J Neurosurg66:542-547, 1987

The impact-absorbing effects of facial fractures in

closed-head injuries

An analysis of 2 l0 patients

K. FRANCIS LEE, M.D., LOUS K. WAGNER~ PH.D., Y. EUGENIA LEE, M.D.,

JUNG HO SUH, M.D., AND SEUNG RO LEE, M.D.
Departments of Radiology and Ophthalmology, University of Texas Health Science Center, Houston,
Texas; Yonsei University Medical Center, Seoul, Korea; and Department of Radiology, Hanyang
University Medical Center, Seoul, Korea

~" A series of 210 patients with facial fractures sufficiently severe to require cranial computerized tomography
(CT) to evaluate suspected closed-head injury (CHI) was studied. The injuries were separated into five grades
of severity based on neurological examination, including cranial CT. The injuries were also grouped into three
categories based on facial regional involvement, using chi-square contingency table analysis. The data
demonstrated that patients with upper facial fractures were at greatest risk for serious CHI. Injuries to both
the mandibular and the midfacial regions with no upper facial involvement more frequently resulted in mild
CHI with a modest likelihood of no neurological deficits. Trauma to only the mandibular region or to only
the midfacial region was least likely to involve CHI.

KEY WORDS 9 facial bone fracture 9 closed-head injury 9 computerized tomography

15 lbs x 80 = 1200 lbs, which exceeds the fracture

B
ETWEEN D e c e m b e r 1, 1980, and N o v e m b e r 30,
1985, more than 1500 patients were treated at
the H e r m a n Hospital T r a u m a Center, Univer-
sity of Texas Health Science Center at Houston. O f
these, 210 patients with m a j o r facial injuries underwent
cranial computerized t o m o g r a p h y (CT) to investigate
the possible occurrence of closed-head injuries (CHI's).
A surprisingly large n u m b e r of patients with severe
facial injuries demonstrated either m i n o r or no CHI on
CT scans. The purpose of this study was to correlate
these severe regional facial fractures with the occurrence
of CHI, as determined from CT findings and neurolog-
ical examination.
Biomechanical Aspects of Facial Trauma
In motor-vehicle collisions, the head is often sub-
jected to forces m a n y times that o f gravity. The force
o f gravity is often expressed as a G force. The force of
impact (F) can be determined from the equation F =
MA, where M represents mass and A acceleration. It is
easy for an adult h u m a n head to be subjected to an 80-
G force in a collision at 30 m p h (50 km/hr). If the head
weighs 15 lbs, the force on the face in this situation is
limits of m o s t o f the facial skeleton as derived from
impact experiments on cadavers (Fig. 1).1~'~8"22"27'28
The types of craniofacial injuries resulting from a
motor-vehicle accident depend on the following: 22'28
l) force and direction of the collision; 2) impact inter-
face geometry (shape and texture of opposing surfaces);
3) energy-absorbing characteristics of the opposing ob-
jects; and 4) use of restraints such as seat belts. Protrud-
ing areas with lower tolerance are m o s t likely to sustain
injury in motor-vehicle accidents. Thus, the nasal bones
are most c o m m o n l y injured, followed by the zygomat-
icomaxillary bones, the orbital rims, and the mandi-
ble. 4'19"26 Females have lower impact tolerance levels
than males. 22 The frontal bone is the area most resistant
t o i n j u r y . 18'22 AS fractures occur, the facial skeleton
absorbs some o f the impact and cushions the brain
against some of its violent effects. 9'21,25 The triplanar
arrangement o f the facial bones (Table 1) in the hori-
zontal, sagittal, and coronal planes 7,8 m a y act as an
effective cushion against violent forces to the cranium.
Complex midfacial fractures have been classified as
orbitoethmoidal, zygomaticomaxillary, and Le Fort I,
II, and III. 1"3"10"14'15"19 As the nature o f motor-vehicle

