J Oral Maxillofac Surg 49:926-932, 1990

An Epidemiologic Survey of Facial Fractures and Concomitant lnj~~ies

RICHARD H. HAUG, DDS,* JOHN PRATHER, DDS,t AND A. THOMAS INDRESANO, DMDS
A 5-year review of facial fractures and concomitant injuries at a level I trauma center is presented. The anatomic location of the facial fractures, age and sex of the patients, cause of injury, and associated systems injuries are presented. The majority of facial fractures were found in males; the most prevalent age range was 16 to 30 years. Mandible fractures outranked zygomatic and maxillary fractures (6:2:1). Assaults and motor vehicle accidents were the most frequent causes of facial fractures, and lacerations followed by neurologic and orthopedic injury were the most frequently encountered concomitant injuries. Motor vehicle accidents were the most frequent cause of associated injury.

Periodic epidemiologic reviews are valuable in reaffirming previously established trends or identifying new patterns of disease frequency. The purpose of this study was to review the facial fractures treated by the division of oral and maxillofacial surgery in a level I trauma center over a period of approximately 5 years and to identify patterns of facial fracture. Likewise, concomitant injury was reviewed to establish its relationship with facial fractures, relative frequency, and cause. Materials and Methods This study was performed at the Cleveland Metropolitan General Hospital, a level I trauma center and county facility treating a population of 3.4 mil-

* Assistant Professor of Surgery, Cleveland Metropolitan General Hospital and the Case Western Reserve University, Cleveland, OH. t Resident, Division of Oral and Maxillofacial Surgery, the Cleveland Metropolitan General Hospital, Cleveland, OH. $ Director, Division of Oral and Maxillofacial Surgery, Cleveland Metropolitan General Hospital; Associate Professor of Surgery, the Case Western Reserve University, Cleveland, OH. Address correspondence and reprint requests to Dr Haug: Oral and Maxillofacial Surgery, Department of Surgery, Cleveland Metropolitan General Hospital, 3395 Scranton Rd, Cleveland, OH 44109. 0 1990 American
geons 0278-2391/90/4809-0004$3.00/0 Association of Oral and Maxillofacial Sur-

lion in northeast Ohio. Hospital charts and radiographs of 402 patients treated by the division of oral and maxillofacial surgery between March 1984 and January 1989 were reviewed by two investigators. Between March 1984 and June 1988, all facial fractures in the institution were treated by our service. During the 6-month period of July 1988 to January 1990, zygoma and maxillary fractures were shared with the plastic surgery service. This represented approximately 15 patients that were eliminated from the study. The fractures were identified according to anatomic location, age and sex of the patient, cause of injury, additional facial fractures, and systems injuries. Anatomic location of the mandibular fractures was classified according to the system described by Ivy and Curtis (Fig l). Anatomic location of zygomatic fractures was classified according to the system described by Knight and North (Fig 2) Anatomic location of maxillary fractures was classified according to the system described by Le Fort (Fig 3).3-5 Systems injuries were grouped into the following categories: integument, abdomen, neurologic, pulmonary, cardiac, ophthalmologic, and orthopedic. Integumental injuries included lacerations and abrasions. Abdominal trauma included injuries to the liver, kidneys, bladder, and bowels. Neurologic injury ranged from loss of consciousness to depressed skull fracture. Pulmonary injury ranged from atelectasis to adult respiratory distress syndrome (ARDS). Cardiac injury ranged from cardiac contusion to pericardial tamponade . 926

HAUG ET AL

927

cause of mandibular injury than were motor vehicle accidents (Fig 5).
ZYGOMA FRACTURES

FIGURE I.

Anatomic distribution of mandibular fractures.

Results MANDIBULAR FRACTURES

Of the 402 patients treated for facial fractures, 307 suffered fractures of the mandible. Of these patients, there were 421 separate mandibular fractures. Males with mandibular fractures outnumbered females by a ratio of 3: 1. Right- and left-sided fractures had equal distribution. There was a distinct prevalence of mandibular fractures in the t6to 35year age group (Fig 4). The anatomic order of frequency of mandibular fractures was the body (29.5%), angle (27.3%), condyle (21.1%), symphysis (19.5%), ramus (2.4%) and coronoid (0.2%) (Fig 1). Assaults and motor vehicle accidents dominated all other causes of mandibular injury by a factor of 10. Yet, assaults were 1.7 times as prevalent as a

