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Cervical injury related to mandibular fractures.

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 CRANIO®
The Journal of Craniomandibular & Sleep Practice

ISSN: 0886-9634 (Print) 2151-0903 (Online) Journal homepage: http://www.tandfonline.com/loi/ycra20

Cervical injury related to mandibular fractures. A

retrospective study of 315 cases

Tommaso Cutilli, Secondo Scarsella, Desiderio Di Fabio, Antonio Oliva,

Maria Adelaide Continenza, Giacomo Sollecchia, Stefano Necozione & Sara
Bernardi

To cite this article: Tommaso Cutilli, Secondo Scarsella, Desiderio Di Fabio, Antonio Oliva,
Maria Adelaide Continenza, Giacomo Sollecchia, Stefano Necozione & Sara Bernardi (2017):
Cervical injury related to mandibular fractures. A retrospective study of 315 cases, CRANIO®, DOI:
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 CRANIO®: The Journal of Craniomandibular & Sleep Practice, 2017
https://doi.org/10.1080/08869634.2017.1398921

MAXILLOFACIAL SURGERY

Cervical injury related to mandibular fractures. A retrospective study of 315 cases

Tommaso Cutilli MDa  , Secondo Scarsella MDa, Desiderio Di Fabio MDa, Antonio Oliva MDa,
Maria Adelaide Continenza MDb  , Giacomo Sollecchia BSca, Stefano Necozione MDb  and
Sara Bernardi PhD, DDSb 
a
Department of Life, Health & Environmental Sciences – Maxillofacial Surgery Operative Unit, “San Salvatore” City Hospital, L’Aquila, Italy;
b
Department of Life, Health & Environmental Sciences, University of L’Aquila, L’Aquila, Italy

ABSTRACT KEYWORDS
Objective: To define the association between mandibular fractures and alterations of the cranio- Mandibular fractures;
atlo-axial joint (CAAJ). atlanto-axial joint
Methods: 315 cases of displaced mandibular fractures were retrospectively evaluated by CT scan subluxation; cervical sprain
and cervical X-ray for associated alterations of the CAAJ. Statistical analysis employed the chi-square traumatology; computer
tomography; rotation
and Cohen’s kappa coefficient.
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Results: Single fractures amounted to 69.84% and multiple fractures to 30.16% of total fractures.
CT scans showed a rotation of the atlas on the same side of single fractures and subluxation of the
CAAJ. Vertical derangement of the joint was observed in 79.65% of single fractures and in 20.35%
of multiple fractures. Approximately16.19% of all displaced mandibular fractures showed cervical
disorders at long-term follow-up.
Discussion:  The outcomes of this study revealed an association between traumatic mandibular
fractures and CAAJ, accompanied by clinical disorders. These conditions require clinical attention
due to their effects on long-term craniocervical functionality and future forensic issues.

Introduction Materials and methods

Mandibular fractures result in an acute unilateral or
bilateral interruption of the anatomical integrity of the
osseous structure. In displaced fractures, the dislocation
of bone fragments is due to the action of the mandibular
masticatory muscles [1–5]. Often, these patients present
loss of lordosis of the cervical spine. Indeed, it is likely in
these cases for the musculoskeletal displacement accom-
panying mandibular fractures to also affect cranio-axial
morphology and expose patients to future clinical cervical
disorders.
Due to an increase in cases of mandibular fractures
[6–8] and the clinical and forensic importance of their
traumatic sequelae [9], the possible effects on the cra-
nio-atlo-axial joint (CAAJ) in subjects with mandibular
fractures are a broad topic of investigation. Therefore, after
preliminary studies on the association between condylar
fractures of the mandible and the modification of cra-
nio-cervical structures [10,11], this second study aims
to assess the conditions of the CAAJ structures in other
mandibular fractures.
Patients
The authors conducted a longitudinal, retrospective study
of a cohort of 315 non-consecutive cases of displaced
mandibular fractures: 193 males (61%) and 122 females
(39%), 18–36 years of age, treated from January 1, 2006
to December 31, 2014. Cases were analyzed by means of
existing data, such as medical records, imaging, and a
database.
The inclusion criteria were:
(1) trauma resulting in mandibular fractures;
(2) CT scans and cervical X-rays taken at initial ER
visit;
(3) adequate records for evaluation.
Exclusion criteria included the following:
(1) severe polytrauma (presence of brain, thoracic
and/or abdominal injury);
(2) direct cervical trauma (as determined by neuro-
surgical evaluation);

CONTACT  Sara Bernardi  sara.bernardi@univaq.it

© 2017 Informa UK Limited, trading as Taylor & Francis Group
 2   T. CUTILLI ET AL.

