 percent) also had cervical spine injuries and 2175 (45.5 percent) had associated head injuries. Fractures of the upper face were associated with increased likelihood of mid lower cervical spine injuries, severe intracranial injuries, and increased mortality rates. Unilateral mandible injuries were associated with an increased likelihood of having upper cervical spine injuries, whereas unilateral midface injuries were associated with basilar skull fractures and several intracranial injuries. Finally, bilateral midface injuries were associated with basilar skull fracture and death. Craniomaxillofacial fractures are commonly associated with head and cervical spine injuries that involve predictable patterns of force dispersion from the maxillofacial skeleton and transmission to the cranial vault and cervical spine. These results suggest that concomitant injuries should be investigated closely with distinct types of facial fractures.

Facial Fractures in Children

To determine the patterns of facial fractures observed in pediatric patients after acute trauma. The computed tomography studies of 338 patients (63% male, 37% female; 7 months to 18 years of age) performed after acute nonpenetrating facial trauma were retrospectively reviewed to evaluate for facial fractures and associated orbital hematomas or contiguous skull fractures. Fracture patterns were characterized as orbital roof, orbital floor, medial orbital wall, nasal bone, naso-orbital-ethmoid, zygomatic complex, isolated zygomatic arch, Le Fort type (I, II, or III), maxillary sagittal, alveolar ridge, or mandibular. The frequency of the various fracture types was determined. The correlation between fracture type and orbital hematomas or contiguous skull fractures was assessed (Kendall tau rank correlation). Computed tomography demonstrated facial fractures in 188 (54%) patients. The number and frequency of the fractures observed were as follows: orbital roof, 67 (36%); zygomatic complex, 38 (20%); naso-orbital-ethmoid, 30 (16%); orbital floor, 28 (15%); nasal bone, 25 (13%); mandibular, 24 (13%); medial orbital wall, 16 (9%); maxillary sagittal, 11 (6%); alveolar ridge, 8 (4%); isolated zygomatic arch, 3 (2%); Le Fort type I, 4 (2%); Le Fort type II, 4 (2%); and Le Fort type III, 0 (0%). Fifty children (27%) had multiple fractures. Orbital hematomas were seen in 28 patients (15%), and contiguous skull fractures were seen in 54 patients (29%). There was strong correlation between orbital hematomas and orbital roof fractures (0.62, P < 0.0001), orbital hematomas and naso-orbital-ethmoid fractures (0.18, P = 0.001), contiguous skull and orbital roof fractures (0.57, P < 0.0001), and contiguous skull and naso-orbital-ethmoid fractures (0.39, P < 0.0001). Fractures of the orbital roof are the most common facial fractures observed in pediatric patients after acute nonpenetrating trauma. Orbital roof and naso-orbital-ethmoid fractures are frequently associated with orbital hematomas and contiguous skull fractures.

Changing pattern of maxillofacial fractures in a sub-urban nigerian teaching hospital

To ascertain the current pattern of facial fractures presenting in the Obafemi Awolowo University Teaching Hospital (OAUTH) and compare this with two earlier reports from the same institution. All patients presenting with facial bone fractures at the OAUTH between January 1996 and December 2004 were included in the study. Information obtained were patients' demographics, date, cause, site and type of injury. The interval before presentation in the hospital was documented. Data was analysed and compared with two earlier studies carried out in the same institution. 451 patients (351 males and 100 females) presented with 632 facial bone fractures between January 1996 and December 2004. This shows a greater female involvement compared with earlier studies. Similar to earlier studies, majority of the patients (39.7%) were aged 21-30 years however, more cases occurred in the first decade of life in the present study than in the previous. Road traffic crashes remained the leading cause of fractures (74.7%), followed by fight/assaults (8.0%). There was a significantly higher prevalence of motorcycle related crashes and gunshot injuries. While the incidence of mandibular fractures declined, a statistically significant increase was observed for fractures of the middle face specifically Le Fort 1 and zygomatic complex fractures. Facial bone fractures appear to be on the increase in the studied location. More females and younger children are involved now. Road traffic crashes accounted for most facial bone fractures but violence related causes are on the increase.

Changing trends in causes and patterns of facial fractures in children

To review the epidemiology of facial fractures in children and to analyze whether it has changed over time. Retrospective review of records of children aged < or = 15 years diagnosed for fracture during 2 10-year periods. A total of 378 children were diagnosed with fractures, 187 in 1980-1989 and 191 in 1993-2002. The proportion of children with mandibular fractures decreased by 13.6 percentage-points from the first period to the second, whereas the proportion of patients with midfacial fractures increased by 18.7 percentage-points. Assault as a causative factor increased by 5.5 percentage-points, almost exclusively among children aged 13-15 years, with a high percentage (23.5%). Recognition of a change in fracture patterns over time is probably due to the increased use of computerized tomographic scanning.

