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Int. J. Oral Maxillofac. Surg.

2008; 37: 10801088


doi:10.1016/j.ijom.2008.06.008, available online at http://www.sciencedirect.com

Leading Clinical Paper


Trauma

A comprehensive classification
of mandibular fractures: a
preliminary agreement

validation study
C. H. Buitrago-Tellez, L. Audige, B. Strong, P. Gawelin, J. Hirsch, M. Ehrenfeld, R.
Ruddermann, P. Louis, C. Lindqvist, C. Kunz, P. Cornelius, K. Shumrick, R. M.
Kellman, A. Sugar, B. Alpert, J. Prein, J. Frodel: A comprehensive classification of
mandibular fractures: a preliminary agreement validation study. Int. J. Oral
Maxillofac. Surg. 2008; 37: 10801088. # 2008 International Association of Oral
and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

Abstract. This study evaluates a comprehensive classification system for mandibular


fractures based on imaging analysis. The AO/ASIF scheme, defining three fracture
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) was used. The mandible is divided into two vertical units
(I and V), two lateral horizontal units (II and IV) and one central unit (III)
comprising the symphyseal and parasymphyseal region. Type A fractures are nondisplaced, type B are displaced and type C are multifragmentary/defect injuries.
Groups and subgroups are further defined in the classification system. Two
classification sessions using semi-automatic software with 7 and 9 surgeons were
performed to evaluate 100 fracture cases in the first session and 50 in the second.
Inter-observer reliability and individual raters accuracy were evaluated by kappa
coefficient and latent class analysis, respectively. The analysis of inter-observer
agreement for the detailed coding showed kappa coefficients around 0.50 with
higher agreement among raters in the vertical units. This system allows
standardization of documentation of mandibular fractures, although improvement
in the definition of categories and their application is required.

The classification of mandibular fractures is


difficult in clinical practice because of a lack
of agreement on a standardized system for

describing fracture patterns. As a result, therapeutic decisions about the best approach,
and about the urgency and extent of a sur-

C. H. Buitrago-Tellez1, L. Audige2,
B. Strong3, P. Gawelin4, J. Hirsch4,
M. Ehrenfeld5, R. Ruddermann6,
P. Louis7, C. Lindqvist8, C. Kunz9,
P. Cornelius10, K. Shumrick11,
R. M. Kellman12, A. Sugar13,
B. Alpert14, J. Prein9, J. Frodel15
1
Institute of Radiology, Zofingen Hospital AG
and Hightech Research Center University of
Basel, Switzerland; 2AO Clinical Investigation
and Documentation, Dubendorf, Switzerland;
3
Department of Otolaryngology-HNS, U.C.Davis Med. Ctr. Sacramento, USA;
4
Department of Surgical Sciences, Oral &
Maxillo-Facial Surgery, Uppsala University
Hospital, Uppsala, Sweden; 5Clinic and
Policlinic Oral & Maxillo-Facial Surgery, LMU
University Hospital, Munich, Germany;
6
Private Clinic Alpharetta, USA; 7Department
of Oral & Maxillofacial Surg., Birmingham,
USA; 8Department Oral & Maxillofacial
Surgery, Helsinki University Central Hospital,
Finland; 9Oral & Maxillo-Facial Surgery, Basel
University Hospital, Switzerland; 10Oral and
Maxillofacial Surgery, Military Hospital Ulm,
Germany; 11Department of OtolaryngologyHead & Neck Surgery, University of Cincinati,
USA; 12Department of Otolaryngology-Head
& Neck Surgery and Communication
Sciences, Syracuse, USA; 13Cleft and
Maxillofacial Unit, Morriston Hospital, UKSwansea, Wales, UK; 14Department of Oral &
Maxillofacial Surgery, University of Louisville
School of Dentistry, Louisville, USA;
15
Department of Otolaryngology-Head &
Neck Surgery Geisinger Medical Center,
Danville, USA

Keywords: mandibular fractures; classification;


face; fractures; conventional panoramic tomography; fractures; validation; reliability.
Accepted for publication 6 June 2008
Available online 30 July 2008

gery, if indicated, are more difficult to make


because there is not always sufficient information about the real extent of the fracture.