There were 99 zygoma fractures in 98 patients. Zygoma fractures associated with Le Fort III level fractures were eliminated from this group. Fractures of the zygoma occurred more frequently in males than females by a ratio of 3:2. The 21- to 35-year age group dominated all other age groups (Fig 4). The most dominant fracture, according to the Knight and North classification system, was the arch fracture (27.3%) (Fig 2). This was followed closely by the unrotated fracture (25.3%) and the medially rotated fracture (22.2%). Nondisplaced and comminuted fractures were of similar incidence, comprising 20.1% of the cases. The least frequent fracture was the laterally displaced fracture (5.0%). Assaults and motor vehicle accidents outnumbered all causes of zygoma fracture by a factor of 8 (Fig 5); assaults predominated. Left-side fractures outnumbered right by a ratio of 3:2.
MAXILLARY FRACTURES

Fifty-three patients suffered maxillary fractures. Males outnumbered females by a ratio of 5: 1. There were 20 patients with fractures at the Le Fort I level, 15 at the Le Fort II level, and 9 at the Le Fort III level. Five patients suffered fractures at the hemi-Le Fort I level, 3 at the Le Fort III/II level,

FIGURE 2. Anatomic distribution of zygomatic fractures.

928

AN EPIDEMIOLOGIC SURVEY OF FACIAL FRACTURES

FIGURE 3. Anatomic distribution of maxillary fractures. Right and left combination Le Fort fractures: IIUII, 5.7%; II/I, 1.9%; l/o, 9.4%.

and 1 at the Le Fort II/I level (Fig 3). Patients between the ages of 16 and 30 dominated all age groups, with the 26- to 30-year group the most frequent (Fig 4). Motor vehicle accidents outnumbered all other causes of injury by a factor of more than 5 (Fig 5).
CONCOMITANT INJURIES

Concomitant injuries accompanying mandibular fractures were significant (Fig 6). Thirty-two per-

cent of all mandibular fractures were accompanied by abrasions or lacerations. There was a 24% rate of neurologic injury, ranging from depressed skull fracture to loss of consciousness associated with mandibular fractures (Table 1). Additional orthopedic injury occurred in 20% of the patients with mandibular fractures. An additional 8.5% had other facial fractures. Other rates of injury included pulmonary (5.5%), abdominal (5.2%), and cardiac (1.3%) (Tables 2-4). Lacerations were the most frequently encountered concomitant injury associated with zygoma fractures (43%) (Fig 6). Orthopedic injury was encountered 32% of the time. Additional facial fractures, including mandibular, nasal, or isolated Le Fort I or II level fractures, ranked third at 22%. Neurologic injury ranging from loss of consciousness to skull fracture occurred 27% of the time when a zygomatic fracture was found (Table 1). Less prevalent injuries were pulmonary (7.1%), abdominal (4. I%), and cardiac (1 .O%) (Tables 2 to 4). The most frequently encountered concomitant injuries associated with maxillary fractures were lacerations and abrasions (75%) (Fig 6). Fifty-one percent of patients with maxillary fractures had additional orthopedic injury. An additional 42% suffered other facial bone fractures including zygoma, mandible, and nose. Fifty-one percent of patients with maxillary fractures sustained neurologic injury ranging from loss of consciousness to open depressed skull fractures (Table 1). Additional injuries included pulmonary (13%), abdominal (5.7%), and cardiac (3.8%) (Tables 2 to 4). Of particular interest was the frequency of concomitant injury with even simple mandibular or zygomatic fractures (Tables 1 to 4). It was not the facial fracture that influenced the frequency of concomitant injury, but the mechanism of injury (Table

0 60

Percentage oi

Mandible fractures

q q

Percentage ot Zygomatic Fractures Percentage oi Maxillary fractures

10

O-5

S-10

11-15

16-20

21-25

26-30

31-35

36-40

41-45

46-50

51-55

56-60

61-65

66-70

&F
FIGURE 4. Incidence of facial fracture by age (yr).

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929

I;il
5

Percentage of Mandible Fractures Percentage of Zygomatic Fractures Percentage of Maxillary Fractures

q q

FIGURE 5. Mechanisms injury for facial fractures.

of

MVA

MCA

Assault

Sports

Occupational

Home

Associated Injury
motor vehicle accidents stood out as the cause of the vast majority of concomitant injuries (Table 6), it was the occupational accident that caused the most nonmaxillofacial injuries per patient (Table 5). Three occupational injuries resulted in 12 concomitant injuries, a rate of 4.00: 1; each of these was a blast injury. Seventeen motorcycle accidents rendered 40 concomitant injuries, a ratio of 2.35:l. One hundred sixty-five motor vehicle accidents produced 234 concomitant injuries, a ratio of 1.4f:l.
5). Although 100

Discussion Epidemiologic surveys will vary with geographic region, population density, socioeconomic status, regional government, era in time, and type of facility in which the study was conducted. Comparison of surveys requires consideration of these factors. This study was conducted in a level I trauma center and county institution serving an urban population of 1.4 million and a surrounding suburban and rural population of another 2.0 million in northeastern

q
80 i i: k m H

Percentage of Mandible Fractures Percentage of Zygomatic Fractures Fractures

Percentage of Maxillary

60

Laceration/ Abrasion

Orthopedic

Cardsac

Pulmonary

Additional Facial Fractures

Abdominal

Neurologic

Opthalmotogic

Associated
FIGURE 6.