542 J. Neurosurg. / Volume 66/April, 1987

Effect of facial fracture in head injury

TABLE 1
Osseous architecture offacial skeleton in three planes*

Level of Coronal Plane Struts Horizontal Plane Struts Sagittal Plane Struts
Impact
upper face anterior facial: frontal bone, frontal sinus, fovea ethmoidalis/cribriform median: crista galli
supraorbital ridge plate parasagittal: cribriform plate
posterior facial: posterior maxillary sinus orbital roof lateral: frontozygomatic
wall, pterygoidplate
midface nasal bones orbital floor median: nasal septum
zygomaticofrontal:anterior maxillary zygomaticarch parasagittal: medial orbital wall, medial
sinus wall, anterior alveolar ridge hard palate maxillary sinus wall
lateral: lateral orbital wall, lateral maxillary
sinus wall, lateral alveolar ridge
lower f a c e symphysis body median: symphysis
(mandible) angle lateral: body, angle, ramus, coronoid,
ramus condyle
* Modified from the data of Gentry, et al. 7

accidents in the past few decades has changed with TABLE 2

high-velocity travel, previously unusual combinations Cause offacial fractures in 210 patients
of facial fractures have become increasingly com-
mon. 3,~9Most important among these combinations are Cases
Cause
frontomaxillary fractures which are characterized by No. %
disjunction o f parts o f the frontal bone, the orbital roof, motor-vehicle accidents 149 71.0
or even the sphenoid bone, so that both the midface assaults & falls 33 15.7
and anterior base o f the skull are separated from the sporting accidents 7 3.3
main body o f the cranium. 19'23 These are unlike a Le industrial accidents 6 2.8
miscellaneous 10 4.8
Fort III fracture, which is a dislocation of the midface unknown 5 2.4
from the base of the skull. Injuries of sufficient force
and magnitude to produce a Le Fort III fracture usually
result in fractures of the Le Fort II and I distribution as
well ("total facial smash"). 4'5'1~176
Over 75 % o f the patients in this study sustained high-
G trauma (such as in motor-vehicle, motorcycle, auto-
pedestrian, and industrial accidents). Under 25% of
them were injured by low-G impacts (for example, in
assaults, falls, and sporting accidents) (Table 2).

Clinical Material and Methods

Major facial fractures were documented on plain
radiography, panradiography, CT, and physical exami-
nation in the 210 patients in this series. The age dis-
tribution of these patients is given in Fig. 2. The
male:female ratio was 3.1:1. A total of 596 craniofacial
CT examinations were performed, for an average of 2.8
examinations per patient. A GE 8800 CT scanner (320
x 320 matrix) was used between 1980 and 1983, and
two GE 9800 scanners (512 x 512 matrix) were used
in 1984 and 1985 for the facial and cranial CT exami-
nations.~5'~6 For the facial bones, multiple axial sections
with a slice thickness o f 5 or 3 m m were performed,
and reformatted images in the sagittal and coronal FIG. 1. Tolerances of the facial bones to violent forces. A
planes were also obtained in the majority o f the pa- 30-mph collision can easily result in an 80-G force, which is
tients. When the patients' condition permitted, direct sufficiently large to cause fractures of the nasal bones, zygoma,
mandibular ramus, and frontal sinus. (Reproduced with per-
coronal CT scans with a slice thickness of 5 or 10 m m mission from Luce EA, Tubb TD, Moore AM: Review of
were obtained. With the fast scanner, the entire CT 1,000 major facial fractures and associated injuries. Plast
examination in the axial and coronal planes could be Reconst Surg 63:26-30, 1979.)