The sponsor of this study is the AO Classification Supervisory Committee.

0901-5027/1201080 + 09 $30.00/0

# 2008 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

A comprehensive classification of mandibular fractures: a preliminary agreement validation study

1081

Fig. 1. Mandibular views with division lines for the vertical, lateral horizontal and central units. (a) Panoramic view showing the vertical
mandibular units (green), the lateral horizontal units (orange) and the central mandibular unit (red). The vertical mandibular units include the
subcondylar/condylar region, the ascending ramus and the mandibular angle. The lateral horizontal mandibular units comprise the lateral
mandibular bone and the dentoalveolar components. The central mandibular unit includes symphyseal and parasymphyseal regions. (b) Lateral
view showing the vertical mandibular unit (green), the lateral horizontal unit (orange) and the central mandibular unit (red).

Several classification systems have


been proposed to define condylar head
and condylar process, angle, mandibular
body, alveolar process and mandibular
fractures as a whole4,79,1115,2023. None
of these classifications follows a commonly accepted systematic scheme and
none has been thoroughly validated1,2.
The shortcomings of existing classification systems include the lack of: scoring
for a combined fracture, an ability to
classify multiple separate osseous regions
with isolated fractures, ability to classify
severe fractures patterns resulting from
high-velocity or gun-shot injuries.
The aims of this study are to: incorporate
a new mandible fracture classification system into the existing AO/ASIF (Arbeitsgemeinschaft fur Osteosynthesefragen/ASIF:
Association for the Study of Internal Fixation) scheme used successfully in other
anatomical regions10,16,17,24; evaluate the
reliability and accuracy of the proposed
classification system among experienced
surgeons; and implement developed
semi-automatic software for classifying
and documenting mandibular fractures in
a database using this classification system.
The potential benefits of a standardized
classification scheme for the mandible
include improved interdisciplinary communication between the teams involved in
diagnosis, therapy and cost management
(radiologists, surgeons, health administration authorities) as well as the potential for
use in outcome analysis, facilitating comparison of different therapeutic strategies
and health-care units.
Material and methods
AO-analogue classification system of
mandibular fractures

The proposed classification system differentiates one vertical and one lateral horizontal mandibular compartment on each

side as well as a central sympyseal/parasymphyseal compartment. It is divided


into five units. Right and left vertical units
(I + V), right and left lateral horizontal
units (II + IV) and a central unit (III).
The vertical units (I and V) are further
subdivided into three subunits: the subcondylar/condylar region; the ascending
ramus; and the mandibular angle. The
lateral horizontal units (II and IV) include
the mandibular bone and the dentoalveolar
regions. The central unit (III) comprises
the symphyseal and parasymphyseal
regions (Fig. 1). Each compartment is
separated by specific anatomical landmarks. The division line between the vertical and lateral horizontal units lies
between the eighth and seventh molars
(Fig. 1).
The division line between the lateral
horizontal units and the central unit lies
on a line through the apices of the canine
teeth. The central unit lies anterior and
medial of the lines through the canines,
with a further definition of symphyseal
fractures between the apices of the central
incisors.
Each compartment is classified independently, describing the degree of
displacement and the presence of multifragmentation or osseous defects. Each
fracture is classified: type A, nondisplaced fractures (no change of axis and
no step off and full contact along the
fracture line); type B, displaced fractures
(change of axis or step off or no contact
along fracture line); and type C, multifragmentary/defect fractures (no or minimal contact between main fragments and
two or more separate major intermediate
fragments or major bone defect/bone
loss).
Each fracture is divided into 3 groups,
specific to the mandibular unit. For the
vertical units, the following definitions
apply: Group 1 fractures involve one of
the three subunits (mandible angle,

ascending ramus or subcondylar/condylar)