Injury

Distribution of concomitant injury associated with facial fractures.

930 Table 1, Frequency of Neurologic Injury Associated With Facial Fractures

Neurologic Injury Cervical spine Loss of consciousness Closed head Skull fracture Cerebral contusion Intracranial bleeding Total Fracture Mandible 10 36 10 7 8 2 73 Zygoma 1 13 I 3 2 0 26 Maxilla 3 8 5 I 0 4 27 Total 14 57 22 11 10 6

AN EPIDEMIOLOGIC

SURVEY OF FACIAL FRACTURES

Table 3. Frequency of Abdominal Injury Associated With Facial Fractures

Fracture Abdominal Injury Bladder Kidney Liver Peritoneal laceration Hematoma Ileus Spleen Total Mandible Zygoma 1 0 1 0 0 1 1 4 Maxilla 0 0 1 0 1 0 4 6 Total 4 1 5 1 5 2 I

Ohio. The study was conducted over a 5-year period between March 1984 and January 1989 in a region with laws against driving while intoxicated, seatbelt laws, and a 55/65 mph speed limit enforced. Many epidemiologic investigations of mandibular fractures have appeared in the American literature. Despite local demographic and socioeconomic differences, this study parallels other investigations published during this decade.6-0 Ellis and coworkers reviewed 2,173 patients with mandibular fractures over a lo-year period between 1974 and 1983 in a regional trauma center in Scotland.6 Chuong et al studied an urban population between 1975 and 1978 in Boston, MA.7 James et al performed a prospective study during 1978 in New Orleans, LA. Olson et al reviewed mandibular fractures between 1972 and 1978 in the tertiary care center for the state of Iowa during which a 55 mph speed limit went into effect. Bochlogyros reviewed mandibular fractures in West Germany between 1960 and 1980. With this very broad range of locations, it is interesting to note that our investigation contained similar demographics. Each investigation reported a large majority of mandibular fractures occurring in males.6-0 Each study also reported that most mandibular fractures occurred between 11 and 40 years, with the 21- to 30-year age group being the most frequent.6-10 Anatomic distribution in each study was also similar.6-10 While Olson et al and Bochlogyros reported motor vehicle accidents as the primary cause of mandibular injury and altercations second, Ellis,6 James, and this author found the altercations to be the predominant cause of injury.
Table 2. Frequency of Pulmonary Injury Associated With Facial Fractures
Fracture Pulmonary Injury Pulmonary contusion Pneumothorax Inhalation Pneumo/hemothorax Atelectasis ARDS Total Mandible 8 3 1 3 1 1 17 Zygoma 2 3 1 0 0 1 7 Maxilla 4 2 0 0 1 0 7 Total 14 8 2 3 2 2

Investigations of the epidemiology of zygoma fractures are found less frequently than for mandibular fractures. Knight and Norths study occurred over an 8-year period between 1949 and 1957 in a regional trauma referral center in England.2 Martin and others reviewed zygoma fractures over a 6-year period between 1950 and 1955 at a university hospital center in Ohio, and Lund investigated zygoma fractures over a 5-year period between 1960 and 1964 in Copenhagen, Denmark.12 Turvey investigated midfacial fractures secondary to blunt trauma in Parkland Memorial Hospital in Dallas, TX, between 1968 and 1972.13 Pozatek and coworkers investigated zygoma fractures at an urban teaching center in Boston, MA, between 1969 and 1972.14 Wisenbaugh reviewed zygoma fractures at an urban hospital center in San Francisco, CA, between 1967 and 1969. l5 Ellis and others reviewed 2,067 zygoma fractures over a IO-year period between 1974 and 1983 in a regional trauma center in Scotland.16 Our investigation and the surveys reviewed are very similar despite the significant differences in geography, government, era, and type of institution investigated. Males with zygoma fractures significantly outnumbered females.2*1-13,16 The most frequently affected age group was between 11 and 40 years, with the 21- to 30-year age group having the highest occurrence.2,11,12,15 Of the studies reviewed, only Ellis, Martin, and Turvey investigated cause.11,13*16 Martin ranked motor vehicle accidents as the predominant cause (50%), followed by home-related injury (19%), and assaults (14%) Ellis cited assault as the predominant cause (46.6%), followed by falls (22.4%), most of which were at home, and then motor vehicle accidents (13.3%). Turvey reported
Table 4. Frequency of Cardiac In/ury Associated With Facial Fractures
Fracture Cardiac Iniurv Cardiac contusion Pericardial tamponade Total Mandible 3 1 4 Zvaoma 1 0 1 Maxilla 1 0 Total 5 1

