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Journal of Cranio-Maxillofacial Surgery (2009) -, 1e7


2009 European Association for Carnio-maxillofacial Surgery
doi:10.1016/j.jcms.2009.01.008, available online at http://www.sciencedirect.com

Skull base and maxillofacial fractures: Two centre study with correlation of
clinical findings with a comprehensive craniofacial classification system
CHLI1, Christoph LEIGGENER2,7, Petter GAWELIN3, Laurent AUDIGE4, Per ENBLAD5,
Heidi BA
Hans-Florian ZEILHOFER2,7, Jan HIRSCH3, Carlos BUITRAGO-TELLEZ6,7
1

Department of Neurosurgery, University Hospital Basel, Switzerland; 2 Department of Reconstructive Surgery, Unit
of Cranio-Maxillofacial Surgery, University Hospital Basel (Head: Prof. Dr. F. Zeilhofer), Switzerland; 3 Departments of
Surgical Sciences, Oral and Maxillofacial Surgery, Uppsala University Hospital, (Head: Prof. Dr. J. Hirsch), Sweden;
4
AO Clinical Investigation and Documentation, Dubendorf (AO Foundation), Switzerland; 5 Departments of Surgical
Sciences, Neurosurgery, Uppsala University Hospital, Sweden; 6 Institute of Radiology, Hospital Zofingen (Head:
Radiology Hospital Zofingen), Switzerland; 7 Hightech Research Centre for Cranio-Maxillofacial Surgery, University
Hospital Basle (Head: Prof. Dr. F. Zeilhofer), Switzerland

Purpose: A comprehensive classification based on high resolution computed tomography (CT) of


the whole craniofacial region was correlated with clinical findings of combined skull base and maxillofacial fractures. Material and methods: In a study of two clinical centres, 70 patients with such injuries were admitted at
the Universities of Basel (n 29) and Uppsala (n 41). Clinical signs (rhinorrhoea, periorbital haematoma and
pneumencephalus) and surgical versus conservative treatment were correlated with a cranio-maxillofacial injury severity score (CMF-ISS) calculated from the classification system. Fracture classifications were decided
in consensus on the basis of CT and semiautomatic classification software. The classification system defined 3
fracture types (A, B, C), 3 groups (A1, A2, A3), and 3 subgroups (A1.1, A1.2, A1.3) with increasing severity
from A1.1 (lowest) to C3.3 (highest). Results: Of 70 patients, 43 were operated upon and 27 conservatively
treated. The operated patients had significantly higher severity scores than non-operated. Patients with or without periorbital haematoma do not differ significantly in the severity score. The severity of the CMF-ISS score was
significantly associated (two sample T-test P\ 0.01) with the occurrence of pneumencephalus, rhinorrhoea and
treatment approach. Conclusion: Based on our present results, this system seems to be clinical useful for operative decisions and interventions. 2009 European Association for Carnio-maxillofacial Surgery
SUMMARY.

Keywords: skull base fractures, cranio-maxillofacial injury severity score (CMF-ISS), periorbital haematoma,
pneumencephalus, rhinorrhoea

extent of the fractures (Katzen et al., 2003). Therefore,


frontobasal (FB) fractures may be not diagnosed in
a timely fashion. This leads to complications such as
meningitis with posttraumatic fistulas and secondary rhinorrhoea, intracranial or ethmoidal infections or osteomyelitis which frequency differs from clinic to clinic.
Therefore, the clinical examination should be combined
with detailed neuroradiological skull base analysis to prevent future complications. The introduction of computed
tomography (CT) was accompanied with an increased
sensitivity and accuracy in the detection of skull base
fractures. One important point is that these fractures are
often complex and not included in the original Le Fort
classification and that diagnostic evaluation should consider the detection of fractures of the central and lateral
parts of the skull base (Schuknecht and Graetz, 2005).
Combined skull base and maxillofacial fractures may
be missed, especially if the skull base component is not
recognized. Clinical findings may indicate the need to
rule out a skull base fracture. The aim of this study is
to clarify indications for operative treatments of skull
base fractures combining clinical findings with