in isolation; Group 2 fractures involve 2
subunits (angle, ascending ramus, etc)
without condylar head luxation; and
Group 3 fractures include an associated
luxation of the condylar head.
For the lateral horizontal mandibular
units and central fractures the groups are
defined according to the severity of the
fracture pattern and the presence of associated atrophy.
Group 1 fractures are single fracture
lines involving the dentoalveolar component or the mandibular body or the symphyseal/parasymphyseal region. Group 2
fractures involve either a basal triangle or
two separate fracture lines. Group 3 fractures include associated alveolar process
atrophy.
The proposed classification scheme,
with groups, subgroups and further specifications is summarized in Table 1. A short
anatomical keyword is linked to each
fracture subgroup to identify the subgroup
with the coding system and its assigned
topography. The complete fracture formula of a complex mandibular fracture
describes the exact fracture pattern of each
compartment separately.
Mandibular fracture classification
software

The analysis of craniofacial fractures is


complex and time-consuming, therefore a
computer software tool has been developed to facilitate its use (Buitragos CrAnio-Facial Fracture Automatic Classifier:
CAFFAC 2001)19. This software was
developed with support from an AO/ASIF
Research Commission Grant (Project
2000-B55). On the basis of this software
a further mandible module was developed
in the setting of this study. The software
generates an interactive drawing of the
mandible and the user can specify the
fracture lines as well as the fracture loca-

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Buitrago-Tellez et al.

tion and type of fracture (A, B or C: nondisplaced, displaced or multifragmentary/


defect fractures). This allows the semiautomatic classification of every segment
and the corresponding fracture code is
recorded (Fig. 2).
Classification sessions

Two classification sessions of patients


with previously confirmed mandibular
fractures were performed without access
to independent clinical data to test the
classification scheme and CAFFAC software. Seven experienced surgeons evaluated 100 consecutive mandibular fractures
from a single institution on anonymized
panoramic radiographs as well as a second
view (inverse Waters view or PA or oblique views) in a first session. The second
session involved 9 experienced surgeons
evaluating 50 fractures using the same
protocol. In addition, 10 transaxial CT
scans with coronal reconstructions were
evaluated using the classification scheme
and the CAFFAC software. All identification marks were removed and the fractures
were presented in random order for classification. After receiving appropriate
instruction on the CAFFAC software each
surgeon classified the fractures independently using two computers: one for visualizing the diagnostic images, the other to
classify the fractures using the CAFFAC
software.
Statistical analysis

The classification software saves the


results in specific files for each case as
well as in an MS Access database. All data
were transferred and combined into the
statistical software Intercooled Stata version 8 (Stata corporation, Texas, USA) for
detailed analysis. Data from each side
were combined. The authors hypothesized
that the coding and classification process
would not differ according to the side of
the bones. They looked at the full classification code given by the software for
each vertical unit, as well as the more
specific part (A,B,C and for the groups
1,2,3). The analysis of subgroup classification within subgroups was only descriptive within the full detailed coding given
the limited sample size. Each anatomical
region was considered separately, along
with the type of fracture identified.
Because of possible multiple fractures,
the classification may be understood as
a combination of multiple individual classifications of anatomical structures as
being fractured or not fractured and
for fractured regions, as being non dis-

placed, displaced or multifragmentarydefect. This part of the analysis was


conducted on that principle: all the cases
were considered together first, and then

cases for which no fracture was reported


by any of the raters were excluded.
The number of cases showing full coding agreement among raters is presented.

Table 1. AO-analogue classification of mandibular fractures

A comprehensive classification of mandibular fractures: a preliminary agreement validation study

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Results
Mandibular fracture classification
software

Implementation of the mandible module


of the Buitrago-CAFFAC software was
achieved after receiving appropriate
instruction. Each surgeon classified the
fractures independently using the software
to draw the fracture lines interactively in
the affected unit in a scheme of the mandible (Fig. 2) and deciding on displacement,
fragmentation and atrophy. The result of
the fracture formula was documented in
the software and the specific score was
sent to a data bank automatically for statistical analysis.
Kappa coefficient analysis of
interobserver agreement (session 1
and 2)

Kappa coefficients were computed for


all categories. Rater pair-wise kappa coefficients were computed when the overall
kappa coefficient was >0.6.
The kappa coefficient is described
as (Po Pe)/(1 Pe), i.e. a chancecorrected measure of agreement with
Po being the observed proportion of
agreement and Pe the proportion of
agreement expected by chance alone.
It ranges from +1 (complete agreement)
through 0 (agreement by chance alone)
to less than 0 (less agreement than
expected by chance). Although interpretation remains difficult in many circumstances1, the authors considered that a

kappa >0.70 was a good sign of reliability.


