Research Article| Volume 33, ISSUE 8, P651-668, October 2002

A comprehensive classification of craniofacial fractures: postmortem and clinical studies with two- and three-dimensional computed tomography


      A comprehensive classification of midfacial/craniofacial fractures, based on two- and three-dimensional computed tomography (2D and 3D-CT) is presented.
      We performed a postmortem analysis of 24 patients who had died from trauma with signs of craniofacial fractures, based on 2D and 3D-CT studies with pathoanatomical findings. In addition, CT findings for 100 patients with craniofacial injuries requiring an emergency CT were correlated with surgical findings and follow-up results. On the basis of the analysis of a total of 377 fractures a classification system is proposed. The system is based on the use of the AO/ASIF (Arbeitsgemeinschaft für Osteosynthesefragen/Association for the Study of Internal Fixation) scheme, defining three types (A, B, C), three groups within each type (e.g. A1, A2, A3) and three subgroups within each group (e.g. A1.1, A1.2, A1.3) with increasing severity from A1.1 (lowest) to C3.3 (highest). The craniofacial region is divided into three units: the lower midface (I), the upper midface (II) and the craniobasal-facial unit (III). Lateral and central fractures are also distinguished. Type A fractures are non-displaced fractures, type B are displaced fractures and type C are complex/defect fractures. Groups A1, B1 and C1 comprise fractures of an isolated unit; groups A2, B2 and C2, combined fractures without involvement of the skull base; and groups A3, B3 and C3 are those combined fractures with involvement of the skull base. A correlation between the severity of the fracture and (i) the number of posttraumatic functional limitations (Spearman rank test, correlation coefficient r=0.42), (ii) the need for bone grafting or dural plastic (r=0.39) and (iii) facial asymmetry (r=0.37), was observed. The proposed classification system allows standardised documentation of midfacial and craniofacial fractures, including those not precisely defined by the Le Fort classification scheme.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Injury
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Le Fort R.
        Etude experimentale sur les fractures de la machoire superieure.
        Rev. Chir. 1901; 23: 479-507
        • Laine F.J.
        • Conway W.F.
        • Laskin D.M.
        Radiology of maxillo-facial-trauma.
        Curr. Probl. Diagn. Radiol. 1993; 22: 147-186
      1. Luka B, Brechtelsbauer D, Gellrich N, König M. 2D and 3D CT reconstructions of the facial skeleton: an unnecessary option or a diagnostic pearl? Int J Oral Maxillofac Surg 1995;24:76–83.

        • Manson P.
        • Markowitz P.
        • Mirvis S.
        • Dunham M.
        • Yaremchuk M.
        Toward CT-based facial fracture treatment.
        Plast. Recconstr. Surg. 1990; 85: 202-212
        • Buitrago-Téllez C.H.
        • Wächter R.
        • Ferstl F.
        • Stoll P.
        • Langer M.
        3D-CT zur Befunddemonstration bei komplexen Gesichtsschädelverletzungen.
        Fortschr. Röntgenstr. 1994; 160: 106-112
        • Markowitz B.L.
        • Manson P.N.
        • Sargent L.
        • et al.
        Management of the medial canthal tendon in nasoethmoid orbital fractures: the importance of the central fragment in classification and treatment.
        Plast. Reconst. Surg. 1991; 87: 843-853
        • Gruss J.S.
        Naso-ethmoid-orbital fractures: classification and role of primary bone grafting.
        Plast. Reconst. Surg. 1985; 75: 303-317
        • Zingg M.
        • Laedrach K.
        • Chen J.
        • et al.
        Classification and treatment of zygomatic fractures: a review of 1025 cases.
        J. Oral Maxillofac. Surg. 1992; 50: 778-790
      2. Haug RH, Greenberg AM. Etiology, distribution and classification of fractures. In: Greenberg AM, editor. Craniomaxillofacial fractures: principles of internal fixation using the AO/ASIF technique. New York: Springer, 1993. p. 5–20.

        • Cooter R.D.
        • David D.J.
        Computer-based coding of fractures in the craniofacial region.
        Br. J. Plast. Surg. 1989; 42: 17-26
        • Jackson I.T.
        Classification and treatment of orbito-zygomatic and orbitoethmoid fractures—the place of bone grafting and plate fixation.
        Clin. Plast. Surg. 1989; 16: 77-91
        • Herman G.T.
        Three-dimensional imaging on a CT or MR scanner.
        JCAT. 1988; 12: 450-458
      3. Müller ME, Nazarian S, Koch P, Schatzker J. The comprehensive classification of fractures of long bones. Berlin: Springer, 1990.