INTRODUCTION
Skull base fractures are a great challenge for the surgeons
involved. The treatment is still controversial including best
operative approach, urgency and extent of surgical procedure. The singular anatomical relationship of the skull base
is the reason for particular problems that may arise after injury such as dural laceration, severe neurovascular damage
e.g. (Samii and Tatagiba, 2002). The decision on management must consider all these aspects. Another important
point is that a lot of patients are polytraumatized including
severe brain injuries which complicates early operative interventions. Additionally the involvement of different specialities, such as oral and maxillofacial surgeons,
neurosurgeons, plastic surgeons and ENT may lead to controversies about therapeutic decisions, including timing reconstruction and specific kind of technical procedures
(Kessler and Hardt, 1998; Samii and Tatgiba, 2002; Gabrielli et al., 2004; Sandner et al., 2006).
It is well known that there is a high coincidence of
fractures and dural lacerations. But the problem is that
there is not always sufficient information about the real
1

Please cite this article in press as: Bachli H, et al. Skull base and maxillofacial fractures: Two centre study with correlation of clinical findings with
a comprehensive craniofacial classification system, J Craniomaxillofac Surg (2009), doi:10.1016/j.jcms.2009.01.008

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2 Journal of Cranio-Maxillofacial Surgery

a comprehensive classification system with different severity scores (Buitrago-Tellez et al., 2002). To tackle
this problem, the present study is based on a retrospective
evaluation of patients with skull base and maxillofacial
fractures in two clinical centres.
MATERIAL AND METHODS
Patients
A retrospective analysis (1997e2005) of the clinical data
of a total of 70 patients (55 males, 15 females) with craniofacial fractures which were managed by neurosurgery
and maxillofacial surgery of the University Hospital of
Basel (Switzerland; n 29) and Uppsala (Sweden;
n 41). The patients were aged between 5 and 80 years
(mean 43.4).

nents. The classification system defines 3 fracture types


(A, B, C), 3 groups (A1, A2, A3) and 3 subgroups
(A1.1, A1.2, A1.3) with increasing severity from
A1.1 (lowest category) to C3.3 (highest). The craniofacial regions are divided into 3 units: lower midface (I),
upper midface (II), craniobasal-facial unit (III), also laterals and central fractures are distinguished. The 3 fracture types are defined as followed: Fractures of type A
are non-displaced; type B displaced and type C multifragmentary (2 or more intermediate fragments) or defect fractures. Fractures of isolated units are defined as
group A1, B1 or C1. Combined fractures without involvement of the skull base are group A2, B2 or C2.
At least combined fractures with involvement of the
skull base belong to group A3, B3 or C3. An example
of a severe craniofacial fracture with a FB component
is represented by formula C3.2/C3.2//C3.2/C3.2 as
shown in Fig. 3.

Radiology
CT-studies of the craniofacial region performed in the
acute setting were available for classification. CT-Studies
were obtained either in single or multislice-CT technique
with collimation of 1.5 mm with secondary 2D coronal
reconstructions with a SOMATOM PLUS S scanner,
Volume Zoom (Siemens, Erlangen, Germany) or GE
CT (GE, Milwaukee, USA) scanner. 3D CT reconstructions were obtained in selected cases. Clinical signs (rhinorrhoea, periorbital haematoma and pneumencephalus)
were registered in the clinical records.
Fracture Classification System
For the purpose of this study, all cases were classified
according the comprehensive classification of craniofacial fractures proposed by the senior author (BuitragoTellez et al., 2002). Fig. 1 shows a cranio-midfacial
view with skull base (red) and calvarial (green) compo-