For the second classification session,
the level of classification accuracy using
the technique of latent class modelling1,25 was assessed using the software
Latent Gold26. This evaluation was conducted only when the kappa coefficient
was >0.60 and for limited targeted items
in the classification. The potential
change in classification accuracy that
may result from a combination of categories (e.g. displaced and multifragmentary fractures together instead of asking
surgeons to differentiate them) was also
assessed.

In general, overall kappa coefficients


rarely exceeded 0.70 for detailed codes,
coding of A,B,C or fracture severity. The
analysis of inter-observer agreement
for the detailed coding showed kappa
coefficients around 0.50 with higher
agreement among raters in the vertical
units (Table 2).
When considering only A,B,C type
categories, kappa coefficients for coding
units separately were 0.600.70 with all
units included, but remained in the ranged
0.400.60 when non-fractured units were
excluded (Table 3). Considering the individual regions separately, the highest
reliability was observed for the vertical
mandibular units, lower third of the subcondylar region, with kappa values of 0.62
and 0.73 with and without non-fractured
regions, respectively. Most other kappa
coefficients were between 0.20 and 0.60.
For the coding of severity subtypes
1,2,3 categories, kappa coefficients for
coding units separately were 0.600.70
with all units included, but fell to 0.20
0.40 when non-fractured units were
excluded (Table 4).
For both A,B,C and 1,2,3 ratings and all
units, ranges of surgeons pair-wise kappa
coefficients of reliability were between
0.300.50 and 0.700.80 (Table 5) suggesting possibilities for improvement.
Latent class analysis of accuracy for
detection of fracture type (A,B,C) in
session 2

Latent class analysis allows a differentiated evaluation of accuracy of the classification system based on estimation of a
reference standard using clusters identified from all ratings. This standard is

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Buitrago-Tellez et al.

Fig. 2. Buitragos CrAnio-Facial Fracture Automatic Classifier (CAFFAC) software. Mandibular module: panoramic view showing documentation of a multifragmentary subcondylar fracture on the right with involvement of the condylar head, a non-displaced lateral mandibular body
fracture on the right and a displaced symphyseal fracture. Note the exact display of the fracture formula and the corresponding ICD 10 on the left
corner of the scheme. The system automatically gives the fracture formula: right vertical unit/right horizontal unit/central unit/left horizontal unit/
left vertical unit.: C1.3/A1.2/B1.2//.

compared with the single rating of each


rater, so this analysis allows a separate
insight into the accuracy of each rater and
detects possible diagnostic problems1.
Classification data for vertical unit mandibular fractures were consistent with
three classes of fractures with a distribution of 48%, 13% and 39%, respectively
(Table 6). The first cluster was classified in
93% to 98% as not fractured by all
surgeons; it is likely that this cluster represents the group of non-fractured units. The
second cluster was classified in 65% to
85% as A (non-displaced fractures) with
some misclassification being observed
with not fractured (most surgeons) or
displaced fractures (raters 6, 8 and 9).
This is a small fracture cluster including
both non-displaced fractures not easily
identified (hence overlooked by some
raters), as well as clear fractures classified
as displaced by one-third of raters. The
third cluster likely represents displaced or
multifragmentary fractures. Either C fractures were too rare or the sample size was
too small for proper identification.