        • Donat T.L.
        • Endress C.
        • Mathog R.H.
        Facial fracture classification according to skeletal support mechanisms.
        Arch. Otolaryngol. Head Neck Surg. 1998; 124: 1306-1314
        • Kalender W.A.
        • Seissler W.
        • Klotz E.
        • Vock P.
        Spiral volumetric CT with single-breath-hold technique, continuous transport, and continuous scanner rotation.
        Radiology. 1990; 176: 181-183
      4. Buitrago-Téllez, CH, Bohnert M, Kimmig M, Allmann KH, Gellrich NC, Langer M. Spiral CT in maxillofacial trauma. In: Krestin GP, Glazer GM, editors. Advances in CT IV. Berlin: Springer, 1998. p. 76–82.

        • Gentry L.R.
        • Manor W.F.
        • Turski P.S.
        • et al.
        High resolution CT analysis of facial struts in trauma, II: osseous and soft tissue complications.
        Am. J. Radiol. 1983; 140: 533-541
        • Marsh J.L.
        • Vannier M.V.
        • Gado M.
        • Stevens W.G.
        In vivo delineation of facial structures: the application of advanced medical imaging technology.
        Ann. Plast. Surg. 1986; 17: 364-375
        • Buitrago-Téllez C.H.
        • Zollikofer C.P.E.
        • Cantini J.L.
        • et al.
        Preoperative planning of complex craniofacial fractures.
        AO-dialogue. 1997; 10: 18-19
      5. Buitrago-Téllez CH, Wächter R, Gufler H, Beseeching M, Stoll P, Langer M. Reproducible 3D-CT of the maxillofacial complex for preoperative planning. In: Lemke HU, et al., editors. Computer assisted radiology. Amsterdam: Elsevier, 1996. p. 975–80.

        • Haug R.H.
        • Adams J.M.
        • Conforti P.J.
        • Likavec M.J.
        Cranial fractures associated with facial fractures: a review of mechanism, type and severity of injury.
        J. Oral. Maxillofac. Surg. 1994; 52: 729-733
        • Slupchynskyj O.S.
        • Berkower A.S.
        • Byrne D.W.
        • Cayten C.G.
        Association of skull base and facial fractures.
        Laryngoscope. 1992; 102: 1247-1250
        • Martello J.Y.
        • Vasconez H.C.
        Supraorbital roof fractures: a formidable entity with which to contend.
        Ann. Plast. Surg. 1997; 38: 223-227
        • Burstein F.
        • Cohen S.
        • Hudgins R.
        • Boydston W.
        Frontal basilar trauma: classification and treatment.
        Plast. Reconstr. Surg. 1997; 99: 1314-1321
        • Raveh J.
        • Laedrach K.
        • Vuillemin T.
        • Zingg M.
        Management of combined frontonaso-orbital/skull base fractures and telecanthus in 355 cases.
        Arch. Otolaryngol. Head Neck Surg. 1992; 118: 605-614
        • Fujii N.
        • Yamashiro M.Y.
        Classification of malar complex fractures using computed tomography.
        J. Oral Maxillofac. Surg. 1983; 41: 562-567
        • Magerl F.
        • Aebi M.
        • Gertzbein S.D.
        • Harms J.
        • Nazarian S.
        A comprehensive classification of thoracic and lumbar injuries.
        Eur. Spine J. 1994; 3: 184-201
        • Ong T.K.
        • Dudley M.
        Craniofacial trauma presenting at an adult accident and emergency department with an emphasis on soft tissue injuries.
        Injury. 1999; 30: 357-363
        • Hussain T.A.
        • Wijetunge D.
        • Grubnik S.
        • Jackson I.
        A comprehensive analysis of craniofacial trauma.
        J. Trauma. 1994; 36: 34-37
        • Lee R.H.
        • Gamble W.B.
        • Robertson B.
        • Manson P.N.
        The MCFONTZL classification system for soft-tissue injuries to the face.
        Plast. Reconstr. Surg. 1999; 103: 1150-1157
        • Shepherd J.P.
        • Irish M.
        • Scully C.
        • Leslie I.
        Alcohol intoxication and severity of injury in victims of assault.
        Br. Med. J. 1988; 296: 1299