(3) presence of pre-existing functional and sympto- atlanto-cervical junction in addition to the routine cer-
matic cervical pathologies; vical X-ray, absence of pre-existing cervical pathologies,
(4) presence of condylar fractures (since condylar and absence of previous facial or cervical trauma. This
fractures were already considered in previous control group was considered to demonstrate that the
studies performed by the authors [10,11]). cervical distortion observed in mandibular fractures has
a different mechanism to that of whiplash trauma. Indeed,
At admission, patients were studied through cranial
the main difference between whiplash injury and mandib-
and maxillofacial computed tomography (CT), and cer-
ular fractures consists of the different kinetic plane of the
vical X-ray with complete visualization of the C7 and T1
action of the injury; whiplash injury occurs only in the
vertebrae (C7-T1 transition). A retrospective study was
sagittal plane, whereas mandibular fractures can occur in
performed by analysis of the radiological exams, in par-
any kinetic plane.
ticular, CT and three-dimensional CT.
Swelling, hematomas and ecchymosis of the facial
and oral soft tissue were present at admission, as well Methods
as difficulty in opening the mouth, together with pain.
All patients underwent routine surgical treatment of
Varying degrees of post-traumatic malocclusion were also
fractures with internal fixation by titanium miniplates.
described, as well as dental injuries, such as luxation, frac-
Intermaxillary fixation was also applied for four weeks.
tures, and loss of teeth.
Clinical, radiological, and functionality assessments were
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A control group was studied by a retrospective investi-

performed for the patients treated from January 1 2006
gation of records of 20 patients, 10 males and 10 females,
to December 31 2014 adhering to the study who were
aged 19–24 years (mean: 21.6), suffering solely from acute
to come back for the follow up. The CT-scans were per-
cervical sprain (whiplash), for which they had been admit-
formed by a neuro-radiologist. The ethical board of the
ted to the emergency room.
University of L’Aquila approved this observational study.
These control patients were selected according to the
Patients gave their informed consent to be included in
following criteria: availability of CT examination of the
the study.
Table 1. Resuming table of the distribution of the single fractures.
Fracture Right Left Total Statistical analysis
Mandibular angle 73 51 124
Parasymphysis 48 39 87
Contingency tables and chi-square test for the trend were
Ramus 5 4 9 used to evaluate the association between the post-trau-
Total 126 94 220 matic degree of atlas displacement and cervical disorders

Figure 1. Bilateral displaced mandibular fractures, right parasymphisis and left angle (full white arrows) as they appear on axial CT scan.
Right rotational dislocation of mandibular fragments (empty black arrow) corresponds to similar rotation of the cranium-atlo-axial joint
(CAAJ), as well shown in the beside image. The rotation of the atlas in the horizontal plane appears to be of Degree III.
 CRANIO®: THE JOURNAL OF CRANIOMANDIBULAR & SLEEP PRACTICE   3
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Figure 2. The three typologies of cranium-atlo-axial joint (CAAJ) displacement. (a) Degree I, (b) Degree II, (c) Degree III.

Table 2.  Contingency table associating the type of dislocation vertical derangement of the CAAJ and single and multi-
and the degree of CAAJ displacement with single and multiple ple mandibular fractures; and (c) the association between
fractures. the degree of atlas rotation and the type of fracture. A p
Multiple n value below 0.05 was considered to indicate a statistically
Single n (%) (%) Chi2 test p significant result. Statistical analysis was performed using
Side of higher Right 126 (57.27%) 62 (65.26%) p = 0.161 SAS/STAT Software version 9.2.
dislocation Left 94 (42.72%) 33 (34.74%)
Axial Disloca- Right 126 (57.27%) 62 (65.26%) p = 0.161
tion Left 94 (42.72%) 33 (34.74%)
Vertical de- Right 130 (59.09 %) 72 (75.79%) p = 0.0046 Results
rangement Left 90 (40.91%) 23 (24.21%)
Sub-scoliotic Absence 193 (87.73%) 91 (95.79%) p = 0.0275 The most common cause of trauma (132 cases, 41.90%)
alteration Presence 27 (12.27%) 4 (4.21%) was identified as road traffic accidents (RTA), followed by
Degree I 130 (100%) 0 (0%) p < 0.0001
II 0 (0%) 72 (100%) work injuries (78 cases, 24.76%), accidental falls (37 cases,
III 90 (79.65%) 23 (20.35%) 11.74%), assaults (27 cases, 8.57%), falls caused by illness
Note: CAAJ: Cranio-atlo-axial joint. (28 cases, 8.88%), and sports injuries (13 cases, 4.12%).

