classification of mandible, midface, zmc and noe fractures

CLASSIFICATION OF FACIAL FRACTURES

INDEX

• MANDIBULAR FRACTURE CLASSIFICATION

• MIDFACE FRACTURE CLASSIFICATION

• ZMC FRACTURE CLASSIFICATION

• NOE FRACTURE CLASSIFICATION

CLASSIFICATION OF MANDIBULAR FRACTURES

KRUGER’S GENERAL CLASSIFICATION

• SIMPLE / CLOSED

• COMPOUND / OPEN

• COMMUNITED

• COMPLICATED / COMPLEX

• IMPACTED

• GREENSTICK

• PATHOLOGICAL

KRUGER’S GENERAL CLASSIFICATION

SIMPLE- no communication with exterior or interior

COMPOUND- communication through skin externally

through mucosa or PDL

KRUGER’S GENERAL CLASSIFICATION

COMMUNITED - splintering

crushed multiple pieces

violent forces / high velocity - fire arm / missiles

COMPLICATED / COMPLEX- damage to vital structures

complicates treatment

KRUGER’S GENERAL CLASSIFICATION

• IMPACTED – rare

one fragment driven firmly into the other

clinical movement not appreciable

• GREENSTICK -

one cortex broken and other bent

incomplete fracture- common children- resilience

KRUGER’S GENERAL CLASSIFICATION

PATHOLOGICAL

GENERALISED SKELETAL DISEASE LOCALISED SKELETAL DISEASE

Osteoporosis, pagets, osteomalacia osteomyelitis, cysts, ORN

ANATOMICAL CLASSIFICATION

• Rowe & Killey Classification

• A Fractures not involving basal bone

• Eg- dentoalveolar

• Fractures involving the basal bone

i. Single unilateral

ii. Double unilateral

iii. Bilateral

iv. multiple

DINGMAN & NATWIG CLASSIFICATION

A. SYMPHYSIS #

B. CANINE REGION #

C. BODY OF MANDIBLE #

D. ANGLE REGION #

E. RAMUS REGION #

F. CORONOID REGION #

G. CONDYLAR #

H. DENTOALVEOLAR #

RELATION OF FRACTURE TO THE SITE OF INJURY

DIRECT FRACTURES INDIRECT FRACTURES

(COUNTERCOUP)

COMPLETENESS

• Complete versus incomplete

1. Complete fractures

Adults - usually complete - interrupt entirely the continuity of the arch.

Usually mobile and have various degree of displacement.

COMPLETENESS

• INCOMPLETE FRACTURES

• Do not extend through both the buccal and the lingual cortices as well as the alveolar and basal borders.

• Occasionally in adults , more often in children.

• nondisplaced and nonmobile.

• Might not require surgical treatment

Direction & favorability of treatment

Horizontally Favourable

Fracture line runs

downward & forward so

upward displacement

avoided

HorizontallyUnfavourable

Fracture line runs Down

Wards and Back Wardsso

upward Displacement

Unrestricted

VERTICALLY FAVORABLE VERTICALLY UNFAVORABLE

FRACTURE LINE RUNS FROM THE

OUTER BUCCAL PLATE OBLIQUELY

BACKWARDS AND LINGUALLY , MEDIAL

MOVEMENT RESTRICTED

FRACTURE LINE RUNS FROM THE

INNER LINGUAL PLATE OBLIQUELY

BACKWARDS AND BUCCALLY , MEDIAL

MOVEMENT UNRESTRICTED

DEPENDING UPON THE MECHANISM

I. AVULSION FRACTURE

II. BENDING FRACTURE

III. BURST FRACTURE

IV. COUNTERCOUP FRACTURE

V. TORSIONAL FRACTURE

DEPENDING ON NUMBER OF

FRAGMENTS

SINGLE

MULTIPLE

COMMINUTED

ACCORDING TO SHAPE OF FRACTURE

TRANSVERSE

OBLIQUE

BUTTERFLY

OBLIQUE SURFACED

Presence or absence of teeth

Kazanjian V.H. & Converse J.M.

