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Facial Trauma 7
https://t.me/med1917
ORBIT
Jaquiéry Classification of Orbital Fractures
is system describes orbital fractures in relation to size of
defects, anatomical area of orbit involved and whether the
bony ledge at the medial margin of the infraorbital ssure is
spared. Patterns of fractures with large defects of the orbital
oor and medial wall correspond to increasing complexity of
surgical repair.
1. Isolated defect of the orbital oor or of the medial wall,
1–2cm2, within the anterior two-thirds
2. Defect of the orbital oor and/or of the medial wall, >2cm2 ,
within the anterior two-thirds, bony ledge preserved at the
medial margin of the infraorbital ssure
3. Defect of the orbital oor and/or of the medial wall, >2cm2 ,
within the anterior two-thirds, missing bony ledge medial to
the infraorbital ssure
4. Defect of the entire orbital oor and of the medial wall,
extending into the posterior one-third, missing bony ledge
medial to the infraorbital ssure
5. Same as #4 plus defect extending into the orbital roof
MIDFACE
Le Fort Classification of Fractures
is classication describes the degree of separation of midfacial bones from the skull base.
1. Guerin/oating plate – midface retrusion, anterior open bite
(AOB), midface elongation
2. Pyramidal – at or below frontonasal suture, involving lacrimal bones, oor and rim, infraorbital foramen to pterygomaxillary ssure and pterygoid plates
3. Craniofacial disjunction
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8 Classifications and Lists in Oral and Maxillofacial Surgery
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Stranc ‘Plane’ Classification of Nasal Fractures
is classication describes nasal fractures in terms of three
dierent planes, which correspond to extent of injury from the
nasal tip. Extensive injuries can lead to involvement and disruption of the NOE complex. Hence, more complex surgical management is warranted with these types of injuries.
1. Distal bridge and tip – septal deviation, therefore septorhinoplasty (SRP)
2. Mid-dorsum – saddle nose, therefore dorsal augmentation
rhinoplasty
3. Pyriform aperture ± NOE, therefore ORIF and medial canthal
resuspension
MAXILLA AND ZYGOMA
Henderson Classification of Zygomatic Fractures
is system classies zygomatic injuries according to degree of
fracture displacement and involvement of the zygomatico-maxillary complex (ZMC). Cosmetic and functional decits are associated with disruption of the fronto-zygomatic (FZ) suture and
will necessitate surgical management with two-point arch xation aer elevation. More complex fractures are associated with
comminution.
1. Undisplaced
2. Arch
3. ZMC (FZ intact)
4. ZMC (FZ displaced/disrupted)
5. Pure blow out
6. Rim only
7. Comminuted
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Facial Trauma 9
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Zingg Classification of ZMC Fractures
is classication describes zygomatic fractures according to
the areas of ZMC involved, which form part of the lateral wall,
orbital oor and cheek projections.
A. Single pillar
1. Arch
2. Lateral orbit
3. Infraorbital rim
B. All four areas (arch, FZ, ZM buttress, infraorbital rim/oor)
C. Comminuted
MANDIBLE
Frequency of Mandible Fractures Overall by Site
is list describes frequency of fractures according to the anatomical site of the mandible. e most common site is the angle
of the mandible, and the site least involved is the coronoid process of the mandible.
1. Angle 31%
2. Condyle 18%
3. Body 15%
4. Parasymphysis 14%
5. Symphysis 8%
6. Canine 7%
7. Ramus 6%
8. Coronoid 1%
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10 Classifications and Lists in Oral and Maxillofacial Surgery
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Loukota Classification of Condyle Fractures
According to this classication, condylar fractures are described
in relation to the Loukota line, which runs perpendicular
through the sigmoid notch to the tangent of the ramus of the
mandible.
A. Head (fracture line starting in the articular surface and may
extend outside the capsule)
B. Neck (mainly above the Loukota line)
C. Base (mainly below the Loukota line and behind the man-
dibular foramen)
Luhr Classification of Atrophic Mandibles
is system describes mandibular atrophy in terms of residual
vertical bone height and straties it into mild, moderate and
severe for both partially dentate and edentulous mandibles.
1. 16–20mm (typically managed with load-sharing
osteosynthesis)
2. 11–15mm
3. ≤10mm (typically managed with load-bearing osteosynthesis)
Neff Classification of Condylar Head Fracture
is classication system groups head of condyle fractures of
the mandible according to the involvement of medial and lateral components and whether vertical mandibular height is
preserved. More complex patterns involve capsular attachments
and fracture dislocations of the condylar head.