CrAnio-Facial Fracture Automatic Classifier


(CAFFAC) Software
Since the analysis required the use of the proposed AO
analogue CMF fracture classification system which is
systematic but somewhat time-consuming, automatic
analysis software has been used to classify fractures after
interactively drawing the fracture pattern (Fig. 2).
For that reason special software (Buitragos CrAnioFacial Fracture Automatic Classifier: CAFFAC) with
these capabilities and with a database has been developed
in the setting of a FORK-Project (support of a grant from
the AO/ASIF Research Commission: FORK-Project
2000-B55). The software has been updated in cooperation with the AO Clinical Investigation and Documentation and with the participation of members of the AO
CMF Classification Group. The software used for this
study was the version Buitrago-CAFFAC 2004 (Ing.
M. Marschelke, D. Sauter, Reichenau, Germany).

Fig. 1 e Cranio-midfacial views with division lines for the skull base (red) and calvarial (green) components of the craniobasal-calvarial unit of the
craniomidface. (a) Front view showing the calvarial (green) and skull base (red) components of the craniobasal-calavarial unit. The skull base
component includes in this view the laterobasal aspect of the sphenoid bone (greater wing) until the level of the dorsal lateral orbital wall and the orbital
roof. The calvarial component includes the parietal, frontal and squamoustemporal calvarial bones, the supraorbital rim and the anterior wall of the
frontal sinus. (b) Top view showing the calvarial (green) and skull base (red) components of the craniobasal-calavarial unit. The skull base component
includes in this view the FB and laterobasal aspect of the sphenoid bone, the dorsal wall of the frontal sinus, the orbital roof, the rhinobasis with the
cribriform plate, the middle fossa, the clivus, the petrous part of the temporal bone and the dorsal occipital skull base. The calvarial component includes
the parietal, F and squamoustemporal bones and the anterior wall of the frontal sinus.

Please cite this article in press as: Bachli H, et al. Skull base and maxillofacial fractures: Two centre study with correlation of clinical findings with
a comprehensive craniofacial classification system, J Craniomaxillofac Surg (2009), doi:10.1016/j.jcms.2009.01.008

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Skull base and maxillofacial fractures 3

Fig. 2 e Buitrago-Craniofacial Fracture Automatic Classifier (CAFFAC) 2004. Note that A-fractures (non-displaced) appear green; B-fractures
(displaced) orange and C-fractures (multifragmentary) red.

CT evaluation and Fracture Classification

RESULTS

CT evaluation was performed in consensus by two experienced readers (radiologist and neurosurgeon in Basel,
radiologist and maxillofacial surgeon in Uppsala). For
classification purposes, the CAFFAC software was
used drawing the fracture lines on the craniofacial
scheme. The software automatically gives the fracture
formula in all four compartments. Furthermore, the software calculates a Cranio-Maxillofacial Injury Severity
Score (CMF-ISS) which results from the sum of the
scores in all compartments with a weighting system emphasising the presence of skull base fractures. The fracture types (A, B or C) are multiplied by a factor 2, the
group by a factor 3 and the subgroup by a factor 1.
This calculation is made for each compartment (max.
value for one compartment 18 points).
For example, a complete multifragmentary fracture of
the craniofacial region with all compartments involved
would get a maximum of 72 points (4  18 points).

Association of Severity Score (CMF-ISS) with Clinical


Findings

Statistical Data Analysis


Differences in injury severity score between patient
groups defined by treatment (operative versus non-operative) or the occurrence of clinical signs (periorbital haematoma,
pneumencephalus,
rhinorrhoea)
were
investigated by T-test (univariable analysis). In addition,
the injury severity score was assessed as a potential prognostic factor in multivariable regression models for the
occurrence of clinical signs with statistical adjustment
for the variables of age, gender and treatment. The significance level was set to 0.05 for all tests.

