Traditional classification were given 100 years back when RTA , assaults, sports injuries, industrial accidents were minimal. Over the past 100 years RTA (high speed & Low speed) assaults, sports injuries (high contact/ low contact), industrial accidents have increased. Fracture patterns which are not matching the traditional injuries pattern. Can speed up diagnosis and treatment planning Cohorting / clubbing of complication to Specific Fractures. It facilitate communication between peers and assist documentation and research. It also have prognostic value for patients and assist Surgeons in planning their management. It serves as a basis for treatment and for evaluation of the results. Different fractures/ Areas of fracture has different treatment plan / approaches. Undisplaced fracture : conservative/ surgical Displaced Fractures: Surgical/ conservative with traction

1. Classification of
Facial Fractures
PRESENTER: DR KAMINI DADSENA

2. Objective:
 To review facial fracture classifications in view of
emergence of atypical fracture patterns over the last
30 years.

3. Contents
 Mid face fracture
 ZMC fracture
 Nasal bone fracture
 NOE fracture
 Orbital fracture
 Palatine fracture
 Mandibular fracture
 Condylar fracture
 Current AOCMF Classification
 Conclusion

4. Current concepts of facial
fractures
 Traditional classification were given 100 years back
when RTA , assaults, sports injuries, industrial
accidents were minimal.
 Over the past 100 years RTA (high speed & Low
speed) assaults, sports injuries (high contact/ low
contact), industrial accidents have increased.
 Fracture patterns which are not matching the
traditional injuries pattern.

5. Need for classification of
facial fracture
 Can speed up diagnosis and treatment planning
 Cohorting / clubbing of complication to Specific
Fractures.
 It facilitate communication between peers and assist
documentation and research.
 It also have prognostic value for patients and assist
Surgeons in planning their management.
 It serves as a basis for treatment and for evaluation of
the results.
 Different fractures/ Areas of fracture has different
treatment plan / approaches.
 Undisplaced fracture : conservative/ surgical
 Displaced Fractures: Surgical/ conservative with traction
Audige L etal, A Concept for the Validation of Fracture Classifications. J Orthop Trauma 2005;19:404–409

6. MIDFACE FRACTURES

7. CLASSIFICATION
CLASSIFICATION
RENE LEFORT
1901
ROWE & WILLIAMS
1985
MARCIANI 1993
TERRY L DONAT 1998

8. Rene lefort 1901
 Rene Lefort -1901 gave a classification based
on his study of the lines of weakness present
on the human skull
Lefort I (low level/Guerin)
Lefort II (Pyramidal/Sub-zygomatic)
Lefort III (Transverse/supra zygomatic)
Le Fort R. Étude expérimentale sur les fractures de la machoire supérieure. Rev Chir 1901;23:208–227

9. Lefort I(Low Level / Guerin )

10. Lefort I (Low Level / Guerin )
A horizontal fracture above the level of the nasal floor.
Extends backwards from the lateral margin of the anterior nasal aperture
below the zygomatic buttress to cross the lower third of the pterygoid
laminae.
Also passes along the lateral wall of the nose and the lower third of the
nasal septum to join the lateral fracture behind the tuberosity.

11. Lefort II (Pyramidal/Sub-zygomatic)

12. Lefort II (Pyramidal/Sub-zygomatic)
Fracture runs from the middle area of the nasal bones down either side,
crossing the frontal process of the maxillae into the medial wall of each
orbit.
Within each orbit the fracture line crosses the lacrimal bone behind the
lacrimal sac before turning forward to cross the infraorbital margin slightly
medial to or through the infraorbital foramen.
The fracture now extends downwards and backwards across the lateral wall
of the antrum below the zygomatico maxillary suture and divides the
pterygoid laminae about half way up.

13. Lefort III(Transverse/Supra zygomatic)

14. Lefort III(Transverse/Supra zygomatic/High level)
The fracture runs from near the frontonasal suture transversely backwards
Parallel with the base of the skull and involves the full depth of the ethmoid bone, including
the cribriform plate within the orbit the fracture passes along below the optic foramen into
the posterior limit of the inferior orbital fissure.
From the base of the inferior orbital fissure the fracture line extends in two direction;
backwards across the pterygomaxillary fissure to fracture the roots of the pterygoid laminae
and laterally across the lateral wall of the orbit separating the zygomatic bone from the frontal
bone.