A similar result pattern was observed


regarding the lateral-horizontal unit, with
Cluster 1, representing 70% of all units,
being clearly identified by all surgeons as
not fractured. The second and third clusters made 10% and 19% of the units,
respectively.
Results for the central-horizontal unit
showed a similar pattern with 75%, 12%
and 14% of units being identified in a
non-fractured cluster of units, a nondisplaced fracture cluster of units, and a
cluster with the remaining units, respectively. The latter cluster appears to contain
units that were less frequently classified as
multifragmentary or defect than in the
lateral-horizontal units.
Discussion

A classification scheme for mandibular


fractures should meet several requirements. It should be logically structured
and systematic and should provide an
accurate representation of the potential
complexity of mandibular fracture pat-

terns. It should also provide information


about the therapeutically relevant regions
involved, including the vertical and horizontal components. It should provide
information regarding the severity of the
injury and guidance as to the choice of
treatment. The classification system
should be comprehensive, so that every
relevant injury can be precisely defined. It
should also be compatible with electronic
data collection and facilitate the comparison of the outcomes of different therapeutic approaches to mandibular fractures.
A systematic method for analyzing
mandible fractures and quantitatively
summarizing the extent and severity of
the injury is long overdue20.
After defining the classification categories according to the proposed AO-analogue system, the classification process
was evaluated using specific diagnostic
images evaluated by experts in a series
of agreement studies3.
The aim of this study phase was to
develop a classification system that is
clinically relevant and demonstrates suffi-

A comprehensive classification of mandibular fractures: a preliminary agreement validation study


Table 2. Kappa coefficients of raters reliability for full coding of mandibular units
Session 1
Excluding
units not
fractureda

All cases
Unit
Vertical Unit
Lat-Horiz Unit
Central-Horiz Unit
a

Session 2

All cases

Excluding
units not
fractureda

Kappa

Kappa

Kappa

Kappa

200
200
100

0.63
0.49
0.50

114
63
56

0.53
0.36
0.31

120
120
60

0.67
0.57
0.53

74
41
37

0.54
0.46
0.29

Excluding units for which all raters classified not fractured.

Table 3. Kappa coefficients of raters reliability for A, B, C fracture types coding for mandibular
units
Session 1

All units
Units

Session 2

Excluding
units not
fractureda

All units

Excluding
units not
fractureda

Kappa

Kappa

Kappa

Kappa

Vertical
not fractured
A
B
C

200

0.66
0.80
0.50
0.63
0.12

114

0.45

120

0.71
0.85
0.62
0.67
0.24

74

0.53

Lat-Horiz
not fractured
A
B
C

200

0.57
0.68
0.39
0.51
0.55

63

0.64
0.74
0.58
0.56
0.54

41

Central-Horiz
not fractured
A
B
C

100

0.56
0.69
0.47
0.46
0.12

56

0.66
0.78
0.49
0.63
0.50

37

0.52
0.45
0.10
0.51

120

0.52
0.51
0.50
0.39
0.41
0.38
0.34

60

0.62
0.51
0.27
0.61
0.71
0.56
0.54
0.50
0.48
0.48
0.64

Categories: A, non-displaced fracture; B, displaced fracture; C, fracture multifragmentary or


defect.
a
Excluding units for which all raters classified not fractured.

cient reliability and accuracy prior to


implementation in daily practice. Current
results provide a solid basis for further
development. The proposed classification
system is logically structured and systematic and provides an accurate image
of the complexity of a specific mandibular
fracture.
It provides information about the therapeutically relevant regions involved,
including the vertical and horizontal components. It mirrors the severity of the
injury and provides information necessary
for the choice of treatment. This system is
comprehensive, so that every relevant
injury can be defined precisely. It is compatible with electronic data collection, as
implemented successfully by the CAFFAC software with data base capabilities
throughout the study. Such a system facilitates the comparison of the outcomes of
different therapeutic approaches to mandibular fractures, within or between surgical units, for bench-marking.

