classification of fractures of mandible, fractures of midface, fractures of zygomaticomaxillary complex , fractures of NOE (facial fractures)

1. CLASSIFICATION OF FACIAL FRACTURES

2. INDEX
• MANDIBULAR FRACTURE CLASSIFICATION
• MIDFACE FRACTURE CLASSIFICATION
• ZMC FRACTURE CLASSIFICATION
• NOE FRACTURE CLASSIFICATION

3. CLASSIFICATION OF MANDIBULAR
FRACTURES

4. KRUGER’S GENERAL CLASSIFICATION
• SIMPLE / CLOSED
• COMPOUND / OPEN
• COMMUNITED
• COMPLICATED / COMPLEX
• IMPACTED
• GREENSTICK
• PATHOLOGICAL

5. KRUGER’S GENERAL CLASSIFICATION
 SIMPLE- no communication with exterior or interior
 COMPOUND- communication through skin externally
through mucosa or PDL

6. KRUGER’S GENERAL CLASSIFICATION
COMMUNITED - splintering
crushed multiple pieces
violent forces / high velocity - fire arm / missiles
COMPLICATED / COMPLEX- damage to vital structures
complicates treatment

7. 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

8. KRUGER’S GENERAL CLASSIFICATION
PATHOLOGICAL
GENERALISED SKELETAL DISEASE LOCALISED SKELETAL DISEASE
Osteoporosis, pagets, osteomalacia osteomyelitis, cysts, ORN

9. 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

10. 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 #

11. RELATION OF FRACTURE TO THE SITE OF INJURY
DIRECT FRACTURES INDIRECT FRACTURES
(COUNTERCOUP)

12. 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.

13. 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

14. Direction & favorability of treatment
Horizontally Favourable
Fracture line runs
downward & forward so
upward displacement
avoided
Horizontally
Unfavourable
Fracture line runs Down
Wards and Back Wards
so
upward Displacement
Unrestricted

15. 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

16. DEPENDING UPON THE MECHANISM
I. AVULSION FRACTURE
II. BENDING FRACTURE
III. BURST FRACTURE
IV. COUNTERCOUP FRACTURE
V. TORSIONAL FRACTURE

17. DEPENDING ON NUMBER OF
FRAGMENTS
 SINGLE
 MULTIPLE
 COMMINUTED

18. ACCORDING TO SHAPE OF FRACTURE
 TRANSVERSE
 OBLIQUE
 BUTTERFLY
 OBLIQUE SURFACED

19. 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

20. AO Classification
F NO. OF FRACTURE OR FRAGMENTS
L LOCATION OF THE FRACTURE
O STATUS OF OCCLUSION
S SOFT TISSUE INVOLVEMENT
A ASSOCIATED FRACTURES

21. F: NO. OF FRACTURES
F0 Incomplete fractures
F1 Single fractures
F2 Multiple fractures
F3 Comminuted fractures
F4 Fracture with bone defect

22. L: Location of fracture
L1 Pre-canine
L2 Canine
L3 Post-canine
L4 Angle
L5 Supra-angular
L6 Condyle
L7 Coronoid
L8 Alveolar process

23. O: Status of occlusion
O 0 No malocclusion
O 1 Malocclusion
O 2 Edentulous mandible

24. 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

25. 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

26. LEFORT CLASSIFICATION
FRACTURES OF THE MIDFACE

27.  GIVEN BY THE FRENCH SURGEON RENE LE-FORT IN 1901
AS
LEFORT I , II & III FRACTURES

28.  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 .

29. 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

30. LEFORT l

31. 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

32. LEFORT ll

33. ALSO CALLED :
• TRANSVERSE FRACTURE
• SUPRAZYGOMATIC #
• HIGH LEVEL #
•CRANIO-FACIAL DYSJUNCTION
LEFORT III FRACTURES

34. LEFORT lll

36. 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.

37. 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)

38. RELATIONSHIP OF # LINE TO ZYGOMATIC BONE
1. BELOW ZYGOMATIC
subzygomatic fracture
1. ABOVE ZYGOMATIC
2. Suprazygomatic fracture

39. ERICH CLASSIFICATION - 1942
 HORIZONTAL
 PYRAMIDAL
 TRANSVERS
E

40. 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 #

42. FRACTURE ZMC
CLASSIFICATION

43. 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.

44. 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.

45.  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)

46. Rowe & Killey (1968)
 Type VI : Displacement of orbitoantral partition
 - Inferiorly
 - Superiorly
 Type VII : Displacement of orbital rim segments
 Type VIII : Complex comminuted fractures.

47. Type I : no significant displacement

48. Type II . Fracture of the zygomatic arch

49. Outward Displacement
Inward Displacement
Type III. Rotation around vertical axis

50. Type IV. Rotation around longitudinal axis

51. Type V. Displacement of the complex en bloc

52. Type VI. Displacement of orbitoantral partition

53. Type VII. Displacement of orbital rim segments

54. Type VIII. Complex comminuted fractures

55. 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.

56.  MARKUS ZING (1992)
 Type A : Incomplete zygomatic fracture.
 Type B : Complete monofragment zygomatic fracture
(tetradpod fracture).
 Type C : Multifragment zygomatic fracture.

57. 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
.

58. ROWE’S & WILLIAM’S CLASSIFICATION :
 c. Dislocations enblock
 Inferior
 Medially
 Posterio-laterally.
 d. Comminuted fracture

59. 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

60.  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

61. 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

62. FRONTO-NASOETHMOIDAL REGION
• NOE complex fractures involve the medial vertical (nasomaxillary)
buttresses of the facial skeleton

63. • 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:

64. 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.

65. 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

66. 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.

67. Bilateral type II fracture with nasal bone
involvement
• bone grafting of the nasal dorsum may be necessary

68. 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.

69. Type III + Involvement of the nasal bone

70. Bilateral type III fracture with nasal bone
involvement

71. 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.