A. Fracture with displacement of the medial parts of condyle –
vertical mandibular height is preserved
B. Fracture of lateral condyle – decrease in mandibular height
C. High capsular fractures/dislocations
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Strasbourg Osteosynthesis Research Group
(SORG) Management Classification of
Subcondylar Fractures
is classication allows the assessment and management
of subcondylar fractures of the mandible based on degree
of displacement and the corresponding management strategies.
1. Minimally displaced (<10 degrees, l<2mm) – closed treatment
2. Moderately displaced (>10 degrees, 2–15mm) – ORIF
3. Severely displaced (>45 degrees, >15mm) – ORIF
SORG Strong Evidence for Condylar FractureORIF
e following list highlights criteria for which there is a strong
case for open reduction internal xation of condylar fractures.
●
≥2mm loss of height
●
≥45 degrees of tilt
●
Bilateral condyles
●
Unstable midface fractures with condyle(s)
●
Unstable occlusion
●
Periodontal disease/fewer than three teeth per quadrant
●
Physio is impossible
NB: 10–45 degrees of tilt have mixed evidence.
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Spiessl and Schroll Classification of
Condyle Fractures
is classication describes condyle fractures in relation to
higher and lower neck fractures and the associated angulation
and displacement of the condyle. e highest class includes fracture of the condylar head.
1. Neck fracture, undisplaced
2. Low neck with angulation
3. High neck with angulation
4. Low neck with dislocation
5. High neck with dislocation
6. Fracture of condylar head
Zide and Kent Criteria for ORIF Condyle
e following list highlights the absolute and relative indications
for ORIF of condylar fractures.
Absolute indications:
●
Displacement into middle cranial fossa (MCF)
●
Foreign body
●
Lateral extra-capsular displacement
●
Malocclusion not amenable to closed reduction
Relative indications:
●
Bilateral edentulous mandible fractures and no Gunning
splints
●
Not possible, midfacial fractures with AP discrepancy, periodontal disease or loss of teeth, unilateral condyle
●
Fracture with unstable glenoid base
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Facial Trauma 13
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NERVES AND SOFT TISSUE INJURIES
Binocular Diplopia Classification
e following system describes diplopia when both eyes are open
and can include a mechanical component involving the extraocular muscles, a neurogenic component as a result of nerve
injury/neuronal decit or a combination of both.
1. Mechanical (positive forced duction test, upward gaze
aected) – MOST COMMON
2. Neurogenic (negative/normal forced duction test, downward
gaze aected)*
3. Mixed (forced duction positive and all vertical gaze aected)*
*Types 2 and 3 warrant neuro-ophthalmic input, usually resolve
spontaneously by 1year.
Classification of Neuromas in Nerve Injury
e following list describes benign growths of nerve tissue as a
result of injury.
●
Lateral adhesive
●
Lateral exophytic
●
Neuroma in continuity (seen in Sunderland 4)
●
Amputation neuroma
Meyer Protocol for Injury Causing Dysesthesia
e following protocol allows the stratication of abnormal pain
sensation into various groups and their management options.
●
TEST AT 3 MONTHS
●
Level A – brushstroke, if painful is allodynia
●
Level B – repetitive stimulus, if painful is hyperpathia
●
Level C – painful stimulus, if exaggerated response is hyperalgesia
●
Do a diagnostic nerve block – if it helps, then do
MICROSURGERY; if it persists, then management will
include medical/physio/CBT and ‘sensory re-education’
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14 Classifications and Lists in Oral and Maxillofacial Surgery
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Meyer Protocol for Injury Causing Loss of Sensation
is protocol describes a strategy to diagnose the severity of sensory
loss as a result of nerve injury and gives the management options.
●
TEST AT 3 MONTHS
●
Level A – two-point discrimination with Boley gauge/direction of stroke
●
Level B – contact (touch), if normal it is mild hypoesthesia
●
Level C – painful stimulus, if normal it is moderate hypoesthesia, if not it is severe hypoesthesia or anaesthesia
●
Complete anaesthesia is treated earlier than 3 months (i.e., 1
month), but for all others wait 3 months before moving on to
microsurgery
●
If microsurgery fails, then management will include ‘sensory
re-education’
Nerve Injury Classifications by Seddon
and Sunderland
The following system categorises nerve injuries according
to the anatomical parts of the nerve tissue involved. More
complex injuries require management with microsurgical
repair.
