Classification of Mandible, Midface, ZMC and NOE Fractures

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

1. CLASSIFICATION OF FACIAL FRACTURES Dr ARJUN SHENOY

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 Single unilateral Double unilateral Bilateral multiple

10. DINGMAN & NATWIG CLASSIFICATION SYMPHYSIS # CANINE REGION # BODY OF MANDIBLE # ANGLE REGION # RAMUS REGION # CORONOID REGION # CONDYLAR # DENTOALVEOLAR #

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

12. COMPLETENESS Complete versus incomplete 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 AVULSION FRACTURE BENDING FRACTURE BURST FRACTURE COUNTERCOUP FRACTURE 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

35. 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.

36. 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)

37. RELATIONSHIP OF # LINE TO ZYGOMATIC BONE BELOW ZYGOMATIC subzygomatic fracture ABOVE ZYGOMATIC Suprazygomatic fracture

38. ERICH CLASSIFICATION - 1942 HORIZONTAL PYRAMIDAL TRANSVERSE

39. 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 #

40. FRACTURE ZMC CLASSIFICATION

41. 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.

42. 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.

43. 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 )

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

45. Type I : no significant displacement

46. Type II . Fracture of the zygomatic arch

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

48. Type IV. Rotation around longitudinal axis

49. Type V. Displacement of the complex en bloc

50. Type VI. Displacement of orbitoantral partition

51. Type VII. Displacement of orbital rim segments

52. Type VIII. Complex comminuted fractures

53. 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.

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

55. 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   .

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

57. Group A : Stable fracture – Showing minimal or no displacement and requires no intervention. Group B : Unstable fracture – With great displacement and distruption at the frontozygomatic suture and comminuted fracture. Requires reduction as well as fixation. Group C : Stable fracture – Other types of zygomatic fractures, which requires reduction, but no fixation. Fractures of the zygomatic arch alone Minimum or no displacement. V type in fracture. Comminuted fracture. LARSEN &THOMSEN CLASSIFICATION

58. 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

59. 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

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

61. 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:

62. 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.

63. 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

64. 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.

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

66. 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.

67. Type III + Involvement of the nasal bone

68. Bilateral type III fracture with nasal bone involvement

69. REFERENCES FONSECA – VOL 1 3 rd EDITION KILLEYS – 3 rd EDITION ROW AND WILLIAMS – VOL 1 PETER WARD BOOTH – VOL 1 COMPLICATION IN ORAL AND MAXILLOFACIAL SURGERY-KABBAN CONTEMPORARY ORAL AND MAXILLOFACIAL SURGERY,4 th EDITION-LARRY.J.PETERSON,JAMES.R.HUPP,MYRON.