Fig. 3.21  Example of major craniofacial injury. Comminution and disruption of the subcranial midfacial skeleton including the naso-frontal region. Distocaudal dislocation of the midfacial complex with telescoping of the naso-fronto-ethmoidal region. Lateral dislocation of both zygomatic complexes. Bilateral dislocation of the nasal frame. Polyfragmentation of the anterior skull base, segmentation of the lower maxilla with dislocation of the alveolar segments. Paramedian fractures of the mandible

(1986, 1998) introduced a classification system according to fracture dimension, with a sub-division into craniofacial and subcraniofacial fractures. These fractures are referred to as comminuted (complex), to document the dimension and severity of the combined subcranial and craniofacial fractures.

•Complex subcranio-facial fractures (CUMF, CMF, LMF)

•Complex cranio-facial fractures (CCMF, PF)

The advantage of this classification is that the frontobasal region forms the central reference point for craniofacial fractures, whereas in the old classification system it was the maxilla (Hardt et al. 1992).

3.3.2  Subcranial Facial Fractures

According to Manson (1986, 1998), the subcranial fractures of the Le Fort II, III, and Wassmund II, III, IV types are classified as:

•Comminuted midface fractures (CMFs)

•Comminuted upper midface fractures (CUMFs) — those fractures running beneath the skull base through the orbit and naso-ethmoidal region of the upper midface

•Lower midface fractures (LMFs) — the infrazygomatic fractures (Le Fort I fractures) (Figs. 3.22 and 3.23)

Craniofacial fractures are subdivided into:

•Comminuted cranio-maxillary fractures (CCMFs)

−−a combination of differing cranio-maxillary fracture types with variable involvement of the orbital, naso-ethmoidal, and frontal regions

•Comminuted panfacial fractures (PFs)

−−which comprise the frontofacial region and the total facial skeleton

So, in PFs there is a combination of cranio-frontobasal fractures and fractures of the central and/or centrolateral midface complex and the mandible, thus largely destroying the three-dimensional projection of the midface (Fig. 3.24).

CCMFs, which are confined to the cranio-fronto-orbital region, may be further subdivided into:

•Central cranio-frontal fractures (CFFs)

•Lateral cranio-orbital fractures (COFs)

according to the dimension of the fracture (Gruss 1982, 1985; Jackson et al. 1986) (Figs. 3.25 and 3.26).

The complex CFFs in the central frontal region affect the frontal sinus, the naso-ethmoidal complex and the neighboring orbital region either as isolated or combined fractures (Gross 1984; Donald 1998).

There may be an isolated or combined involvement of the anterior and posterior walls of the frontal sinus. As the lamellae of the posterior wall are significantly thinner than those of the anterior wall, a frontal stressvector, with distorsion of the skull through lateral tension can result in isolated bursting of the posterior wall (Hybels 1977) (Figs. 3.27 and 3.28).

3.3.5  Lateral Cranio-Orbital Fractures

The complex COFs comprise fractures of the lateral cranio-zygomatico-orbital region with variable participation of the orbital walls, anterolateral skull base, orbital roof and temporal region. Both orbital wall injuries and fractures of the orb ital apex may result in neurovascular injuries (Fig. 3.29).