●
Seddon 1=Sunderland 1=NEUROPRAXIA (hours to 1
month), sheath intact and has nerve conduction
●
Seddon 2=Sunderland 2=AXONOTMESIS (2 months),
sheath intact but no conduction, has brillation potentials
ifmotor nerve
●
Sunderland 3=AXONOTMESIS (3 months), loss of endoneurium so Wallerian degeneration, has brillation potentials if
motor nerve
●
Sunderland 4=NEURONOTMESIS (4 months), if no resolution then microsurgery, neuromas form, has brillation
potentials if motor nerve
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Facial Trauma 15
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●
Seddon 3=Sunderland 5=NEURONOTMESIS (complete
transection), needs microrepair, has brillation potentials if
motor nerve
●
MacKinnon 6=MIXED, some fascicles are aected more
severely than others
Timing of Nerve Repair
e following list describes the timing of nerve repair as the
paramount factor which dictates the success of regaining nerve
function.
●
Immediate
●
Delayed primary – within days
●
Delayed secondary – more than 3 weeks aer injury
Trauma Zones Neck (Inferior to Superior)
e following list describes zones of the neck in relation to neck
trauma. Each zone contains vital head and neck structures
which are at risk, depending on the level of the injury. is can
serve as a useful framework in the clinical assessment and management of neck injuries.
1. Clavicle to inferior cricoid (highest mortality, dicult to gain
access and vascular control)
2. Cricoid to angle (most common zone, amenable to surgical
access)
3. Angle to base of skull (more dicult to access than zone 2)
FURTHER READING
Alao T, Waseem M. Neck trauma [Updated 2022 Aug 7].
In: StatPearls [Internet]. Treasure Island, FL: StatPearls
Publishing; 2023.
Chhabra A, Ahlawat S, Belzberg A, Andreseik G. Peripheral nerve
injury grading simplified on MRneurography: As referenced
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to Seddon and Sunderland classifications. Indian J Radiol
Imaging. 2014;24(3):217–24.
Cornelius CP, Audigé L, Kunz C, etal. The comprehensive AOCMF
classification system: Mandible fractures—level 3 tutorial.
Craniomaxillofac Trauma Reconstr. 2014;7(Suppl 1):S31–43.
Gonty AA, Marciani RD, Adornato DC. Management of frontal
sinus fractures: Areview of 33 cases. J Oral Maxillofac Surg.
1999;57(4):372–9.
Jaquiéry C, Aeppli C, Cornelius P, Palmowsky A, Kunz C, Hammer
B. Reconstruction of orbital wall defects: Critical review of 72
patients. Int J Oral Maxillofac Surg. 2007;36(3):193–9.
Kassam K, Messiha A. Fractured zygomatic arch: Atraumatic
cause for trismus. BMJ Case Rep. 2014;2014:bcr2013202633.
Loukota RA, Eckelt U, De Bont L, Rasse M. Subclassification of
fractures of the condylar process of the mandible. Br J Oral
Maxillofac Surg. 2005;43(1):72–3.
Markowitz BL, Manson PN, Sargent L, etal. Management of the
medial canthal tendon in nasoethmoid orbital fractures: The
importance of the central fragment in classification and treat
ment. Plast Reconstr Surg. 1991;87(5):843–53.
Neff A, Cornelius CP, Rasse M, Torre DD, Audigé L. The com-
prehensive AOCMF classification system: Condylar process
fractures—level 3 tutorial. Craniomaxillofac Trauma Reconstr.
2014;7(Suppl. 1):S44–58.
Patel BC, Wright T, Waseem M. Le Fort fractures [Updated 2023
Apr 3]. In: StatPearls [Internet]. Treasure Island, FL: StatPearls
Publishing; 2023.
Sawhney C, Arora MK, Kumar S, Barik PK, Ranjan P. Initial man-
agement in blunt trauma neck. J Anaesthesiol Clin Pharmacol.
2018;34(2):275–76.
Seddon HJ. Areview of work on peripheral nerve injuries
in Great Britain during World War II. J Nerv Ment Dis.
1948;108(2):160–8.
Slutsky DJ, Hentz VR, Jabaley M, eds. Primary nerve repair
peripheral nerve surgery: Practical applications in the upper
extremity. Philadelphia, PA: Churchill Livingstone Elsevier;
2006: 23–38.
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