Die neue AO-CMF-Traumaklassifikation für Erwachsene – Überblick, Präzisions-Level und anatomische Module für Unterkiefer, Kiefergelenkfortsätze, Mittelgesicht und Orbita

Zusammenfassung

Neue Bildgebungstechnologien haben Einzug in klinische Routineanwendungen gehalten und zu innovativen Behandlungskonzepten geführt, was v. a. bei Kiefergelenkfortsatzfrakturen und Verletzungen des Orbitarahmens sowie der internen Orbita (Orbitawände) zum Ausdruck kommt. Das neue AO-CMF-Trauma-Klassifikationssystem für Erwachsene (3. Generation) beabsichtigt, den Fortschritten in der Frakturdarstellung auf CT-Basis Rechnung zu tragen. Drei Präzisionslevel bieten die Möglichkeit, Frakturlinienverläufe und -muster nach ihrer Lokalisation und hinsichtlich morphologischer Eigenschaften abgestuft bis zu einer bisher nicht dagewesenen Genauigkeit zu dokumentieren. Zur Dokumentation wird die CMF-Komponente des AOCOIAC-(AO COmprehensive Injury Automatic Classifer-)Software-Programms verwendet. AOCOIAC CMF ist benutzerfreundlich strukturiert mit Visualisierung der Regionen und Subregionen innerhalb der anatomischen Module. Durch Anklicken wird die Topografie und Ausdehnung einer Fraktur in den Illustrationen markiert. Über Pull-down-Menüs sind die Eigenschaften der Frakturen ebenso anwählbar wie über Datentabellen mit ankreuzbaren Kästchen. In Level 2 wird der Unterkiefer in 9 Subregionen unterteilt: Symphysis (S) + Bilateral: Body (B), Angle/Ascending Ramus (A), Coronoid Process (C), Condylar Process (P). Midface Level 2 differenziert laterale (= Zygoma/Zygomatic Arch Ensemble) und zentrale Kompartimente, wobei das zentrale Mittelgesicht 3 Etagen umfasst: Upper Central Midface (UCM), Intermediate Central Midface (ICM) und Lower Central Midface (LCM). In Level 3 werden die Subregionen im Processus condylaris und im Mittelgesicht in noch feinere Einheiten aufgegliedert. Zudem sind individuelle Patientenmerkmale, nämlich der prätraumatische Zahnstatus und die Alveolarfortsatzatrophie bei Zahnlosigkeit registrierbar. Auf dieser Basis wird es dann einfach, typische Frakturentitäten, d. h. Unterkiefer-Gelenkfortsatzfrakturen, Nasenskelett und Naso-Orbit-Ethmoidalfrakturen, Jochbein/Jochbogenfrakturen und Frakturen der Orbitawände in ihrem ganzen Variantenreichtum und bis ins Detail aufzuzeichnen, sowie Zahnhartsubstanz-, Zahnhalteapparatverletzungen und Alveolarfortsatzfrakturen zu dokumentieren. Die Morphologieeigenschaften der Frakturen (Fragmentation, Displacement/Dislokation, Knochendefekte) lassen sich als Attribute hinzufügen, um die Klassifikation auf dieser Stufe zu vervollständigen. In der Hoffnung der Autoren wird die vorliegende AO-CMF-Traumaklassifikation ein Nukleus zu einer verbesserten Standardisierung in der Befunderhebung und Diagnose von Traumen des gesamten Schädelskeletts, damit in Zukunft gleiche Worte auch das Gleiche meinen.

