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.