classificationfacialfracturekamini-200801184051.pptx

classification helps to categorise the entire section into simple format it helps in diagnosis and treatment planning of the patient

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

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 )

11. Lefort II (Pyramidal/Sub- zygomatic )

12. Lefort II (Pyramidal/Sub- zygomatic )

13. Lefort III(Transverse/Supra zygomatic )

14. Lefort III (Transverse/Supra zygomatic /High level)

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 High level lefort III supra zygomatic fractures – lefort III Lefort III with midline split 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  “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

22. 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.

23. 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

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

25. 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) Single fracture (Type II-A) Plural fracture (Type II-B) 1) Reduced (Type II-B-R) 2) Displaced (Type II-B-D) x Irfan Ozyazran et al ;A New Proposal of Classification of Zygomatic Arch Fractures; JOMS, Volume 65, Issue3, March 2007, Pages 462–469

26. ORBITAL FRACTURE

27. Classification of orbital wall defects C. Jaquiery et al., Maxillofacial unit , University Hospital, Basel, Switzerland IJOMS ‘07 :36;193-199 Orbital floor, anterior third Orbital floor, middle third Orbital floor ,dorsal third Infraorbital fissure Supraorbital fissure ON Lateral wall Nasal lachrymal duct Medial border of infraorbital fissure

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

29. 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

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

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

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

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

34. 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 3 rd (Lacrimal recess) Central 3 rd (supra orbital nerve) Medial 3 rd (frontal sinus) 2) Inferior rim Central 3 rd (inferior orbit nerve) Medial 3 rd (inferior oblique muscle origin) 3) Medial rim Medial canthal ligament Lacrimal passages

35. 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

36. 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

37. Nasal bone Fracture

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

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

40. 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.

41. 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

42. 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,

43. NOE

44. 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 classi fi cation and treatment. Plast Reconstr Surg 1991;87(5):843 – 853

45. 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

46. 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

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

48. 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

49. Classification of mandible fracture

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

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

52. 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

53. 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

54. 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

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

56. O: Soft Tissue component S 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

57. A: Associated fracture A 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 Gratzs A., In :Internal Fixation of Mandible . B. Spiessel ; Spriner-Verlag ., Berli:Haidelberg , 1989; 375

58. Condylar fracture

59. 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

60. 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

61. 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

62. 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

63. 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

64. 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–S30 Tutorial

65. Carl-Peter Cornelius, The Comprehensive AOCMF Classification System: Mandible Fractures- Level 2. Craniomaxillofac Trauma Reconstruction 2014;7( Suppl 1):S15–S30 Tutorial

66. Carl-Peter Cornelius, The Comprehensive AOCMF Classification System: Mandible Fractures- Level 2. Craniomaxillofac Trauma Reconstruction 2014;7( Suppl 1):S15–S30 Tutorial

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

68. THANK YOU