Abstract

New imaging technologies are now reaching clinical practice and generating innovative treatment concepts that have become particularly apparent in fractures of the mandibular condylar process and the internal orbit. The new comprehensive AO CMF trauma classification for adults has become a reality, i.e., the 3rd generation, and is intended to reflect the progress in the delineation of fracture patterns using CT imaging. Three precision levels, from elementary through basic to focused, provide the opportunity to document the location and morphology of fracture lines and patterns in hitherto unprecedented detail and clarity. The CMF partition of the AOCOIAC (AO COmprehensive Injury Automatic Classifer) software programme for the entire human skeleton is used for this documentation. This is organised in a user friendly format visualising the regions and subregions within each anatomic module. The topographical extent of a fracture is conveniently marked by locating and klicking the mouse cursor on the illustrations. The properties of the fracture are selected in pull-down menus or by ticking checkboxes in a side table data sheet. In Level 2 the mandible is divided into 9 subregions: symphysis (S) + bilaterally: body (B), angle/ascending ramus (A), coronoid process (C), condylar process (P). Midface level 2 distinguishes between lateral (= zygoma/zygomatic arch ensemble) and central compartments, the latter being a stack of three horizontal partitions: upper central midface (UCM), intermediate central midface (ICM) and lower central midface (LCM). In level 3 the topography of the subregions is further subdivided to display even more refined areas for fracture delineation. Moreover, individual patient features, namely the pre-injury dental state and the degree of alveolar atrophy in edentulism can be recorded. Based on the refined structural layout, it is easy to plot common fracture entities, i.e. mandibular condylar process fractures, nasal and naso-orbito-ethmoid (NOE) fractures, zygoma/zygomatic arch fractures and fractures of the internal orbits in their enormous range of variability and with ultimate sophistication as well as to assess tooth injuries, periodontal trauma and fracture involvement of the alveolar process. As a key attribute the focused level 3 approach permits to document the fracture morphology in terms of fragmentation, displacement and bone loss. The authors wish to express their hope that the present AO CMF Trauma Classification will provoke a flagship initiative for an incorporation of future innovations and amendments in the standardised description and diagnosis of CMF trauma in order to give an identical meaning to seemingly common terminology.

• Literatur

• 1 Audigé L, Bhandari M, Hanson B et al. A concept for the validation of fracture classifications. J Orthop Trauma 2005; 19: 401-406
• 2 Audigé L, Cornelius CP, Di Ieva A et al. CMF Classification Group 2013. Introduction to the Comprehensive AO Classification System for fractures of the craniomaxillofacial skeleton: rationale, methodological background, developmental process and objectives. Craniomaxillofac Trauma Reconstr (in press)
• 3 Audigé L, Cornelius CP, Buitrago-Téllez CH et al. The Comprehensive AO Classification system for fractures of the craniomaxillofaxial skeleton: software solution for documentation. Craniomaxillofac Trauma Reconstr (in press)
• 4 Bächli H, Leiggener C, Gawelin P et al. Skull base and maxillofacial fractures: Two centre study with correlation of clinical findings with a comprehensive craniofacial classification system. J Craniomaxillofac Surg 2009; 37: 305-311
• 5 Bagheri SC, Dierks EJ, Kademani D et al. Application of a facial injury severity scale in craniomaxillofacial trauma. J Oral Maxillofac Surg 2006; 64: 408-414
• 6 Buitrago-Téllez CH. Neue therapiebezogene Klassifikation von Mittelgesichtsfrakturen – Postmortale experimentelle und klinische Studien mit 2- und 3-dimensionaler Computertomographie. Freiburg: Habilitationsschrift Albert Ludwigs-Universität; 1998
• 7 Buitrago-Téllez CH, Schilli W, Bohnert M et al. A comprehensive classification of craniofacial fractures: postmortem and clinical studies with two- and three-dimensional computed tomography. Radiology 1999; 213 (Suppl.) S445