Periorbital haematoma (raccoon eye)


32 patients suffering periorbital haematoma had a mean
ISS of 45 points (Standard deviation (SD) 15.6) and
did not differ significantly from a mean ISS of 52 points
(SD 14.4) of those without periorbital haematoma (T-test
P 0.08; logistic regression P 0.44, Fig. 4). Age, gender and treatment were all significantly associated with
the occurrence of periorbital haematoma.
Pneumencephalus
44 patients with a mean severity score of 56 points (SD
9.8) had a pneumencephalus. Twenty-five patients without pneumencephalus had a significantly lower mean severity score of 35 points (SD 15). Fig. 5 shows the
statistical analysis (T-test P \ 0.001; logistic regression
P \ 0.001). When the score was between 40 and 50
the risk of pneumencephalus was increased by a factor
2.5 (Relative Risk; P 0.07) compared with patients
with a score # 40. When the score was .50e60 and
higher .60, this risk was increased by a factor of 4.3
(P 0.001) and 3.8 (P 0.003), respectively.
Rhinorrhoea
Twenty-nine patients developed rhinorrhoea. They seemed
to have a higher mean severity score of 55 points (SD 13.7)
compared with a mean of 44 points (SD 15) in 40 patients
without rhinorrhoea, but this difference was not significant
after statistically adjusting for age, gender and treatment (Ttest P 0.003; logistic regression P 0.11, Fig. 6).

Please cite this article in press as: Bachli H, et al. Skull base and maxillofacial fractures: Two centre study with correlation of clinical findings with
a comprehensive craniofacial classification system, J Craniomaxillofac Surg (2009), doi:10.1016/j.jcms.2009.01.008

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4 Journal of Cranio-Maxillofacial Surgery

Fig. 3 e Cranio-midfacial fracture with FB component. Involvement of all four vertical compartments: (right lateral/right central left central/left
lateral), involving midface and fronotobasis (arrows). Fracture formula: C3.2/C3.2//C3.2/C3.2.

Association of Severity Score (CMF-ISS) with


Treatment (Operative versus Non-operative)
In Basel, 22 patients were treated operatively (75.9%)
and 21 in Uppsala (51.2%), non-operatively 7
(24.1%) versus 20 (48.8%) respectively. Patients
treated operatively had a significantly higher severity
score by 9.5 points (P 0.011) than patients treated
non-operatively (Fig. 7). This difference was more
pronounced in Basel than in Uppsala, since non-operated patients in Basel all had severity scores below 40
points. All 16 patients with a severity score .60
points were operated upon.
DISCUSSION
The complexity of skull base fractures are often underestimated and indications for surgical treatments differ
from the involved specialities.
Skull base fractures are often associated with severe
brain injuries. Especially in polytraumatized patients,
life threatening treatments have to be the first priority
and such fractures can initially be easily overlooked.

Fig. 4 e Correlation of CMF-ISS with periorbital haematoma in Basel


and Uppsala and therapeutic approach (two sample test with equal
variances).

Another problem is the complex anatomy of the FB region which leads to the development of several classification systems with different nomenclature (Kienstra and
VanLoveren, 2005). Detailed definition of specific regions were described, such as nasoethmoidal fractures

Please cite this article in press as: Bachli H, et al. Skull base and maxillofacial fractures: Two centre study with correlation of clinical findings with
a comprehensive craniofacial classification system, J Craniomaxillofac Surg (2009), doi:10.1016/j.jcms.2009.01.008

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Skull base and maxillofacial fractures 5

Fig. 5 e Correlation of CMF-ISS with pneumencephalus in Basel and


Uppsala and therapeutic approach (two sample test with equal
variances).

Fig. 6 e Correlation of CMF-ISS with rhinorrhoea and therapeutic


approach in both centres together (two sample test with equal variances).