CLASS 1 TEETH ON BOTH

SIDES OF FRACTURE LINE

MONOMAXILLARY

CLASS II TEETH ONLY ON ONE SIDE

OF THE FRACTURE LINE

INTERMAXILLARY

FIXATION

CLASS III EDENTULOUS PATIENT OPEN REDUCTION

/ PROSTHESIS

AO Classification

F NO. OF FRACTURE OR FRAGMENTS

L LOCATION OF THE FRACTURE

O STATUS OF OCCLUSION

S SOFT TISSUE INVOLVEMENT

A ASSOCIATED FRACTURES

F: NO. OF FRACTURES

F0 Incomplete fractures

F1 Single fractures

F2 Multiple fractures

F3 Comminuted fractures

F4 Fracture with bone defect

L: Location of fracture

L1 Pre-canine

L2 Canine

L3 Post-canine

L4 Angle

L5 Supra-angular

L6 Condyle

L7 Coronoid

L8 Alveolar process

O: Status of occlusion

O 0 No malocclusion

O 1 Malocclusion

O 2 Edentulous mandible

A: Associated fracture

A 0 None

A 1 Dentoalveolar fracture

A 2 Nasal bone fracture

A 3 Zygoma fracture

A 4 Lefort I

A 5 Lefort II

A 6 Lefort III

According to WHO/1997, 2003//3/ the

international classification

S 02.6 - Fractura mandibulae

S 02.60 - Fractura processus alveolaris

S 02.61 - Fractura corpus mandibulae

S 06.62 - Fractura processus articularis/condylaris

S 06.63 - Fractura processus muscularis /coronoideus

S 02.64 - Fractura ramus mandibulae

S 02.05 - Fractura symphysis

S 02.66 - Fractura angulus mandibulae

S 02.67 - Fracturae mandibulae multiplex

S 02.68 - Unspecified mandibular fractures

LEFORT CLASSIFICATION

FRACTURES OF THE MIDFACE

GIVEN BY THE FRENCH SURGEON RENE LE-FORT IN 1901

AS

LEFORT I , II & III FRACTURES

Provides uniform method to describe the level of major fracture lines .

Allows references regarding the probable points of stability for surgical treatment .

Does not incorporate vertical or segmental fractures, comminution or bone loss .

ALSO CALLED :

• GUERINS FRACTURE

• FLOATING FRACTURE

• PTERYGOMAXILLARY

DYSJUNCTION

• HORIZONTAL FRACTURE

THERE IS COMPLETE SEPERATION

OF THE DENTOALVEOLAR PART OF

MAXILLA

AND THE FRAGMENT IS HELD ONLY

BY SOFT TISSUES.

LEFORT I FRACTURES

LEFORT l

ALSO CALLED:

• PYRAMIDAL #

•SUBZYGOMATIC #

LEFORT II FRACTURE HAS A PYRAMIDAL

APPEARANCE ON THE PA SKULL .

MAXILLA IS SEPERATED FROM THE

SKULL BASE .

LEFORT II FRACTURES

LEFORT ll

ALSO CALLED :

• TRANSVERSE FRACTURE

• SUPRAZYGOMATIC #

• HIGH LEVEL #

•CRANIO-FACIAL DYSJUNCTION

LEFORT III FRACTURES

LEFORT lll

ROWE AND WILLIAMS CLASSIFICATION -1985

A. FRACTURES NOT INVOLVING OCCLUSION :

I. Central Region :

a.Fractures of the nasal bones/nasal septum.

- Lateral nasal injuries

- Anterior nasal injuries

b. Fractures of frontal process of maxilla

c. Nasoethmoidal fractures

d. Fractures of type (a), (b) and (c) extending into the frontal

bone (frontoorbitonasal dislocation).

II. Lateral region:

Fractures involving the zygomatic bone, arch and maxilla excluding dentoalveolar component.

ROWE AND WILLIAMS CLASSIFICATION -1985

B. FRACTURES INVOLVING OCCLUSION :

Dentoalveolar

Subzygomatic

- Lefort I (low level or Guerin)

- Lefort II (Pyramidal Fracture)

Suprazygomatic

- Lefort III (High level)

RELATIONSHIP OF # LINE TO ZYGOMATIC BONE

1. BELOW ZYGOMATIC

subzygomatic fracture

1. ABOVE ZYGOMATIC

2. Suprazygomatic fracture

ERICH CLASSIFICATION - 1942

HORIZONTAL

PYRAMIDAL

TRANSVERS

E

Modified LeFort Fracture

Classification - 1993

Le-Fort Level Description

I Low maxillary fracture

la Low maxillary fracture with multiple segments

II Pyramidal fracture

IIa Pyramidal fracture and nasal fracture

IIb Pyramidal and NOE fracture

III Craniofacial dysjunction

IIIa Craniofacial dysjunction and nasal fracture

IIIb Craniofacial dysjunction and NOE

IV II or III fracture and cranial base #

IVa + Supraorbital rim fracture

IVb + Anterior cranial fossa and supraorbial rim #

IVc + Anterior cranial fossa and orbital wall #

FRACTURE ZMC CLASSIFICATION

SCHIELDERUP (1950) :

TYPE 1 : Fractured zygoma hinged on maxillary & frontal attachment.

TYPE 2 : Fractured and hinged on maxillary attachment

TYPE 3 : Fractured and hinged on frontal attachment

TYPE 4 : Fractured and detached enbloc.

TYPE 5 : Comminuted fracture.

KNIGHT AND NORTH’S CLASSIFICATION : 1961

Group I : Undisplaced fractures.

Group II : Arch fractures.

Group III : Unrotated body fractures.

Group IV : Medially rotated body fractures.

Group V : Laterally rotated body fractures.

Group VI : Complex fractures.

