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.
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
0901-5027/1201080 + 09 $30.00/0
# 2008 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
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).
The proposed classification system differentiates one vertical and one lateral horizontal mandibular compartment on each
1082
Buitrago-Tellez et al.
1083
Results
Mandibular fracture classification
software
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
1084
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//.
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
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
1085
1086
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
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
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
1087
References
1. Audige L, Bhandari M, Kellam J.
How reliable are reliability studies of
fracture classifications? A systematic
review of their methodologies. Acta
Orthop Scand 2004: 75: 184194.
2. Audige L, Hunter J, Weinberg A,
Magidson J, Slongo T. Development
and evaluation process of a pediatric
long-bone fracture classification proposal. Eur J Trauma 2004: 30: 248254.
3. Audige L, Bhandari M, Hanson B,
Kellam J. A concept for the validation
of fracture classifications. J Orthop
Trauma 2005: 19: 404409.
4. Clark WD. Management of mandibular
fractures. Am J Otolaryngol 1992: 13:
125132.
5. Ellis III. Outcomes of patients with teeth
in the line of mandibular angle fractures
treated with stable internal fixation. J Oral
Maxillofac Surg 2002: 60: 863865.
6. Ellis III. Treatment considerations for
comminuted mandibular fractures. J Oral
Maxillofac Surg 2003: 61: 861870.
7. Haug RH, Greenberg AM. Etiology,
distribution and classification of fractures. In: Greenberg AM, ed: Craniomaxillofacial Fractures: Principles of
Internal Fixation Using the AO/ASIF
Technique. New York: Springer Verlag
1993: 520.
8. Hlawitschka M, Eckelt U. Assessment of patient treated for intracapsular
fractures of the mandibular condyle by
closed techniques. J Oral Maxillofac Surg
2002: 60: 784791.
9. Joos U, Meyer U, Tkotz T, Weingart
D. Use of a mandibular fracture score to
predict the development of complications. J Oral Maxillofac Surg 1999: 57:
25.
10. Letournel E, Judet R. Fractures of the
Acetabulum. Berlin, Heidelberg, New
York: Springer-Verlag 1993.
11. Lindahl L. Condylar fractures of the
mandible. I. Classification and relation
to age, occlusion, and concomitant injuries of teeth-supporting structures, and
fractures of the mandibular body. Int J
Oral Surg 1977: 6: 1221.
12. 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: 72
73.
13. Luhr HG, Reidick T, Merten HA.
Fractures of the atrophic mandible-a challenge for therapy. Fortschr Kiefer
Gesichtschir 1996: 41: 151154.
1088
Buitrago-Tellez et al.
20. Shetty V, Atchison K, Der-Matirosian C, Wang J, Belin TR. The mandible injury severity score: development
and validity. J Oral Maxillofac Surg
2007: 65: 663667.
21. Spiessl B. Classification of fractures. In:
Spiessl B, ed: Internal fixation of the
mandible. New York: Springer-Verlag
1989 part 2, sect 2.
22. Spiessl B, Schrol K. (1972) Gesichtsschadel. In: Nigst h (Hrsg) Spezielle Frakturen- und Luxationslehre,;1; Bd I. Thieme,
Stuttgart, New York.
23. Thoren H, Iizuka T, Hallikainen D,
Nurminen M, Lindqvist C. An
epidemiological study of patterns of
condylar fractures in children. Br J Oral
Maxillofac Surg 1997: 35: 306311.
24. Tile M. Fractures of the Pelvis and Acetabulum. Philadelphia: Williams & Wilkins 2003.
25. Ubersax JS, Grove WM. Latent class
analysis of diagnostic agreement. Stat
Med 1990: 9: 559572.
26. Vermunt J, Magidson J. Latent Gold 3.0
upgrade manual 2002.