Patterns and Outcomes of Pediatric Facial Fractures in the United States: A Survey of the National Trauma Data Bank

Pediatric trauma involving the bones of the face is associated with severe injury and disability. Although much is known about the epidemiology of facial fractures in adults, little is known about national injury patterns and outcomes in children in the US. The epidemiology of facial injuries in children and adolescents (ages 0 to 18 years) was described using the National Trauma Data Bank (2001 to 2005) to examine facial fracture pattern, mechanism, and concomitant injury by age. A total of 12,739 (4.6%) facial fractures were identified among 277,008 pediatric trauma patient admissions. The proportion of patients with facial fractures increased substantially with age. The most common facial fractures were mandible (32.7%), nasal (30.2%), and maxillary/zygoma (28.6%). The most common mechanisms of injury were motor vehicle collision (55.1%), violence (11.8%), and falls (8.6%). These fracture patterns and mechanisms of injury varied with age. Compared with patients without facial fractures, patients with fractures exhibited substantial injury severity, hospital lengths of stay, ICU lengths of stay, ventilator days, and hospital charges. In addition, patients with facial fractures had more severe associated injury to the head and chest and considerably higher overall mortality. Causes and patterns of facial fractures vary with age. Cranial and central facial injuries are more common among toddlers and infants, and mandible injuries are more common among adolescents. Although bony craniofacial trauma is relatively uncommon among the pediatric population, it remains a substantial source of mortality, morbidity, and hospital resource use. Continued efforts toward injury prevention are warranted.

Safety Device Use Affects the Incidence Patterns of Facial Trauma in Motor Vehicle Collisions: An Analysis of the National Trauma Database from 2000 to 2004

Airbags and seat belts are designed to decrease injuries sustained in motor vehicle collisions. The authors hypothesize that the use of these devices has an effect on the patterns of facial fractures and facial lacerations. The records of 15,293 facial fracture patients and 114,623 facial laceration patients from motor vehicle collisions were analyzed from the National Trauma Database. Five hundred sixty-five patients were identified as having panfacial fractures. Fisher's exact test and chi-square analysis were used to study associations between safety devices and facial trauma. Panfacial fractures occurred in 3.7 percent of all patients sustaining facial fractures. In motor vehicle collisions resulting in facial fractures, 31.2 percent of patients had a seat belt, 5.6 percent had a seat belt and an airbag, 3.9 percent had an airbag only, and 59.3 percent had no safety device. The lack of a safety device in motor vehicle collisions increased the incidence of facial fractures (odds ratio, 2.26), panfacial fractures (odds ratio, 2.98), and facial lacerations (odds ratio, 1.95). Passengers with facial fractures were more likely to have not used a safety device (odds ratio, 1.69). Based on the largest reported series on motor vehicle collision-associated facial fractures in the United States, the use of airbags and seat belts is associated with a significantly decreased incidence of facial fractures and lacerations. Given that fewer than half of these patients used a safety device and the high morbidity and costs associated with these injuries, plastic surgeons should advocate for the increased use of these safety devices.

Cervical Spine Injury in Association with Craniomaxillofacial Fractures

The incidence of cervical spine injuries associated with facial fractures varies from study to study. There is general agreement that immediate management of cervical spine injuries is mandatory to prevent further neurologic injury. Nevertheless, disagreement exists as to the actual incidence of cervical spinal trauma in conjunction with various facial fracture patterns. The purpose of this study was to review the incidence of cervical spine injury associated with various types of facial fractures presenting to St. Michael's Hospital Regional Trauma Center, Toronto, Ontario, Canada. The authors conducted a retrospective chart review of craniomaxillofacial fracture patients presenting to St. Michael's Hospital from January 1, 1994, to December 31, 2003, inclusive. The data from this 10-year time span revealed a total of 124 patients with cervical spine injuries drawn from a cohort of 3356 patients with craniomaxillofacial fractures. The overall incidence of cervical spine injury was 3.69 percent. Of these patients, 928 had isolated upper third facial or skull fractures, whereas isolated middle third facial fractures were seen in 716 patients and isolated lower third facial fractures were present in 798 patients. Combined facial fracture patterns, involving two or more facial thirds, accounted for the greatest number of cervical spine injuries, occurring in 8.86 percent (n = 914). The relationship between cervical spinal injuries and craniomaxillofacial trauma has been better defined as it relates to a regional trauma registry. The implications as related to the trauma assessment, diagnosis, and treatment of these injuries are reviewed.

Lateral impact in closed head injury: A substantially increased risk for diffuse axonal injury—A preliminary study