Rowe & Killey (1968)

Type I : No significant displacement

Type II : Fracture of the zygomatic arch

Type III : Rotation around vertical axis

- Inward displacement of orbital rim

- Outward displacement of orbital rim

Type IV : Rotation around longitudinal axis

- Medial displacement of frontal process

- Lateral displacement of frontal process

Type V : Displacement of the complex en bloc

- Medial

- Inferior

- lateral (Rare)

Rowe & Killey (1968)

Type VI : Displacement of orbitoantral partition

- Inferiorly

- Superiorly

Type VII : Displacement of orbital rim segments

Type VIII : Complex comminuted fractures.

Type I : no significant displacement

Type II . Fracture of the zygomatic arch

Outward Displacement

Inward Displacement

Type III. Rotation around vertical axis

Type IV. Rotation around longitudinal axis

Type V. Displacement of the complex en bloc

Type VI. Displacement of orbitoantral partition

Type VII. Displacement of orbital rim segments

Type VIII. Complex comminuted fractures

MANSON AND COLLEAGUES (1990) :

Based on amount of energy dissipated & findings in C.T. Scan-

a. High energy fractures.

b. Moderate energy fractures.

c. Low energy fractures.

MARKUS ZING (1992)

Type A : Incomplete zygomatic fracture.

Type B : Complete monofragment zygomatic fracture

(tetradpod fracture).

Type C : Multifragment zygomatic fracture.

ROWE’S & WILLIAM’S CLASSIFICATION :

1) Fractures stable after elevation

a. Arch only (medially displaced)

b. Rotation around the vertical axis.

Medially

Laterally

2) Fracture unstable after elevation.

a. Arch only (inferiorly displaced).

b. Rotation around the horizontal axis.

Medially

Laterally

.

ROWE’S & WILLIAM’S CLASSIFICATION :

c. Dislocations enblock

Inferior

Medially

Posterio-laterally.

d. Comminuted fracture

1. Group A : Stable fracture – Showing minimal or no displacement and

requires no intervention.

2. Group B : Unstable fracture – With great displacement and distruption at

the frontozygomatic suture and comminuted fracture. Requires reduction

as well as fixation.

3. Group C : Stable fracture – Other types of zygomatic fractures, which

requires reduction, but no fixation.

4. Fractures of the zygomatic arch alone

• Minimum or no displacement.

• V type in fracture.

• Comminuted fracture.

LARSEN &THOMSEN CLASSIFICATION

MALAR CLASSIFICATION

TYPE 1 : Undisplaced fracture.

TYPE 2 : Arch fracture only.

TYPE 3 : Tripod malar fracture ( FZ intact ).

TYPE 4 : Tripod malar fracture (FZ distracted ).

TYPE 5 : Pure blow-out fracture..

TYPE 6 : Orbital rim fracture.

TYPE 7 : Comminuted and other fractures

SPIESSEL AND SCHROLL’S

CLASSIFICATION :

TYPE 1 : Isolated zygomatic arch fracture

TYPE 2 : Fracture with no significant

displacement

TYPE 3 : Partially displaced medially

TYPE 4 : Totally displaced medially

TYPE 5 : Those with dorsal displacement

TYPE 6 : Those with inferior displacement

TYPE 7 : Comminuted and other fractures

FRONTO-NASOETHMOIDAL REGION

• NOE complex fractures involve the medial vertical (nasomaxillary) buttresses of the facial skeleton

• NOE fractures are most commonly classified according to Markowitz BL, Manson PN, Sargent L, et al (1991)

• Type I• Type II• Type III

• These can be unilateral or bilateral injuries.

• Plast Reconstr Surg. 87(5):843-53:

Type I

• In unilateral Markowitz type I fractures, there is a single large NOE fragment bearing the medial canthal tendon.

• The nasal bone may also be involved and, in cases of comminution, may not provide adequate dorsal support to the nasal bridge.

Unilateral Type II

• In unilateral type II fractures, there is often comminution of the NOE area, but the canthal tendon remains attached to a fragment of bone, allowing the canthus to be stabilized with wires or a small plate on the fractured segment

Unilateral Type II + Involvement of the nasal bone

• The nasal bone may also be involved and, in cases of comminution, may not provide adequate dorsal support to the nasal bridge.

Bilateral type II fracture with nasal bone

involvement

• bone grafting of the nasal dorsum may be necessary

Type III

• In type III fractures, there is often comminution of the NOE area (as in type II fractures) and a detachment of the medial canthal tendon from the bone.

Type III + Involvement of the nasal bone

Bilateral type III fracture with nasal bone

involvement

REFERENCES

FONSECA – VOL 1 3rd EDITION

KILLEYS – 3rd EDITION

ROW AND WILLIAMS – VOL 1

PETER WARD BOOTH – VOL 1

COMPLICATION IN ORAL AND

MAXILLOFACIAL SURGERY-KABBAN

CONTEMPORARY ORAL AND MAXILLOFACIAL

SURGERY,4th EDITION-

LARRY.J.PETERSON,JAMES.R.HUPP,MYRON.