15. Rowe & Williams 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 NL,Williams JL.Maxillofacial Injuries. Edinburgh: Churchill Livingstone ; 1985

16.  B. Fractures involving the occlusion :
 1.Central Region
Dentoalveolar
Subzygomatic
- Lefort I (low level or Guerin)
- Lefort II (Pyramidal Fracture)
 2. Combined central and lateral region fractures
a. High level lefort III supra zygomatic fractures – lefort III
b. Lefort III with midline split
c. Lefort III with midline split + roof of orbit and frontal bone
fracture
Rowe & Williams 1985 cont.
Rowe NL,Williams JL.Maxillofacial Injuries. Edinburgh: Churchill Livingstone ; 1985

17. Marciani 1993
 Le Fort I ................... Low maxillary fracture
 Le Fort I a ................. Low maxillary fracture/multiple segments
 Le Fort II................... Pyramidal fracture
 Le Fort II a.................Pyramidal and nasal fracture
 Le Fort II b.................Pyramidal and NOE fracture
Marcini RD Management of Midface Fracture : 50 years later, J Oral Maxillofac Surg 1993, p960-968

18. Marciani 1993
 Le Fort III.................. Craniofacial dysjunction
 Le Fort III a................Craniofacial dysjunction and nasal fracture
 Le Fort III b................Craniofacial dysjunction and NOE fracture
 Le Fort IV ...................Le fort II or III and cranial base fracture
 Le Fort IV a.................Supraorbital rim fracture
 Le Fort IV b............Anterior cranial fossa and supraorbital rim fracture
 Le Fort IV c..................Anterior cranial fossa and orbital wall fracture
Marcini RD Management of Midface Fracture : 50 years later, J Oral Maxillofac Surg 1993, p960-968

19. Terry L. Donat, Carmen Endress, Robert H. Mathog.
Facial Fracture Classification system according to
skeletal support system. Arch Otolaryngol Head Neck
Surg. 1998;124:1306-1314.
Terry L. Donat 1998

20. ZMC FRACTURE PATTERN
o “The malar bone represents a strong bone on
fragile supports and it is for this reason that,
though the body of the bone is rarely broken, the
four processes fontal, maxillary and zygomatic are
frequent sites of fracture.” - H.D. Gillies, T.P.Kilner and
D.Stone, 1927

21. 1.Knight and North Classification(1961)
Group I : Non-displaced
fractures
Group II : Arch fractures Group III : Displced, Unrotated
body fractures
Group IV : Medially
rotated body fractures.
Group V : Laterally
rotated body fractures.
Group VI : Complex
fractures.
Knight JS, North JK: The classification of malar fractures. Br J Plast Surg 13:325, 1961

23. Rowe and Williams Classification
1) Fractures stable after elevation
 Arch only (medially displaced)
 Rotation around the vertical axis.
Medially
Laterally
2) Fractures unstable after
elevation.
 Arch only (inferiorly
displaced).
 Rotation around the horizontal
axis.
Medially
Laterally
 Dislocations en bloc
Inferior
Medially
Postero-laterally.

24. Markus Zing classifiaction (Joms, 778-90, 1992)
Type A : Incomplete zygomatic fracture
Zingg M, Classification and Treatment of Zygomatic Fractures: A Review of 1,025 Cases. J Oral Maxillofac Surg
50:779-790, 1992

25. Type B : Complete mono-fragment
zygomatic fracture
(tetrapod fracture)
Type C : Multi-fragment
Zygomatic fracture.

26. Ozyazran 2007
Isolated zygomatic arch
fractures(Type I)
Dual fracture (Type I-A)
More than 2 fractures
(Type I-B)
V-shaped fracture (Type I-B-
V)
Displaced (Type I-B-D)
Combined zygomatic arch
fractures (Type II)
A. Single fracture (Type II-A)
B. Plural fracture (Type II-B)
1) Reduced (Type II-B-R)
2) Displaced (Type II-B-D)
Irfan Ozyazran et al ;A New Proposal of Classification of Zygomatic Arch Fractures; JOMS,
Volume 65, Issue3, March 2007, Pages 462–469

28. ORBITAL FRACTURE

29. Classification of orbital wall defects
C. Jaquiery et al.,
Maxillofacial unit , University Hospital, Basel, Switzerland
IJOMS ‘07 :36;193-199
1. Orbital floor,
anterior third
2. Orbital floor,
middle third
3. Orbital floor
,dorsal third
4. Infraorbital fissure
5. Supraorbital
fissure
6. ON
7. Lateral wall
8. Nasal lachrymal
duct
9. Medial border of
infraorbital fissure

30. Category I
JAQUIERY C ET AL Recon of orbit wall defect : crit review of 72 pt IJOMS
2007

31. Category I
JAQUIERY C ET AL Recon Of Orbit Wall Defect : Crit Review Of 72 Pt IJOMS 2007
Category I Isolated defect of the orbital floor or the medial wall, 1–2 cm2,
within zones 1 and 2
Bony ledge preserved at the medial margin of the infraorbital fissure

32. Category II
Category II Defect of the orbital floor
and/or of the medial wall, <2 cm2, within
zones 1 and 2

33. Category III
Category III Defect of the orbital floor and/or of the medial wall, >2 cm2,
within zones 1 and 2

34. Category IV
Category IV Defect of the entire orbital floor and the medial wall, extending
into the posterior third (zone 3)