J. Neurosurg. / Volume 6 6 / A p r i l 1987 543

 K. F. Lee, et al.

TABLE 3
Incidence of various facial fractures in 210 patients
Cases
Facial Fracture Group*
No. %
1 (lowerthird) 15 7.1
2 (middle third) 35 16.7
3 (upper third) 33 15.7
4 (lower& middle thirds: 1 + 2) 41 19.5
5 (lower& upper thirds: 1 + 3) 12 5.7
6 (middle & upper thirds: 2 + 3) 43 20.5
7 (lower,mid, & upper thirds: 1 + 2 + 3) 31 14.8
* For an illustration of facial segments see Fig. 3.

divided into seven groups depending on the area in-

FIG. 2. Age distribution of 210 patients with facial frac-
tures. The highest incidence was noted in the 20- to 29-year-
old group, followed by the 30- to 39-year-old and the 10- to
19-year-old groups.
completed within 20 minutes. Cranial CT scans with a
slice thickness of 8 m m for children and 10 m m for
adults were also obtained without injection of contrast
material.
The clinical status o f the patients was classified into
five grades based on the CT findings combined with
the Glasgow C o m a Scale. 2"6"12't3'17'24'29 The C H I was
classified according to severity into the following grades:
Grade 0 (negative); Grade I (mild); Grade II (moder-
ately severe); Grade III (severe); and Grade IV (grave
or fatal). The etiology o f craniofacial fractures varied;
the great majority o f the patients in this series were
injured in motor-vehicle accidents (Table 2).
Results
The highest incidence (39 %) of severe facial fractures
was noted in the 20- to 29-year-old age group (Fig. 2).
The median age was 26 years. Facial fractures were
volved (Fig. 3 and Table 3). G r o u p 1 fractures involved
the lower third of the facial skeleton (the mandible).
There were 15 cases in this group. Thirteen of these
had fractures involving more than one of the following
areas: condyle, symphysis, angle, alveolar process, as-
cending ramus, mandibular dentition, corpus or body,
and coronoid process. G r o u p 2 injuries involved the
middle third of the facial skeleton (the midface). There
were 35 cases in this group. Multiple fractures were
demonstrated in the following areas: nasal bone and
septum; pterygoid plates; orbit; zygoma; zygomatic
arch; and maxilla, including the alveolar process and
maxillary dentition. Complex fractures such as Le Fort
II and III fractures were observed in 54% of cases.
Group 3 fractures involved the upper third of the facial
skeleton (forehead). There were 33 cases in this group.
Fractures were noted in one or more of the following
areas: supraorbital ridge, glabella (frontal sinuses), and
frontal bone. G r o u p 4 fractures involved a combination
of Group 1 (mandible) and G r o u p 2 (midface) injuries,
and were found in 41 cases. G r o u p 5 fractures included
a combination o f G r o u p 1 (mandible) and Group 3
(forehead) injuries, and were found in 12 cases. Group
6 fractures comprised a combination of Group 2 (mid-

FIG. 3. Schematic drawing of the classification system for regional facial fractures. Group 1: lower third
facial (If) or mandibular fractures; Group 2: middle third facial (mf) or midfacial fractures; Group 3: upper
third facial (uf) or forehead fractures; Group 4: combination of mandibular (1) and midfacial (m) fractures;
Group 5: combination of mandibular and upper facial fractures; Group 6: combination of midfacial and
upper facial fractures; and Group 7: combination of mandibular, midfacial, and upper facial fractures.

544 J. Neurosurg. / Volume 66/April, 1987

Effect of facial fracture in head injury

TABLE 4
Computerized tomography findings in 210 cases of craniofacial trauma*

Fracture No. of Subdural Epidural ICH HRC SAH Midline TTH Edema Pneumocephalus IVH Miscellaneous
Group Cases Hematoma Hematoma Shift
1 15 1 2 1 1 2 1
2 35 4 1 2 9 1 6 1 9 3 3
3 33 6 2 3 14 3 6 2 8 6 5 1
4 41 8 1 6 16 1 3 1 6 3 2
5 12 3 2 2 2 2 2 1 3 2 1 1
6 43 10 6 7 18 4 12 3 2 9 4 1
7 31 8 2 12 16 4 11 1 6 7 3 1
total 210 40 14 32 77 16 41 9 36 31 18 4
* ICH: intracerebral hematorna; HRC: hemorrhagic contusion; SAH: subarachnoid hemorrhage; TTH: transtentorial herniation; IVH: intraven-
tricular hemorrhage. For definition of fracture groups see Table 3.