The proposed system for classification


of mandibular fractures considers the following criteria: fracture location (vertical
or horizontal units with subunits); fracture
type (degree of displacement or fragmentation: A,B or C); presence of associated
condylar head luxation with or without
condylar or subcondylar head fracture;
presence of atrophy and specific fracture
patterns in the horizontal mandible. To
provide an easily recognizable grid for
classifying the mandibular injuries, the
3-3-3 scheme of the AO fracture classification system was adapted to this region.
The three principal categories (the types)
are determined by analyzing the displacement patterns of fragmentation or the presence of osseous defects. These three basic
types (A, nondisplaced; B, displaced; C,
multifragmentary-defect fractures) were
defined precisely before the classification
sessions. For a specific mandible injury a
fracture formula including the classification of the right and left lateral and hor-

1085

izontal units, as well as the central region


is documented after classifying a case
(Fig. 2).
The system showed good agreement
and accuracy in detecting non-fractured
segments and clear fractures. Non-displaced fractures appeared to make a cluster but some surgeons overlooked them
probably because their search for fracture lines was less motivated when they
had identified more relevant injuries in
other anatomical regions. In more complex situations, the distinction between
displaced and multifragmentary/defect
fractures appeared insufficient as highlighted by latent class analyses. This
may have been caused by the relatively
few cases of multifragmentary fractures
evaluated or a lack of uniform understanding and application of definitions to separate these two types. Latent class analysis
could not discriminate very clearly
between displaced and multifragmentary/defect fractures.
A more comprehensive approach to
mandibular fractures was proposed by
SPIESSL21,22, who consider specific locations, fragmentation and soft tissue considerations. Its practical use would be
associated with a lengthy description of
severe fractures, as each segment must be
analyzed for fragmentation, location, soft
tissue or even occlusion. A classification
coding with that system would not be
possible without clinical examination,
which may be a limiting factor for classifying fractures on the base of imaging
studies alone. The concept of SPIESSL
and SCHROL22 (location, degree of fragmentation) is partly integrated in the
actual system and summarized into five
basic mandibular units (two vertical, two
lateral horizontal and one central) with
corresponding subunits. A refinement of
the Spiessl classification system, including
a mandible injury severity score, has
recently been developed20.
The current AO-analogue system describing a complex fracture in a single
fracture formula including all fracture segments allows the calculation of a numeric
score for a specific case, although this was
not the aim of the current study. The
scoring system based on this system will
be the subject of further research, because
of increasing interest in injury severity
scores for prognostic and cost analysis.
Mandibular classifications in general
may include differentiation between compound or closed, incomplete or complete,
unstable or stable fractures. Other classifications to supplement more complex
areas of the mandible, like the condylar
region and alveolar process, have been

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Buitrago-Tellez et al.

Table 4. Kappa coefficients of raters reliability for 1-2-3 fracture subtypes coding for mandibular units
Session 1

All units
Units

Session 2

Excluding
units not
fractureda

Kappa

Vertical
not fractured
1
2
3

200

0.74
0.80
0.73
0.20
0.00

114

Lateral-Horizontal
not fractured
1
2
3

200

0.56
0.68
0.48
0.39
0.00

63

Central-Horizontal
not fractured
1
2
3

100

0.63
0.69
0.60
0.33
0.00

56

Kappa
0.16

All units
n

Kappa

Kappa

120

0.75
0.85
0.74
0.31
0.02

74

0.28

0.63
0.74
0.58
0.37
0.58

41

0.68
0.78
0.67
0.28
0.15

37

0.20
0.14
0.06
0.27

120

0.27
0.28
0.05
0.25

Excluding
units not
fractureda

60

0.25
0.27
0.03

0.29
0.29
0.02
0.42
0.40
0.34
0.63
0.25
0.24
0.26
0.27

Categories for vertical units: 1 fracture one of the three defined subunits in isolation; 2,
combined fractures of the units without condylar head luxation; 3, associated luxation of the
condylar head.
Categories for Lateral-Horizontal or Central-Horizontal units: 1, single fracture line; 2, basal
triangle or two separate fracture lines; 3, associated atrophy.
a
Excluding units for which all raters classified not fractured.
Table 5. Raters pair-wise kappa coefficient of reliability for classification of types and subtypes
in mandibular units in session 2
Categories