35. Category V
Category V Same as IV, defect extending
into the orbital roof

36. II) According to Rowe Williams
A) Isolated Fracture of Orbital rim :
Caused by a direct impact from an object of a relatively small
cross sectional area upon a specific part of the rim.
1) Superior rim
• Lateral 3rd (Lacrimal recess)
• Central 3rd (supra orbital nerve)
• Medial 3rd (frontal sinus)
2) Inferior rim
• Central 3rd (inferior orbit nerve)
• Medial 3rd (inferior oblique muscle origin)
3) Medial rim
• Medial canthal ligament
• Lacrimal passages

37. 4)Lateral rim
• Lateral canthal ligament
• Suspensory ligament
B) Isolated Fractures Of The Orbital Walls:
Fractures of orbital walls can be as uncomplicated
linear type or complicated and comminuted because of their
communication with important areas;
1) Roof: anterior fossa
• Levator palpebral superioris
• Frontal sinuses

38. 2) Floor antrum
• Infra orbital nerves and vessels
• Inferior rectus or inferior oblique
3) Medial wall
• Lacrimal sac and naso lacrimal canal
• Ethmoidal sinuses
• Medial rectus
• Suspensory ligament
4) Lateral wall
• SOF and associated structures

39. Nasal bone Fracture

40. Rowe and Killey 1968 (resulting from impact )
Lateral
Nasal injuries resulting from lateral imapct
A. Moderate force results in the depression of nasal bone and buckling of the
septum
B. severe force leading to displacement of the nasal pyramid

41. Rowe and Killey 1968 (resulting from impact )
Nasal injuries resulting from anterior impact
A.moderate force results in fracture of the nasal septum and depression of the
nasal pyramid
B. severe impact leading to and open book fracture, Fracture of septum,
permitting flattening and spreading of nasal bones (open book fracture)
Anterior nasal injuries

42. Stranc and Robertson: depending on the depth
of injury
(1979)
These do not
extend beyond
a line joining
the lower end
of the nasal
bones to the
anterior nasal
spine.
Limited to the
external nose
and do not
transgress to the
orbital rims
These extend
to involve the
orbital and
possibly
cranial
structures.

43. Rohrich & Adams 2000
Nasal fracture classification
Nasal # mx minimising sec nasal deformity. Plast reconstruct surg 2000
Type Description
I Simple unilateral
II Simple bilateral
III Comminuted
A Unilateral
B Bilateral
c Frontal process of maxilla
IV Complex nasal bone
fracture with septal
disruption
a Associated with septal
hematoma
b Associated with open nasal
fracture
v Associated NOE Fracture /
midface fracture

44. Palatine bone Fracture
Hendrickson palatal classification
Hendrickson M, Clark N, Manson PN, et al: Palatal fractures: Classification, patterns, and treatment with rigid
internal fixation. Plast Reconstr Surg 101:319, 1998
Type I: Alveolar fracture
Type Ia: Anterior alveolus; contains only
incisor teeth and associated alveolus
Type Ib: Posterolateral; contains premolars,
molars, and associated alveolus
Type II: Sagittal fracture, a split of the palatal
midline
Type III: Parasagittal fracture; most common
fracture pattern in adults (63%) because of thin
bone parasagittally; fracture pattern differs from
type Ia fracture by inclusion of maxillary canine
Type IV: Para-alveolar fracture; occurs palatal to
the maxillary alveolus and incisors
Type V: Complex comminuted fracture
Type VI: Transverse fracture,

45. NOE

46. Markowitz and Manson
 Type I – central fragment
 Type II – comminuted
fracture with lateral
extension not involving MCL
 Type III – comminuted
fracture with extension into
MCL
MCL- Medial Canthal Ligament
Markowitz BL, Manson PN, Sargent L, et al. Management of the medial canthal tendon in
nasoethmoid orbital fractures: the importance of the central fragment in classification and
treatment. Plast Reconstr Surg 1991;87(5):843–853

48. AYLIFFE’S CLASSIFICATION
 Type I – en bloc minimum displaced
fractures of the entire NOE complex
 Type II– en bloc displaced fractures,
usually associated with large
pneumatized sinus and minimal
fragmentation
TYPE I
TYPE II

49.  Type III – comminuted fracture but
canthal ligament firmly attached with
bone fragments which are big enough
to plate.
 Type IV– comminuted fracture with
free canthal ligament not large enough
to be plate.
TYPE III
TYPE IV

50. TYPE V
Type V – gross comminution needing bone grafting

51. FRONTAL BONE FRACTURE
Gerbino G. Analysis of 158 frontal sinus fractures: current surgical management
and complications. Journal of Cranio-Maxillofacial Surgery (2000) 28, 133±139