at follow-up. Cohen’s kappa coefficient was used to eval-
uate the correlation between the rotation of the atlas and
the subluxation of the CAAJ with mandibular fractures.
In particular, the chi-square test evaluated: (a) the associ-
ation between the site of single mandibular fracture and
entity of the CAAJ dislocation (degree of rotation of the
atlas on the axial plane); (b) the association between the
Mandibular fractures
In total, 220 single mandibular fractures were observed
(69.84% of all fractures), distributed as follows: 124 at the
mandibular angle (54.36% of single fractures), 73 on the
right side (58.87%) and 51 on the left side (41.12%); 87
at the parasymphysis (39.54% of single fractures), 48 on
the right side (55.17%) and 39 on the left side (44.82%);
 4   T. CUTILLI ET AL.
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Figure 3.  (a) Bilateral displaced mandibular fractures as they appear on three-dimensional CT reconstruction. (b) From below, it is
possible to observe the right rotation of the cranium-atlo-axial joint (CAAJ) (empty black arrow).
Figure 4.  Very displaced fracture of the right parasymphysis
region. (a) Clinical aspect of the vertical displacement of the distal
fragment. (b) Coronal CT scan shows the vertical homolateral
corresponding alteration of the atlanto-axial articular space
(empty white circle) with asymmetry of the two articulations; the
atlanto-axial subluxation as shown by the loss of the balanced
position of the axis with the increase in the right articular space;
reduction of the left articular space (different lengths of the white
lines).
9 at the mandibular ramus (4.09% of single fractures), 5
on the right side (55.5%) and 4 on the left side (44.4%),
as presented in Table 1.
In all the single mandibular fracture cases, CT showed
a rotation of the atlas towards the side where the frac-
tures occurred (Figure 1) and the subluxation of the CAAJ
(kappa coefficient = 1.000).
A total of 95 multiple fractures were observed (30.15%
of all fractures), of which 55 (57.89%) were multiple bilat-
eral fractures and revealed a greater displacement on the
right side in 37 cases (67.27%) and on the left side in 18
cases (36.72%).
As stated in the Materials and methods section, the
condylar fractures were not included in this study.
Cranio-atlo-axial joint displacement
Concerning the degree of rotation of the atlas in the
horizontal plane, the cranio-atlo-axial joint displace-
ment was classified into three groups: I (from 0° to 3° of
the atlas rotation), II (from 4° to 6° of the atlas rotation),
and III (from 7° to 9° of the atlas rotation) (Figure 2).
Group I, II and III displacements were detected in 130
(41.27%), 72 (22.85%), and 113 (35.88%) cases, respec-
tively (Table 2).
 CRANIO®: THE JOURNAL OF CRANIOMANDIBULAR & SLEEP PRACTICE   5
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Figure 5. Bilateral displaced mandibular fractures. (a) Clinical view; (b) Three-dimensional CT shows the displacement of the osseous
fragments both in the right-angle fracture and in the left parasymphysis region (black arrows). The empty black/white arrow indicates
the left rotation of the atlas.

