ORIGINAL ARTICLE Facial Fracture Classification According to Skeletal Support Mechanisms Terry L. Donat, MD; Carmen Endress, MD; Robert H. Mathog, MD Objective: To construct, propose, and evaluate the use- tures. This scheme was accurately applied and suffi- fulness of a new clinical facial fracture classification cient to describe 87 midfacial fracture patterns in this scheme to accurately denote, communicate, and com- study. In addition, 118 (98%) of 120 mock fracture pat- pare facial fractures. terns were correctly transcribed and reproducibly com- municated among 12 participating physicians. Design: A retrospective, consecutive sample study with application of the proposed classification scheme to de- Conclusions: This newly proposed facial fracture clas- note maxillary and zygomatic fractures with computed sification scheme provides a convenient, specific, de- tomography. scriptive, and reproducible method of denoting fracture patterns. This scheme may be used to accurately com- Setting: Metropolitan tertiary care trauma center. municate and compare, in greater detail than permitted using current independent classification schemes, the es- Patients: A total of 213 consecutive adult patients with sential site and degree-of-severity characteristics of fa- facial fractures evaluated by means of 2-dimensional com- cial fractures critical to their surgical reduction and re- puted tomography. construction. The usefulness of this classification scheme in determining optimal methods and subsequent out- Results: The classification scheme is defined accord- comes in midfacial fracture reduction requires further ing to fractures of vertical buttresses and horizontal beams. investigation. The scheme uses 3 primary descriptors of laterality and support sites to denote the clinical pattern of the frac- Arch Otolaryngol Head Neck Surg. 1998;124:1306-1314 HE INCIDENCE, mecha- tomographic (CT) scanning technology, nisms, and pathophysiol- a major advance over plain x-rays, for ogy of facial fractures are fracture identification and fragment well described in the litera- visualization.17-20 ture, as are the current ap- Despite the widespread acceptance proaches to fracture reduction and fixa- of current diagnostic and treatment T1-5 tion. The 3 goals of therapy in treating methods, the most commonly used clas- midfacial fractures are (1) to restore func- sification for describing facial fractures tional occlusion; (2) to stabilize the ma- remains that classically described by jor facial skeletal supports, thereby restor- French physician Rene LeFort, which ing the premorbid 3-dimensional contour alone yields insufficient information for (height, width, and projection) to the face; fracture description and the complete From the Department of and (3) to provide skeletal support for the planning of treatment. LeFort’s original Otolaryngology–Head and proper function and appearance of the classification described “the great lines Neck Surgery, University of overlying facial soft tissue structures. of weakness” according to fracture pat- Minnesota Health Sciences The current approach to facial frac- terns he experimentally produced.1 The Center, Minneapolis ture repair requires the repositioning of LeFort classification is inadequate in that (Dr Donat), and Departments the fracture segments into anatomic it does not define the facial skeletal sup- of Radiology (Dr Endress) and position, with a focus on the lattice sup- ports or the more severely comminuted, Otolaryngology–Head and ports in relation to each other and to the incomplete, or combination maxillary Neck Surgery (Dr Mathog), cranial base.6-10 Modern therapy also Wayne State University, Detroit, Mich. Dr Donat is now mandates the rigid stabilization of the with the Department of vertical and horizontal facial supports to withstand the forces of mastication.11-16 This article is also available on our Otolaryngology–Head and Web site: www.ama-assn.org/oto. Neck Surgery at Wayne State Such treatment plans are made possible University. by the diagnostic capability of computed ARCH OTOLARYNGOL HEAD NECK SURG/ VOL 124, DEC 1998 1306 ©1998 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 10/01/2021 METHODS Examples shown in Figure 2 through Figure 5 demon- strate the methods. ANATOMIC CONSIDERATIONS EVALUATION FOR CLASSIFICATION The classification system was evaluated retrospectively by The scheme for the midfacial fracture classification sys- reviewing medical records of 213 adult patients with mid- tem in this study was designed by partitioning the 3 pairs facial fractures treated at Detroit Receiving Hospital, De- of horizontal structural supports (beams) and 3 pairs of troit, Mich, from January 1, 1993, through June 30, 1995. vertical structural