• 8 Buitrago-Téllez CH, Schilli W, Bohnert M et al. A comprehensive classification of craniofacial fractures: postmortem and clinical studies with two- and three-dimensional computed tomography. Injury 2002; 33: 651-668
• 9 Buitrago-Téllez CH, Audigé L, Strong B et al. A comprehensive classification of mandibular fractures: a preliminary agreement validation study. Int J Oral Maxillofac Surg 2008; 37: 1080-1088
• 10 Buitrago-Téllez CH, Audigé L, Cornelius CP et al. Systematic radiological approach for diagnosis and classification of craniomaxillofacial fractures using the Comprehensive AO System. Craniomaxillofac Trauma Reconstr (in press)
• 11 Carinci F, Zollino I, Brunelli G et al. Orbital fractures: a new classification and staging of 190 patients. J Craniofac Surg 2006; 17: 1040-1044
• 12 Chen CH, Wang TY, Tsay PK et al. A 162-case review of palatal fracture: management strategy from a 10-year experience. Plast Reconstr Surg 2008; 121: 2065-2073
• 13 Clark N, Birely B, Manson PN et al. High-energy ballistic and avulsive facial injuries: classification, patterns, and an algorithm for primary reconstruction. Plastic Reconstr Surg 1996; 98 (Suppl. 01) 583-601
• 14 Cooter RD, David DJ. Computer-based coding of fractures in the craniofacial region. Br J Plast Surg 1989; 42: 17-26
• 15 Cornelius CP, Audigé L, Prein J. AO Classification of craniomaxillofacial Fractures. In: Ehrenfeld M, Manson PN, Prein J, eds. Principles of internal Fixation of the craniomaxillofacial Skeleton-Trauma and orthognathic Surgery. Stuttgart, New York: Georg Thieme Verlag; 2012: 9-14
• 16 Cornelius CP, Audigé L, Kunz C et al. The Comprehensive AO Classification System for fractures of the craniomaxillofaxial skeleton: Mandible fractures Level 2. Craniomaxillofac Trauma Reconstr (in press)
• 17 Cornelius CP, Audigé L, Kunz C et al. The Comprehensive AO Classification System for fractures of the craniomaxillofaxial skeleton: Mandible fractures Level 3. Craniomaxillofac Trauma Reconstr (in press)
• 18 Cornelius CP, Audigé L, Kunz C et al. The comprehensive AO Classification System for fractures of the craniomaxillofaxial skeleton: Midface fractures Level 3. Craniomaxillofac Trauma Reconstr (in press)
• 19 Cornelius CP, Kunz C, Audigé L et al. The Comprehensive AO Classification System for fractures of the craniomaxillofaxial skeleton: Mandible and Midface Fractures – Case Collection. Journal Maxillofacial Trauma & Reconstruction (in press)
• 20 Cornelius CP, Probst FA, Ratgeber JPC et al. Zur Osteosynthese bei Frakturen im zahnlosen atrophen Unterkiefer – Möglichkeiten zum Hardware Downsizing, Lingual Plating. OP-Journal 2013; 29: 164-174
• 21 Di Ieva A, Audigé L, Kellman RM et al. The Comprehensive AO Classification System for fractures of the craniomaxillofaxial skeleton: Skull base and cranial vault fractures Level 2 and 3. Craniomaxillofac Trauma Reconstr (in press)
• 22 Donat TL, Endress C, Mathog RH. Facial fracture classification according to skeletal support mechanisms. Arch Otolaryngol Head Neck Surg 1998; 124: 1306-1314
• 23 Gruss JS, Hurwitz JJ, Nik NA et al. The pattern and incidence of nasolacrimal injury in naso-orbital-ethmoid fractures: the role of delayed assessment and dacryocystorhinostomy. Br J Plast Surg 1985; 38: 116-121
• 24 Hammer B. Orbital Fractures Diagnosis, operative Treatment, secondary Correction. Seattle, Toronto, Bern: Hogrefe und Huber; 1995
• 25 Jackson IT. Classification and treatment of orbito-zygomatic and orbitoethmoid fractures – the place of bone grafting and plate fixation. Clin Plast Surg 1989; 16: 77-91
• 26 Jaquiéry C, Äeppli P, Cornelius CP. Reconstruction of orbital wall defects: critical review of 72 patients. Int J Oral Maxillofac Surg 2007; 36: 193-199
• 27 Jaquiéry C, Leiggener C, Cornelius C et al. Aktuelle Behandlungsstrategien von knöchernen Verletzungen der Orbitae. OP-Journal 2013; 29: 136-146
• 28 Joos U, Meyer U, Tkotz T et al. Use of a mandibular fracture score to predict the development of complications. J Oral Maxillofac Surg 1999; 57: 2-5
• 29 Kunz C, Cornelius CP, Prein J et al. The Comprehensive AO Classification System for fractures of the craniomaxillofaxial skeleton: Midface fractures – Level 2. Craniomaxillofac Trauma Reconstr (in press)