HALJG ET AL

931 Table 6. Mechanism of Injury in Relation to Facial Fractures

Fracture Mechanism of Injury Motor vehicle accident (n = 165) Motorcycle accident (n = 17) Assault (n = 206) Sports (n = 16) Occupation (n = 3) Home accident (n = 15) Mandible 101 13 165 13 3 12 Zygoma 37 5 44 4 Maxilla 35 4 7 4 2

interpersonal violence as the most frequent cause.i3 Our investigation of zygomatic fracture ranks assault as predominating cause (44.9%),motor vehicle accidents as second (37.8%),and home accidents third (7.1%).The only major difference was found in the rating of anatomic location. Each survey, as well as our study, ranked a different category in a different order.2*2V4~5 No single group was found to predominate or occur last in frequency. The variation is most likely due to differences in radiographic technique as well as individual investigator bias, as this classification system is based on radiographic interpretation rather than objective clinical examination. Epidemiologic reviews of maxillary fractures are infrequent. Turveys previously mentioned study reviewed both zygomatic and maxillary fractures. The incidence of Le Fort I, II, and III level fractures was not reported. Matsunaga et al, in a l-year review of midfacial fractures during 1973 in Los Angeles County/University Medical Center, reported the frequency of maxillary fractures17: 38.1% were at the Le Fort I level, 57.1% were at Le Fort II, and 4.8% were at Le Fort III. Kelly and Harrigan reported facial fractures during a 26-year period between 1948 and 1974 in Bellevue Hospital in New York City **. 47.6% were Le Fort I fractures, 42.9% were Le Fort II, and 9.5% were Le Fort III. Adekeye, in a 5-year prospective investigation in Nigeria, reported 12% at the Le Fort I level, 64% at the Le Fort II level, and 12% at the Le Fort III level, whereas another 12% were right-left combinations. Our survey differs in relative frequency from each of those reviewed, with 37.7% at the Le Fort I level, 28.3% at the Le Fort II level, and 12.0% at the Le Fort III level, with 17.0% combined right-left-sided fractures. No explanation for the differences in results could be derived. With the exception of Irbys book, Facial Trauma and Concomitant Injury,* systemic injuries associated with facial trauma have received only passing comment in the oral and maxillofacial surgical literature. Olson and others found associTable 5.

1
7

ated injuries in 46.6% of patients with mandible fractures and these were mostly due to motor vehicle accidents. In their study, lacerations (29.8%) and neurologic injury (29.8%) were the most frequently associated injuries, followed closely by other facial fractures (25.5%) and orthopedic injury (18.1%). Morgan et al found that the injury most frequently associated with midface trauma was neurologic (76%), followed by other facial fractures (44% to 8 l%), lacerations (36%), and orthopedic injury (35%).*l They attributed the high frequency of associated injuries to motor vehicle accidents. Adekeye found soft tissue lacerations to be the most frequently encountered injury associated with facial fractures (41%)19; neurologic injury was a close second (34%), followed by orthopedic injury (19%). Motor vehicle accidents were the most frequent cause of associated injury. Turvey found that other facial fractures were the predominant associated injury (41%), followed by facial laceration (22%), orthopedic injury (16%), head injury (5%), abdominal or thoracic injury (5%), and ophthalmologic injury (4%). In his study, motor vehicle accidents were the most frequent cause of all injury.13 In both of the studies performed by Ellis and coworkers, orthopedic injury was foremost, followed by undescribed injuries and thoracic injuries.6*6 In each study, the most frequent cause of nonmaxillofacial injuries was the motor vehicle accident, yet the motorcycle accident caused the most nonmaxillofacial injuries

Mechanism of Injury in Relation to Concomitant Injury

Mechanism of Injury

Concomitant Injury Laceration-abrasion Orthopedic Cardiac Pulmonary Abdominal Neurologic Ophthalmologic Total