Assessment, whether location of impact causing different facial fracture patterns was associated with diffuse axonal injury in patients with severe closed head injury. Retrospectively all patients referred to the Trauma Unit of the University Hospital of Zurich, Switzerland between 1996 and 2002 presenting with severe closed head injuries (Abbreviated Injury Scale (AIS) (face) of 2-4 and an AIS (head and neck) of 3-5) were assessed according to the Glasgow Coma Scale (GCS) and the Injury Severity Score (ISS). Facial fracture patterns were classified as resulting from frontal, oblique or lateral impact. All patients had undergone computed tomography. The association between impact location and diffuse axonal injury when correcting for the level of consciousness (using the Glasgow scale) and severity of injury (using the ISS) was calculated with a multivariate regression analysis. Of 200 screened patients, 61 fulfilled the inclusion criteria for severe closed head injury. The medians (interquartile ranges 25;75) for GCS, AIS(face) AIS(head and neck) and ISS were 3 (3;13), 2 (2;4), 4 (4;5) and 30 (24;41), respectively. A total of 51% patients had frontal, 26% had an oblique and 23% had lateral trauma. A total of 21% patients developed diffuse axonal injury (DAI) when compared with frontal impact, the likelihood of diffuse axonal injury increased 11.0 fold (1.7-73.0) in patients with a lateral impact. Clinicians should be aware of the substantial increase of diffuse axonal injury related to lateral impact in patients with severe closed head injuries.

Blunt Carotid and Vertebral Artery Injuries in Relation to Patterns of Facial Fractures

Statement of the Problem: It is unclear whether there is an association between patterns of facial fractures and injury to the vessels of the neck following blunt trauma; as well as whether CT angiograms (CTA) as useful as conventional angiography at detecting damage to the vessels of the neck following blunt trauma.

Patterns of Facial Bone Fractures following Road Traffic Crashes: A Benin City Experience

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The age dependent relationship between facial fractures and skull fractures

Objective: To provide clinical evidence to support the age dependent relationship between facial fractures and skull fractures. Design: Retrospective chart review of all children and adults admitted with combined facial fractures and skull fractures and skull fractures alone between January 1991 and November 1997. Setting: The Albany Medical Center Hospital, a tertiary level-one trauma center. Patients: Two hundred and one children, ages 1 month to 17 years, with skull fractures (frontal, parietal, or temporal), and 41 children with concurrent facial fractures were included in this study. One hundred and thirty-nine adults, ages 18–90 years, with skull fractures, and 70 adults with concurrent facial fractures were also studied. Outcome measures: The gender, age, skull fracture, facial fracture, Glasgow coma score (GCS), mechanism of injury, and outcome of all patients admitted with frontal, parietal, or temporal fractures with or without facial fractures. Results: There are a significantly greater ( P<0.001) number of facial fractures associated with skull fractures among adults as compared to children. Moreover, there is an exponential rise in facial fractures associated with skull fractures between infancy and adolescence. The GCS of children with combined facial and skull fractures is significantly lower than in those with skull fractures only ( P<0.001). Conclusion: The spectrum of craniofacial injuries is related to the specific developmental stage of the craniofacial skeleton. This is demonstrated by the variable pattern of combined facial and skull fractures observed clinically in children and adults.

Effect of air bags and restraining devices on the pattern of facial fractures in motor vehicle crashes.

To examine the relationship between the use of restraining devices and the incidence of specific facial fractures in motor vehicle crashes. Retrospective analysis of patients with facial fractures following a motor vehicle crash. University of Alabama at Birmingham Hospital level I trauma center from 1996 to 2000. Of 3731 patients involved in motor vehicle crashes, a total of 497 patients were found to have facial fractures as determined by International Classification of Diseases, Ninth Revision (ICD-9) codes. Facial fractures were categorized as mandibular, orbital, zygomaticomaxillary complex (ZMC), and nasal. Use of seat belts alone was more effective in decreasing the chance of facial fractures in this population (from 17% to 8%) compared with the use of air bags alone (17% to 11%). The use of seat belts and air bags together decreased the incidence of facial fractures from 17% to 5%. Use of restraining devices in vehicles significantly reduces the chance of incurring facial fractures in a severe motor vehicle crash. However, use of air bags and seat belts does not change the pattern of facial fractures greatly except for ZMC fractures. Air bags are least effective in preventing ZMC fractures. Improving the mechanics of restraining devices might be needed to minimize facial fractures.

Etiology and patterns of facial fractures in the United Arab Emirates.

A retrospective study on facial fractures was carried out in the Department of Oral and Maxillofacial Surgery at Tawam Hospital (Al Ain, United Arab Emirates) between January 1, 1998 and December 31, 2001. The study included 144 patients with a mean age of 26.5 years; the most frequently injured patients belonged to the 16- to 20-year-old age group. The male predilection was 83%. Road traffic accident was the most common causative factor (59%), followed by falls (21.5%), accidents where camels were involved (5.5%), work- and sport-related accidents (4.8% and 4.8%, respectively), and assault (4.1%). A total of 53.4% of the patients suffered isolated mandibular fractures, 32.6% had isolated midface fractures, and 13.8% had combined midface and mandibular fractures. Associated injuries were noted in 22.2% of the patients. The number of patients treated increased from 28.3 (1990-1995) to 36 (1998-2001) on an annual average; a reduction in isolated nasal fractures and associated injuries, including facial lacerations, was noted with no change in age or etiology predilection. Sufficient data could not be obtained to determine if the favorable results with the associated injuries were a result of the effect of a compulsory seat belt law introduced on June 1, 1998, but the increasing number of maxillofacial injuries suggests that the seat belt law is ignored in this country.