• 30 Kunz C, Cornelius CP, Audigé L et al. The Comprehensive AO Classification System for fractures of the craniomaxillofaxial skeleton: Orbital fractures – Level 3. Craniomaxillofac Trauma Reconstr (in press)
• 31 Le Fort R. Étude Experimentale Sur Les Fractures De La Machoire Supérieure, Part I, Part II, Part III. Paris: Rev Chir 1901; 23: 208-227 360 – 379, 479 – 507
• 32 Loukota RA, Eckelt U, De Bont L et al. Subclassification of fractures of the condylar process of the mandible. Br J Oral Maxillofac Surg 2005; 43: 72-73
• 33 Luhr G, Reidick T, Merten HA. Frakturen des atrophischen Unterkiefers – eine Herausforderung für die Therapie. Fortschr Kiefer Gesichtschir 1996; 41: 151-154
• 34 Luhr HG, Reidick T, Merten HA. Results of treatment of fractures of the atrophic edentulous mandible by compression plating: a retrospective evaluation of 84 consecutive cases. J Oral Maxillofac Surg 1996; 54: 250-254
• 35 Madhusudan G, Sharma RK, Khandelwal N et al. Nomenclature of frontobasal trauma: a new clinicoradiographic classification. Plast Reconstr Surg 2006; 117: 2382-2388
• 36 Manson PN. Some thoughts on the classification and treatment of Le Fort fractures. Ann Plast Surg 1986; 17: 356-363
• 37 Markowitz BL, Manson PN, 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 Reconstr Surg 1991; 87: 843-853
• 38 Müller M, Narzarian S, Koch P et al. The comprehensive Classification for Fractures of long Bones. Berlin, Heidelberg, New York: Springer; 1990
• 39 Neff A, Audigé L, Rasse M et al. The Comprehensive AO Classification System for fractures of the craniomaxillofaxial skeleton: Mandibular condylar process fractures – Level 3. Craniomaxillofac Trauma Reconstr (in press)
• 40 Nolasco FP, Mathog RH. Medial orbital wall fractures: classification and clinical profile. Otolaryngol Head Neck Surg 1995; 112: 549-556
• 41 Rafferty MA, Mc Conn Walsh R, Walsh MA. A comparison of temporal bone fracture classification systems. Clin Otolaryngol 2006; 31: 287-291
• 42 Roth FS, Kokoska MS, Awwad EE et al. The identification of mandible fractures by helical computed tomography and panorex tomography. J Craniofac Surg 2005; 16: 394-399
• 43 Schiel S, Smolka W, Leiggener C et al. „Open book“-Frakturen des Mandibularbogens: bilaterale Gelenkfortsatzfrakturen in Kombination mit Paramedian-/Medianfrakturen des Unterkiefers. Operative Behandlungsstrategien. OP-Journal 2012; 28: 194-210
• 44 Schiel S, Probst FA, Mayer P et al. Kiefergelenkfortsatzbasis- und Kiefergelenkhalsfrakturen bei Kindern und Jugendlichen-Plädoyer für eine transoral endoskopisch assistierte operative Versorgung bei starker Dislokation und Luxation. OP-Journal 2013; 29: 156-163
• 45 Schmalzriedt E. Inhumane Klassik, Vorlesung wider ein Bildungsklischee mit den wichtigsten Dokumenten zur Tradition eines fragwürdigen Begriffs. München: Kindler; 1971
• 46 Slongo T, Audigé L. AO Pediatric Classification Group. Fracture and dislocation classification compendium for children – The AO pediatric comprenhensive classification of long bone fractures (PCCF). J Orthop Trauma 2007; 21 (Suppl. 10) S135-S160
• 47 Spiessl B, Schroll K. Gelenkfortsatz- und Gelenkköpfchenfrakturen. In: Nigst H, Hrsg. Spezielle Frakturen- und Luxationslehre, Band I/1 Gesichtsschädel. Stuttgart, New York: Georg Thieme Verlag; 1972: 136-152
• 48 Spiessl B. Internal Fixation of the Mandible. A Manual of AO/ASIF Principles. Heidelberg, New York: Springer; 1989
• 49 Strong EB, Fuller SC, Chahal SH. Computer-Aided Analysis of Orbital Volume: A Novel Technique. Ophthal Plast Reconstr Surg 2013; 29: 1-5
• 50 Tessier P. The classic reprint. Experimental study of fractures of the upper jaw. Parts I and II. In: Le Fort R, Lille MD (Rev. chir. de Paris 23, 208–227, 360–379, 1901). Paris: Plast Reconstr Surg 1972; 50: 497-506
• 51 Tessier P. The classic reprint. Experimental study of fractures of the upper jaw. Part III. In: Le Fort R, Lille MD (Rev. chir. de Paris 23, 479–507, 1901). Paris: Plast Reconstr Surg 1972; 50: 600-605
• 52 Wassmund M. Frakturen und Luxationen des Gesichtsschädels. Berlin: Meusser; 1927
• 53 Zhang J, Zhang Y, El-Maaytah M et al. Maxillofacial Injury Severity Score: proposal of a new scoring system. Int J Oral Maxillofac Surg 2006; 35: 109-114
• 54 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