face) and G r o u p 3 (forehead) injuries, a n d involved 43 tricular h e m o r r h a g e (18), subarachnoid h e m o r r h a g e

cases. G r o u p 7 fractures included injuries f r o m G r o u p s
1, 2, and 3 c o m b i n e d , and were f o u n d in 31 cases.
Thus, middle third (midface) and upper third (forehead)
c o m b i n a t i o n fractures ( G r o u p 6) were seen m o s t c o m -
m o n l y (20%), while the lower third (mandible) and
upper third (forehead) fracture c o m b i n a t i o n ( G r o u p 5)
was observed least frequently (5.7%).
The cranial C T findings in each group o f facial
fractures are s u m m a r i z e d in Table 4. T h e following C T
findings were n o t e d in order o f decreasing frequency:
hemorrhagic c o n t u s i o n (77), midline shift (41), sub-
dural h e m a t o m a (40), cerebral e d e m a (36), intracere-
bral h e m a t o m a (32), p n e u m o c e p h a l u s (31), intraven-
(16), epidural h e m a t o m a (14), transtentorial herniation
(nine), a n d miscellaneous findings in four.
Table 5 a n d Fig. 4 show each fracture g r o u p with the
incidence o f C H I classified according to the cranial C T
findings in c o n j u n c t i o n with neurological e x a m i n a -
tions. Chi-square c o n t i n g e n c y table analysis revealed
that the C H I grade distributions o f G r o u p s 1 ( m a n d i -
bular fractures) a n d 2 (midfacial fractures) were n o t
significantly different (p < 0.35). Similarly, C H I grade
distributions in G r o u p s 3 (upper facial fractures), 5
(mandibular a n d u p p e r facial fractures), 6 (middle a n d
upper facial fractures), a n d 7 (mandibular, middle, a n d
upper facial fractures) were not significantly different

80%

GRAt~ 0 e~jativel GRAD~ I (mild) GRAD~ II (moderate)

60% 60% 60%

l

40% 40%

20% 20%

%IG 1 2 3 4 5 6 7 %IG 1 2 3 5 6 7 %IG 1 2 4 5 7

GRAI~ III|severe) GRADE IV (grave/fatal) G-l: mandibular fractures

G-2: midfacial fractures
G-3: upper facial fractures
30% G-4: ~ a r & midfacial
~ G-5: mandibular & upper facial
20% 20% G-6 : middle and upper facial
G-7: mandilmllar,mid & upper(total)

I-I [7 R
10%
r-i
1 2 3 4 5 6 7 %IG 1 2 3 4 5 6 7
FIG. 4. Regional facialfracturesand severity (grading) of closed-head injuries(CHI's) in 210 patients with
major facial fractures. For definition of CHI grade see Table 5.