Motor Vehicle 82 51 2 22 15 53 9 234

Assault 38 1 0 0 1 22 7 69

Motorcycle 14 11 0 1 3 10 1 40

Occupational 3 2 1 2 0 3 1 12

Home 7 2 0 0 1 4 0 14

sports 4 3 0 0 0 2 0 9

932 per incident. Murray and Hall, as well, attributed associated injuries to motor vehicle accidents. The findings of our study paraliei those of the studies reviewed. The most frequent cause of associated injury was the motor vehicle accident (600/o), with the most frequent concomitant injuries being facial abrasions or lacerations (40%). Neurologic injury ranked second (25%) and orthopedic injury ranked third (18%). Summary Of the 402 patients with facial fractures treated over 5 years, 307 suffered mandibular fractures (67%), 98 suffered zygomatic fractures (21%), and 53 suffered maxillary fractures (11%). In all groupings, males outnumbered females, with the most skewed distribution being in maxillary fractures. Those aged 16 to 30 years were clearly the most prone to facial fractures. Assaults and motor vehicle accidents significantly outweighed all other causes of injury. In mandibular and zygomatic fractures, assaults predominated, whereas in maxillary fractures, motor vehicle accidents predominated. Concomitant injury occurred with all facial fracture types. The most frequent associated injuries were lacerations and abrasions, followed next in frequency by neurologic and orthopedic injury. Motor vehicle accidents caused the most concomitant injuries. References
1. Ivy RH, Curtis L: Fractures of the mandible: An analysis of 100 cases. Dent Cosmos 68:439, 1926 2. Knight JS, North JF: The classification of malar fractures: An analysis of displacement as a guide to treatment. Br J Plast Surg 21:325, 1968

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SURVEY OF FACIAL FRACTURES

3. Le Fort R: Etude experimentale sur les fractures de la machoire suueriere. Rev Chir 23208. 1901 4. Le Fort R: Etude experimentale sur.les fractures de la machoire superiere. Rev Chir 23:360, 1901 5. Le Fort R: Etude experimentale sur les fractures de la machoire superiere. Rev Chir 23:479, 1901 6. Ellis E, Moos KF, El-At& A: Ten years of mandibular fractures: An analysis of 2,137 cases. Oral Surg Oral Med Oral Path01 59: 120, 1985 7. Chuong R, Donoff RB, Guralnick WC: A retrospective analysis of 327 mandibular fractures. J Oral Maxillofac Surg 41:305, 1983 8. James RB, Fredrickson C, Kent JN: Prospective study of mandibular fractures. J Oral Surg 39:275, 1981 9. Olson RA, Fonseca RJ, Zeitter PL, et al: Fractures of the mandible. J Oral Surg 40:23, 1982 10. Bochlogyros PN: A retrospective study of 1,521 mandibular fractures. J Oral Maxillofac Surg 43:597, 1985 11. Martin BC, Trabue JC, Leech TR: An analysis of the etiology, treatment, and complications of fractures of the malar compound and zygomatic arch. Am J Surg 92920, 19~5h 12. Lund k: Fractures of the zygoma: A follow-up study of 62 patients. J Oral Sum 29557. 1971 13. Tu-rvey TA: Midface fractures: A retrospective analysis of 593 cases. J Oral Surg X:887, 1977 14. Pozatek ZW, Kaban LB, Guralnik WC: Fractures of the zygomatic complex: An evaluation of surgical management with special emphasis on the eyebrow approach. J Oral Surg 31:141, 1973 15. Wiesenbaugh JM: Diagnostic evaluation of zygomatic complex fractures. J Oral Surg 28:204, 1970 16. Ellis E, El-Attar A, Moos KF: An analysis of 2,067 cases of zygomatic-orbital fracture. J Oral Maxillofac Surg 43:417, 1985 17. Matsunaga RS, Simpson W, Toffel PH: Simplified protocol for treatment of malar fractures. Arch Otolaryngol 103: 535, 1977 18. Kelly DE, Harrigan WF: A survey of facial fractures: Bellevue Hospital 1948-1974. J Oral Surg 33:146, 1975 19. Adekeye EO: The pattern of fractures of the facial skeleton in Kaduna, Nigeria. Oral Surg Oral Med Oral Path01 49:491, 1980 20. Irby WB: Facial Trauma and Concomitant Injury. St Louis, MO, Mosby, 1979 21. Morgan BDGT Madan DK, Bergerot JPC: Fractures of the middle third of the face: A review of 300 cases. Br 3 Plast Surg 25: 147, 1972 22. Murray JF, Hall HC: Fractures of the mandible in motor vehicle accidents. Clin Plast Surg 2: 131, 1975