(Gruss, 1985; Markowitz et al., 1991), nasoethmoid-orbital injuries (Fedok, 1995), orbito-zygmatic fractures
(Zingg et al., 1992), frontonaso-orbital/skull base fractures and telecanthus (Raveh et al., 1992) or malar complex fractures (Fujii and Yamashiro, 1983). Frontal sinus
fractures are also frequently involved in skull base fractures including their own classification schemes (Rohrich
and Hollier, 1992; Manolidis, 2004) and surgical management. Missing in all these classifications is the midfacial region which is often consecutively involved because
of the high velocity impact of accidents. Mahusudan
et al. (2006) proposed a new comprehensive clinicoradiographic classification which defines anatomical areas
within the FB region, the nature of an injury associated
with midfacial injuries. He divided nine types which include the whole anteroposterior and lateral FB region. He
differentiates three main types: central (type 1), lateral
(type 2) and combined (type 3). Subregions were divided
into frontal (F) including cranial vault, basal (B) with the
floor of the anterior cranial fossa, ethmoid and lateral orbital walls and FB with both frontal and basal regions.
The fracture was called impure if there was a midfacial
fracture and pure without. 48.7% of patients with impure
FB fractures showed cerebrospinal fluid leaks, only
16.7% with pure fractures. This must be noted with

Fig. 7 e Correlation of CMF-ISS with therapeutic approach in Basel


and Uppsala (two sample test with equal variances).

caution because of the increased involvement of basal


parts in impure fractures.
Based on clinical and postmortem studies with 2D and
3D CT, Buitrago-Tellez (Buitrago-Tellez et al., 2002)
proposed a craniofacial fracture classification system
based on hierarchical organization into triads analogous
to the AO scheme, allowing a comprehensive description
and documentation of injuries, including those not precisely defined by the Le Fort classification and those involving the skull base and calvarial bones.
This classification approach enables the user to record
the precise location of bony injuries within the whole craniofacial region. The exact definition of fracture extension including the often-missed associated skull base
fractures allows a more complete description of the real
extension of a given fracture.
Limitations of the system include the familiarity with
the Muller AO classification system and understanding
of radiological/clinical systematic analysis of complex
skull base anatomy.
The relatively complex but systematic classification
system requires further simplification for clinical use,
which is partly achieved by the semiautomatic software
developed in this setting. Moreover, the widespread clinical use of the proposed system may potentially lead to
standardization of documentation, improved interdisciplinary communication and may be considered as a useful
tool for comparative studies of therapeutic approaches
and final outcomes after craniofacial trauma.
A significant correlation between the presence of
pneumencephalus and high CMF-ISS was observed.
All patients in both centres with a score .60 were operated upon with skull base revision and repair. Figure 7
shows that in Basel, conservative treatments were applied
only to patients with a CMF-ISS less than 40 and as soon
as a more severe injury is seen, operative treatment was
applied. The higher variability of the ISS might be
caused by a different group size (Basel n 29, Uppsala
n 41). Patients in Uppsala have generally higher severity scores. It is remarkable that patients in Uppsala had
a higher ISS. However the reason for this remains still
unclear and speculative. May be Uppsala has a larger
catchment area, different injury mechanisms, for example

Please cite this article in press as: Bachli H, et al. Skull base and maxillofacial fractures: Two centre study with correlation of clinical findings with
a comprehensive craniofacial classification system, J Craniomaxillofac Surg (2009), doi:10.1016/j.jcms.2009.01.008

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6 Journal of Cranio-Maxillofacial Surgery