Number of pairs of raters

A-B-C
A-B-C
1-2-3
A-B-C
1-2-3

36
36
36
36
36

Units
Vertical Unit
Lat-Horiz Unit
Central-Horiz Unit

Kappa
Median

Min

Max

0.73
0.68
0.64
0.66
0.69

0.60
0.42
0.33
0.51
0.50

0.82
0.83
0.82
0.80
0.83

Categories: A, non-displaced fracture; B, displaced fracture; C, fracture multifragmentary or


defect; 1, single fracture line; 2, basal triangle or two separate fracture lines; 3, associated
atrophy.

proposed and may be considered as an


add-on to the authors proposed system4,69,1115,2123. They may be of clinical value only in specific settings, but do
not describe the complete fracture pattern
in severe cases, thus complicating the
analysis of treatment outcome.
Fractures of the condylar/subcondylar
region deserve special interest18. LIN11
considered the fracture level for
DAHL
classification of condylar fractures (condylar head, neck or high/low subcondylar
fractures), the relation of the condyle to
the mandible (non-displaced, deviated or
dislocation at the fracture level), condylar
head relation to the articular fossa (nondisplaced, deviated or angulated, displaced in any direction or no bony contact)
and the relation of the condyle to the fossa
(non-displaced, displaced still related to

the fossa or luxation completely out of the


fossa). The issue of fracture level at the
condylar and subcondylar level based on
imaging studies is controversial and needs
to be defined. The proposed system
divided the subcondylar region into three
thirds for classification. SPIESSL and
SCHROL22 proposed a system to classify
these fractures into six groups, including
neck and condylar head fractures with
different degrees of displacement and
luxation. This system was extended by
HLAWITSCHKA and ECKELT8, who differentiated condylar head fractures into: type A
with subluxation of parts of the condylar
head without change of vertical dimension; type B with loss of vertical height
and loss of contact with the fossa; and type
M with multifragmentation and subsequent loss of vertical dimension. Intracap-

sular and extracapsular fractures may be


classified radiologically with high confidence only when the condylar head is
fractured. The degree of displacement of
extracapsular fractures was classified by
MACLENNAN15 in 1952, who identified four
classes: I, non-displaced; II, deviation at
the fracture; III, displacement without loss
of contact with the fossa; and IV, luxation
with complete loss of contact with the
fossa. This kind of focused classification
may be useful for outcome analysis of
single condylar head or neck injuries,
but does not take into account associated
mandibular fractures. The fracture formula using the proposed system includes
the condylar region and all concominant
fractures as a whole fracture pattern.
As the severity score in this AO analogue classification system increases with
increased complexity, the presence of
atrophy is included as an important criterion. The degree of atrophy has been classified by LUHR et al13,14 into three classes:
I, 1620 mm; II, 1015 mm; and III, less
than 10 mm. The proposed system differentiates only two classes: more or less than
10 mm. The threshold of 10 mm is used
widely27 and correlates with higher incidence of complications. Another specific
issue of importance for angular mandibular fractures is the location or impaction of
the third molar, which may increase fracture risk5. This criterion is also included in
the coding of the new system.
One of the limitations of the proposed
system is that it requires familiarity with
the AO classification scheme described by
MUELLER et al17. The general AO guidelines for fracture classification have been
successfully applied in the long bones and
in complex anatomical regions such as the
pelvis10,24 or the spine16.
The proposed classification system does
not directly consider soft tissue injuries,
which are important in facial injury and
may compromise the final outcome in
trauma patients, even if there is adequate
fracture treatment. Soft tissue injuries are
more common than fractures and may not
be assessed properly by imaging methods.
A separate classification system for soft
tissue injuries, based on inspection and
clinical examination would be useful in
daily practice, including functional and
injury severity score grading20,28. A combination of mandibular fractures and soft
tissue injuries has been considered for
calculating a specific mandibular scoring
index9.
The use of the classification system is
systematic but time-consuming. The semiautomatic mandibular classifier software
(CAFFAC) which identifies the basic type

A comprehensive classification of mandibular fractures: a preliminary agreement validation study


Table 6. Latent class analysis of individual raters accuracy in classifying A, B, C fracture types
in mandibular units (session 2)
Lateral-Horizontal
Units