Single fractures comprised 87.10% of group III CAAJ

displacements, and multiple fractures made up 12.90%
(chi-square test p = 0.0275). In these patients, a contex-
tual vertical derangement of the CAAJ was also observed.
Thirty-one cases (27.43% of Degree III) also showed
sub-scoliotic alteration of the vertebral column.
Single mandibular body fractures showed a signifi-
cantly greater CAAJ dislocation than fractures of the angle
and ramus of the mandible (chi-square test, p = 0.0001. In
bilateral multiple fractures, CAAJ displacement appeared
on the side where the muscular imbalance was higher
(Figure 3). These fractures showed greater displacement.
Vertical derangement of the CAAJ, with asymmetrical
modification of the articular spaces was observed in
79.65% of single fractures and in 20.35% of multiple frac-
tures (chi-square test, p = 0.0046) (Figure 4).
Both the patients at shorter (28-month) follow-up
and the patients presented at longer (10-year) follow-up
periods showed good mandibular musculoskeletal and
functional cranio-cervical restoration (Figures 5 and 6).
Cervical clinical disorders were detected in 51 (16.19%
of the total) cases. The distribution of clinical disorders
was as follows: 27 cases (23.89%) among the Degree III
group, 16 cases (22.22%) among the Degree II group, and
8 cases (6.15%) among the Degree I group (chi-square
Mantel-Haenszel test p = 0.0002). (Table 3).
Control group
In all cases, a loss of cervical column lordosis was
observed, while alterations in the horizontal and vertical
planes, such as rotation of the atlas and atlanto-axial or
CAAJ joint displacement, were not present. The specific
treatments used for the control group recovering was not
considered.
 6   T. CUTILLI ET AL.
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Figure 6. The same case as in Figure 4. (a) OPT X-ray at long-term follow-up shows the presence of a mini-plate in the right mandibular
angle and two mini-plates in the left parasymphisis region with a good restoration of the mandibular anatomy. (b) The occlusal result. (c)
Lateral and anterior-posterior X-ray show good restoration of the cervical lordosis and cervical posture.
Discussion
Clinical correlations between facial structures, the cer-
vical spine, and craniofacial pain have been outlined in
the literature reported in Medline, PubMed, Embase, Web
of Sciences, Cochrane Library, Cinahl and HealthStar
databases [8,12]. Previous studies pointed out that neu-
ro-musculoskeletal cranio-maxillo-mandibulo-hyoid
structures and occipital-atlo-axial structures constitute
a unitary and symmetrical complex where the strong
masticatory muscles represent an important anatomical
and functional connection between the mandibular and
cranio-cervical structures [13–15]. This complex shows
three anatomo-functional areas, which can be called the
hyoid-sternal-cingular area (anterior), the stomatognathic
area (middle), and the axial area (posterior). These areas
are in functional equilibrium, and any alteration in any
one of them is reflected in the others. Mandibular frac-
tures occur in the stomatognathic area [16].
Due to bone fragment dislocation caused by the mas-
ticatory muscular groups and unbalanced loads borne
by the myofunctional connections between mandibular
and cranio-cervical structures, it is extremely important
to consider a proper rehabilitation treatment that includes
the cervical spine. The treatment of mandibular fractures
Table 3. Resuming table of the cases presenting the cervical dis-
order at the moment of the follow-up.
Chi-square
Cervical disorders detected at follow-up Mantel-Haenszel Test
Dislocation I 8 cases (6.15%)
0–3°
Dislocation II 16 cases (22.22%) p = 0.0002
4–6°
Dislocation III 27 cases (23.89%)
7–9°
(single or multiple) is well discussed in the scientific lit-
erature. Indications and techniques depend not only on
the characteristics of the fracture and its localization but
also on the surgeon’s experience and preference [17–25].
This study shows that mandibular fractures disturb the
balance in the middle area with implications not only on
the anterior area but also, and importantly, in the posterior
axial/postural area.
In order to homogenize the results analysis, only
subjects without previous cervical pathologies were
considered in this study. The atlas rotation and the
three-dimensional derangement of the occipital-atlo-axial
joint represent the main and most significant alterations in
the patients studied. Loss of physiological cervical lordosis
was also observed in the patient group.
 CRANIO®: THE JOURNAL OF CRANIOMANDIBULAR & SLEEP PRACTICE   7
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Figure 7. Mechanism of whiplash injury. Sudden backward acceleration of the skull causes an extreme extension of the cervical spine.
Head recoils forward and suddenly stops on impact with another object. First, head hyperextension (1 in black circle) is observed, and
after, cervical hyper-flexion (2 in black circle). The kinetic vector is placed on the longitudinal median plane.

In mandibular fractures, sprain of the cervical spine Conclusion

seems to be related to the atlanto-axial subluxation by a
Mandibular fractures determine an alteration of the neu-
different mechanism to whiplash trauma (Figure 7), as it
ro-osteo-muscular balance, with the loss of symmetry
was observed in the control group that did not show CAAJ
and an association with cranium-atlo-axial subluxation.
joint displacement. Indeed, in the event of whiplash, the
The results reported in the present study proved that
kinetic vector is placed on the longitudinal plane, whereas,
articular alteration causes sprain of the cervical spine.
in mandibular fractures, the kinetic vector is placed on
On the basis of the data reported herein, the biome-
different and multiple planes. In the considered cases, not
chanics of mandibular fractures seem to support this
including condylar fractures examined in previous studies
physio-pathological hypothesis and to highlight the
performed by the authors [10,11], the most frequent sites
atlanto-axial subluxation occurring in such traumas.
of single fractures were the angle (56.36% of the cases
Indeed, the cervical sprain is a condition requiring a
and 39.54% of the cases), as in other case series [1–3]. In
great deal of clinical attention due to the subsequent
these fractures, the dynamics of the crash cannot cause
effects on cranium-cervical functionality and to foren-
the sway of the head, as in whiplash [26,27]. Indeed, aside
sic issues in cases of trauma caused by road or work
from what is reported in literature in cases of facial trauma
accidents and personal injury [29].
[28], the observed patients presented the cervical distor-
tion with the loss of physiological lordosis in the sagittal
plane without a whiplash mechanism. At the same time, Disclosure statement
a constant derangement of the cranium-cervical joint and
the atlanto-axial subluxation were present. No potential conflict of interest was reported by the authors.

Limitations of this study ORCID

(1) Inability to clearly determine if preinjury
malalignment of the cranio-atlo-axial joint was
present or not.
(2) Study does not include all mandibular fractures,
as cases with condylar fractures were excluded
from the study.
Tommaso Cutilli   http://orcid.org/0000-0002-0478-2113
Maria Adelaide Continenza    http://orcid.org/0000-0001-
8497-5734
Stefano Necozione   http://orcid.org/0000-0003-2501-1665
Sara Bernardi   http://orcid.org/0000-0001-6130-8533
 8   T. CUTILLI ET AL.
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