J. Neurosurg. / Volume 66/April, 1987 545


80%
I I Mandibular or Midfaeial Fxs
Mandibular & Midfacial Fxs
Upper Facial Area F x s
o
~ 6o~
E
40,
wz
d
2O%
I I I I I II: Moderatelysevere CT and neurological findings; Grade III: Severe
0 I II Ill IV
GRADE OF INTRACRANIAL INJURIES ( 2 1 0 c a s e s )
FIG. 5. Regrouping of the seven regional facial fractures
into three categories based on contingency table analysis (see
text for p values). Severe closed-head injury (CHI) was more
frequently observed in patients with upper facial fractures,
while the majority of patients with mandibular or midfacial
fractures alone demonstrated no CHI or minor CHI. Fxs =
fractures.
(p < 0.5). The CHI grades associated with Group 4
fractures (mandibular and midfacial fractures) were
marginally different from those found with Group 1
and 2 fractures (p < 0.05) and significantly different
from the grades in patients with G r o u p 3, 5, 6, and 7
fractures (p < 0.001). The C H I grades in Group 1 and
2 fractures were significantly different from those asso-
ciated with G r o u p 3, 5, 6, and 7 fractures (p < 0.001).
The seven groups presented in Table 3 can therefore be
reclassified into three categories o f CHI. The first cate-
gory involves fractures to only the mandibular region
or only the midfacial area (Groups 1 and 2). The second
category involves fractures o f both the mandibular and
midfacial areas with no upper facial involvement
(Group 4). The third category includes all fractures
involving the upper facial area (Groups 3, 5, 6, and 7).
A plot of the distribution o f these three categories is
shown in Fig. 5.
Discussion
This study of 210 patients whose facial injuries were
sufficiently severe to require CT for possible C H I dem-
onstrated the following association with neurological
deficits. Fractures involving only the mandibular or the
midfacial areas (Groups 1 or 2) were most likely corre-
lated with Grade 0 C H I (62% of cases with that level
of fracture) with a modest likelihood of a Grade I injury
(24% of cases). More severe injuries were less likely to
be found in this group o f patients (14% of cases).
Combined fractures to the mandibular and midfacial
areas (Group 4) were most likely to be associated with
Grade I CHI (54% o f patients with that fracture group),
with a modest likelihood o f Grade 0 CHI (32% of
546
K. F. Lee, et al.
TABLE 5
Incidence of closed-head injuries in facial trauma*
Fracture No. of Grade G r a d e G r a d e G r a d e Grade
Group Cases 0 I II III IV
1 15 12 (80%) 2 (13%) 1 (7%) 0 0
2 35 19(54%) 10(29%) 4(11%) 2(6%) 0
3 33 4(12%) 9(27%) 16 (48%) 3 (10%) 1 (3%)
4 41 13 (32%) 22 (54%) 5 (12%) 1 (2%) 0
5 12 1 (8%) 2 (17%) 5 (42%) 3 (25%) 1 (8%)
6 43 1 (2%) 12 (28%) 23 (54%) 6(14%) 1 (2%)
7 31 1 (3%) 14 (45%) 13 (42%) 3(10%) 0
* For definition of fracture groups see Table 3. Grade 0: Normal
computerized tomography(CT) without significant neurologicaldefi-
cit; Grade I: Minor CT findingswith slight neurologicaldeficit; Grade
CT and neurologicalfindings; Grade IV: Grave CT findingswith fatal
outcome.
cases). More severe injuries had a lower likelihood of
occurring in this fracture group (14% o f cases).
Any fracture involving the upper facial area (Groups
3, 5, 6, or 7) was most likely to be a Grade II CHI (48%
of cases with this fracture level) with a modest incidence
of Grade I injury (31% o f cases). Grade 0, III, and IV
CHI's occurred less frequently (21% of cases).
The compressible air-filled energy-absorbing facial
bones serve as a decelerating cushion to protect intra-
cranial structures located behind them. This may be a
major reason why extensive crushing injuries of the
facial bones are frequently sustained with little apparent
damage to the brain. In order to prevent serious injury
to the brain in an accident involving facial injury, it is
best to protect the areas o f the forehead and the skull
since injury to these areas is more likely to result in
serious CHI than is injury to other areas of the face.
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Manuscript received March 28, 1986.
Accepted in final form September 11, 1986.
The data presented here have recently been published in a
somewhat different form in Lee KF: High resolution com-
puted tomography of facial trauma associated with closed-
head injuries, in Toombs BD, Sandier CM (eds): Computed
Tomography in Trauma. Philadelphia: WB Saunders, 1987.
Tables 2, 3, 4, and 5 and Figs. 2, 3, and 4 of this text are
adapted from the WB Saunders text with permission of the
publisher.
Address reprint requests to: K. Francis Lee, M.D., Uni-
versity of Texas Health Science Center, 6431 Fannin, Hous-
ton, Texas 77030.
547