Vertical units

Surgeons

Centra-Horizontal Unit

No Fx

B-C

No Fx

B-C

No Fx

B-C

48%

13%

39%

70%

10%

19%

75%

12%

14%

No Fx
A
B
C

96%
2%
2%
0%

14%
85%
1%
0%

5%
32%
59%
4%

100%
0%
0%
0%

75%
25%
0%
0%

40%
21%
21%
17%

98%
2%
0%
0%

23%
70%
7%
0%

2%
62%
31%
6%

No Fx
A
B
C

95%
0%
5%
0%

14%
85%
1%
0%

7%
2%
72%
19%

98%
2%
0%
0%

10%
57%
16%
17%

14%
4%
34%
47%

99%
1%
0%
0%

51%
35%
14%
0%

2%
0%
86%
12%

No Fx
A
B
C

93%
2%
5%
0%

14%
85%
1%
0%

7%
2%
87%
4%

100%
0%
0%
0%

35%
65%
0%
0%

23%
0%
56%
21%

99%
0%
1%
0%

51%
35%
15%
0%

20%
6%
68%
6%

No Fx
A
B
C

98%
0%
2%
0%

14%
85%
1%
0%

2%
13%
83%
2%

99%
0%
1%
0%

2%
98%
0%
0%

31%
9%
52%
9%

98%
1%
0%
1%

37%
63%
0%
0%

2%
19%
74%
6%

No Fx
A
B
C

98%
0%
0%
2%

21%
79%
1%
0%

2%
6%
72%
19%

95%
0%
2%
2%

10%
89%
0%
0%

14%
9%
43%
35%

100%
0%
0%
0%

37%
56%
0%
7%

20%
6%
61%
12%

No Fx
A
B
C

98%
0%
2%
0%

1%
79%
20%
0%

5%
11%
83%
2%

100%
0%
0%
0%

26%
73%
0%
0%

27%
9%
47%
17%

96%
0%
3%
1%

2%
77%
22%
0%

8%
19%
68%
6%

No Fx
A
B
C

96%
2%
2%

15%
84%
1%

3%
11%
85%

100%
0%
0%
0%

41%
58%
0%
0%

6%
5%
78%
10%

100%
0%
0%

51%
48%
0%

2%
27%
71%

No Fx
A
B
C

96%
0%
4%
0%

8%
72%
20%
0%

8%
0%
87%
5%

100%
0%
0%
0%

20%
71%
9%
0%

15%
0%
67%
18%

100%
0%
0%
0%

55%
37%
8%
0%

9%
0%
84%
7%

No Fx
A
B
C

98%
2%
0%
0%

8%
65%
27%
0%

0%
2%
91%
6%

100%
0%
0%
0%

10%
81%
8%
0%

14%
0%
69%
17%

99%
1%
0%
0%

30%
49%
21%
0%

2%
19%
74%
6%

Categories
Clusters
Cluster Sizes
1

Categories: No Fx, no fracture reported; A, non-displaced fracture; B, displaced fracture; C,


fracture multifragmentary or defect.

by drawing the fracture pattern seems to


be easy and reliable for clinical use19.
In conclusion, the proposed mandibular
fracture classification system based on a
hierarchical organization into triads, analogous to the AO scheme, allows comprehensive description and documentation of

all fractures in a singular fracture formula,


which may be the basis for an AOanalogue mandible injury severity score.
This AO-analogue classification system
enables the user to record the precise
location of an osseous injury, displacement degree, fragmentation, presence of

1087

condylar head luxation or mandibular


atrophy. The proposed system allows standardization of documentation of mandibular fractures Reliability and accuracy
estimates suggest the need for further
improvement in understanding the definition of the categories and their application.

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Address:
Carlos H. Buitrago-Tellez
Hightech Research Center University of Basel
Institute of Radiology
Zofingen Hospital
Switzerland
Muhletalstr 27
CH 4800 Zofingen
Tel: +41 (62) 746 5802
Fax: +41 (62) 746 5888
E-mail: carlos.buitrago@spitalzofingen.ch