supports (buttresses). Based on the All patients were evaluated by axial and coronal CT scan intersection of these supports and segmental divisions, imaging. The patients ranged in age from 18 to 70 years there were 11 unilateral sites and 22 bilateral sites with the primary mechanisms of injury being blunt trauma (Figure 1 and Table 1). The 3 primary, paired horizon- caused by altercation or motor vehicle accident in 208 pa- tal beams from superior to inferior were the superior tients (97.6%) or penetrating trauma caused by gunshot orbital rims combined with the glabella (H1), the inferior wounds in 5 patients (2.4%). Twenty-six patients were orbital rims combined with the zygomatic arches (H2), women and 187 were men. and the alveolar processes of the maxilla (H3). The pri- To determine whether the fractures could be ana- mary, paired vertical buttresses from anterior to posterior lyzed and assigned to a specific notation, the CT scans were were the nasal maxillary (V1), the zygomaticomaxillary evaluated for fracture sites and these sites were then dia- (V2), and the pterygomaxillary (V3) buttresses. The grammed and transcribed according to the classification sys- beams were further categorized into central (c) and lateral tem. Evaluations were blinded to any prior medical rec- (l) segments, and the buttresses were categorized into ords or radiology interpretation. Designations were then superior (s) and inferior (i) segments. Nasal fractures, related to a standard method of description to show the thin lamina fractures (such as found along the orbital advantages and disadvantages of the system. walls and the walls of the maxilla), and the degree of frac- To test whether the notations could serve as an effi- ture displacement were not included as part of the classifi- cient and valid means of communication, 12 resident phy- cation system. The classic completed LeFort and zygo- sicians were presented with a series of mock facial frac- matic fracture patterns as herein represented according to ture diagrams and fracture designations. Each physician was buttress and beam support involvement are listed in presented first with 5 distinct fracture patterns dia- Table 2. grammed according to the classification scheme and asked Individual fracture locations were denoted laterally (left to provide notations of the fracture patterns; they were or right), by involvement of the fractured buttress or beam subsequently presented with 5 new distinct notations of (vertical or horizontal), and at the site of the fracture line fractures and asked to diagram the fracture pattern repre- along the buttress, superior or inferior, or along the beam, sented by the notation. The number of the correctly tran- central or lateral. The fractures of patients were denoted scribed fracture diagrams and notations was determined. by listing in sequence the location of individual fractures. Transcription errors were also determined. fractures. Moreover, it does not describe the fractures of nasal bones alone and were not included for analysis. The the part bearing the occlusal segment.4 The LeFort clas- remaining 170 cases were classified and are listed in sification thus often underestimates the complexity of Table 3. Cases were described according to whether the the fractures and limits the complete description of the injury was unilateral left (L), unilateral right (R), or bi- overall facial fracture pattern, which often includes any lateral, and were compared with prior nomenclature sys- array of fronto-orbital, zygomatic, and nasoethmoidal tems, where applicable. fractures in combination with maxillary injury. The classification scheme was easily applied to all The goals of a classification system oriented to- of the fracture patterns determined by axial and coronal ward current therapy for midfacial fractures should ide- CT scan for the patients in this study. No fracture pat- ally include information obtained from the clinical, sur- terns in this study were deemed unassignable, as might gical, and CT radiological examinations (1) to accurately occur due to a fracture line passing through a buttress/ represent the anatomic and functional magnitude and beam intersection. Using the proposed classification, 40 complexity of the overall midfacial fracture pattern, differing unilateral fracture patterns were identified (2) to describe the involved functional skeletal sup- among 122 patients who presented with unilateral fa- ports critical to the proper design for surgical therapy, cial fractures. Forty-seven differing fracture patterns (3) to provide a meaningful common terminology for were identified among the 48 patients presenting with communication of the fracture information between bilateral facial fractures. Therefore,