52. Classification of mandible
fracture

53. Kruger's general classification
• Simple or Closed Fracture
• Compound or Open
• Comminuted
• Complicated or complex
• Impacted
• Greenstick fracture
• Pathological

54. Dingman & Natvig classification
• Midline
• Parasymphyseal
 Symphysis
• Body
• Angle
• Ramus
• Condylar process
• Coronoid process
• alveolar process

55. AO Classification
F NO. OF FRACTURE OR FRAGMENTS
L LOCATION OF THE FRACTURE
O STATUS OF OCCLUSION
S SOFT TISSUE INVOLVEMENT
A ASSOCIATED FRACTURES
Gratzs A., In :Internal Fixation of Mandible . B. Spiessel; Spriner-Verlag., Berli:Haidelberg, 1989; 375

56. F: NO. OF FRACTURES
F0 Incomplete fractures
F1 Single fractures
F2 Multiple fractures
F3 Comminuted fractures
F4 Fracture with bone defect
Gratzs A., In :Internal Fixation of Mandible . B. Spiessel; Spriner-Verlag., Berli:Haidelberg, 1989; 375

57. L: Location of fracture
L1 Pre-canine
L2 Canine
L3 Post-canine
L4 Angle
L5 Supra-angular
L6 Condyle
L7 Coronoid
L8 Alveolar process
Gratzs A., In :Internal Fixation of Mandible . B. Spiessel; Spriner-Verlag., Berli:Haidelberg, 1989; 375

58. O: Status of
occlusion
O 0 No malocclusion
O 1 Malocclusion
O 2 Edentulous mandible
Gratzs A., In :Internal Fixation of Mandible . B. Spiessel; Spriner-Verlag., Berli:Haidelberg, 1989; 375

59. O: Soft Tissue component
S 0 Closed Mandibular Fracture
S 1 Fracture open Intraorally
S 2 Fracture open Extraorally
S 3 Fracture with soft tissue loss
Gratzs A., In :Internal Fixation of Mandible . B. Spiessel; Spriner-Verlag., Berli:Haidelberg, 1989; 375

60. A: Associated fracture
A0 None
A1 Dentoalveolar fracture
A2 Nasal bone fracture
A3 Zygoma fracture
A4 Lefort I
A5 Lefort II
A6 Lefort III
Gratzs A., In :Internal Fixation of Mandible . B. Spiessel; Spriner-Verlag., Berli:Haidelberg, 1989; 375

61. Condylar fracture

62. Wasmund
Type I 10 -45 degree
Type II 45 - 90 degree
Type III Dislocated
Type IV On or anterior to articular
eminence
Type V Vertical or oblique # of
head of condyle

63. Anatomic location of the
fracture
Condylar head
Condylar neck
Subcondylar
Relationship of condylar
fragment to mandible
Nondisplaced
Deviated
Displacement with medialor
lateral overlap
Displacement with anterioror
posterior overlap
No contact between fractured
segments
Relationship of condylar
head& fossa
Nondisplaced
Displacement
Dislocation
Lindahl Classification 1971

64. Condylar fractures
• Intra capsular
• Extra capsular
condylar neck fracture
condylar base fracture
Diacapitular type
•Unilateral
•Bilateral
Classification of condylar process fractures; M. Schneider, U.Eckelt; Journal of the
Canadian Dental Association December 2006,Vol.68,No.11

65. AOCMF Classification of
Central Midface
Carl-Peter Cornelius, The Comprehensive AOCMF Classification System: Midface Fractures - Level 3 Tutorial.
Craniomaxillofac Trauma Reconstruction 2014;7(Suppl 1):S68–S91

66. AOCMF
Classification of
Lateral Midface
Carl-Peter Cornelius, The Comprehensive AOCMF Classification System: Midface Fractures - Level 3 Tutorial.
Craniomaxillofac Trauma Reconstruction 2014;7(Suppl 1):S68–S91

67. AOCMF Classification of
mandibular fracture
Carl-Peter Cornelius,The Comprehensive AOCMF Classification System: Mandible Fractures- Level
2. Craniomaxillofac Trauma Reconstruction 2014;7(Suppl 1):S15–S30Tutorial

68. Carl-Peter Cornelius,The Comprehensive AOCMF Classification System: Mandible Fractures-
Level 2. Craniomaxillofac Trauma Reconstruction 2014;7(Suppl 1):S15–S30Tutorial

69. Carl-Peter Cornelius,The Comprehensive AOCMF Classification System: Mandible Fractures-
Level 2. Craniomaxillofac Trauma Reconstruction 2014;7(Suppl 1):S15–S30Tutorial

70. Conclusion
 Understanding the prevalent Fracture
pattern is the key to giving successful results.

71. THANK YOU