due to different speed limits and different legal blood alcohol limits.
Another interesting point is that in Uppsala, patients
with an ISS between 40 and 60, who would be treated
operatively in Basel, received conservative therapy.
One reason for this may be the more aggressive treatment
of skull base fractures in Basel. CSF rhinorrhoea especially with fractures of frontal sinuses was an indication
for surgical approach in Basel.
Treatment of CSF rhinorrhoea in skull base fractures is
still a controversial topic in the literature. Most CSF leaks
close spontaneously, especially in cases of temporal bone
fractures rather than in anterior fossa fractures (Yilmazlar
et al., 2006). On the other hand, subdural empyema or
brain abscesses developing months or years after trauma
are consequences of untreated CSF leaks. The literature
described 10e50% trauma induced meningitis in patients with CSF fistulas (Yilmazlar et al., 2006). Rocchi
et al. (Rocchi et al., 2005) also identified in a series of
36 patients also a relatively high risk of meningitis associated with dural fistulas, even in those patients who were
treated conservatively. The treatment of persisting fistulae is undisputed because of subsequently high infection
rate. Some neurosurgeons therefore stipulate that all CSF
fistulae should be treated operatively as soon as possible
(Cairns, 1937; Loew et al., 1984). Yilmazlar et al. (Yilmazlar et al., 2006) correlated treatment options with
the severity of neurological deficits and the presence of
intracranial lesions at admission. He offers a treatment algorithm in which patients with associated cranial lesions
were operated upon and those without got CSF drainage.
In this study, the evaluation of correlation of the CMFISS patients with rhinorrhoea revealed a significant association (univariable analysis) with the score system.
However, when adjusting for age, gender and treatment,
the association was no longer significant. This may be
explained by the fact that isolated or less extensive or
non-displaced fractures of the frontal skull base with rhinorrhoea may have a low score and depending of the
therapeutic approach or other factors be operated upon.
Pretto Flores and colleagues (Pretto Flores et al.,
2000) showed that selected clinical signs such as Battles
sign and unilateral blepharohaematoma had higher predictive values for skull base fractures and intracranial lesions even in patients with Glasgow Coma Scale (GCS)
between 13 and 15 which indicates the need for further
radiological investigations. The association of raccoon
eyes with skull base fractures has been described by
several authors too (Goh et al., 1997; Kral et al., 1997;
Herbella et al., 2001).
In our study patients with or without periorbital haematoma showed no difference in severity score. This
means that the presence of such a haematoma does not
allow a definitive conclusion about the severity and extent. Clinical signs of skull base fractures such as periorbital haematoma, rhinorrhoea or pneumencephalus are
not strong enough to justify a decision to perform surgical repair. However, according to the results, a CMF-ISS
score of over 60 points was clearly correlated with an operative approach in both centres.
The exact mechanisms which lead to combined facial
and cranial fractures are still unclear but high energy

impact is regularly required for this type of fracture.


The indication for surgical management and optimal timing are controversial, and none of the existing classification systems could solve this problem, including the
combination of clinical and radiographic methods.
CONCLUSION
A comprehensive craniofacial classification system based
on hierarchal organization of the skull base including
midfacial injuries allows a comprehensive description
and documentation of injuries within the whole craniofacial region. Furthermore, the fracture formula using this
system and Buitrago-CAFFAC software allows the calculation of a severity score, the CMF-ISS. Patients
with or without periorbital haematoma do not differ significantly in the severity score. The severity of the CMFISS score correlates significantly with pneumencephalus,
rhinorrhoea and treatment approach (two sample T-test
P \ 0.01). This system is clinical useful for operative decisions and interventions. A prospective study in two
clinical centres is planned to evaluate these correlations
further, especially with regard to early versus delayed
treatment, quality of life outcomes and health economics.
CONFLICT OF INTEREST
The authors have reported no conflicts of interest.
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a comprehensive craniofacial classification system, J Craniomaxillofac Surg (2009), doi:10.1016/j.jcms.2009.01.008

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CHLI
Dr. Heidi BA
Department of Neurosurgery, University Hospital Basel, Spitalstrasse
21, CH-4031 Basel, Switzerland
Tel.: +41 61 265 7522; Fax: +41 61 265 7138
E-mail: hbaechli@uhbs.ch
Paper received 27 March 2008
Accepted 22 January 2009

Please cite this article in press as: Bachli H, et al. Skull base and maxillofacial fractures: Two centre study with correlation of clinical findings with
a comprehensive craniofacial classification system, J Craniomaxillofac Surg (2009), doi:10.1016/j.jcms.2009.01.008