The First AO Classification System for Fractures of the Craniomaxillofacial Skeleton: Rationale, Methodological Background, Developmental Process, and Objectives

Abstract

Validated trauma classification systems are the sole means to provide the basis for reliable documentation and evaluation of patient care, which will open the gateway to evidence-based procedures and healthcare in the coming years. With the support of AO Investigation and Documentation, a classification group was established to develop and evaluate a comprehensive classification system for craniomaxillofacial (CMF) fractures. Blueprints for fracture classification in the major constituents of the human skull were drafted and then evaluated by a multispecialty group of experienced CMF surgeons and a radiologist in a structured process during iterative agreement sessions. At each session, surgeons independently classified the radiological imaging of up to 150 consecutive cases with CMF fractures. During subsequent review meetings, all discrepancies in the classification outcome were critically appraised for clarification and improvement until consensus was reached. The resulting CMF classification system is structured in a hierarchical fashion with three levels of increasing complexity. The most elementary level 1 simply distinguishes four fracture locations within the skull: mandible (code 91), midface (code 92), skull base (code 93), and cranial vault (code 94). Levels 2 and 3 focus on further defining the fracture locations and for fracture morphology, achieving an almost individual mapping of the fracture pattern. This introductory article describes the rationale for the comprehensive AO CMF classification system, discusses the methodological framework, and provides insight into the experiences and interactions during the evaluation process within the core groups. The details of this system in terms of anatomy and levels are presented in a series of focused tutorials illustrated with case examples in this special issue of the Journal.

Keywords: classification system; craniomaxillofacial; diagnostic process; fracture; reliability.

Figure 1

Multiple patient and injury factors influencing treatment decision and outcomes. Note: The fracture pattern described by location and morphology is only one of the many factors influencing treatment decision and outcomes.

Figure 2

Methodological pathway for the development and validation of injury classification systems. Reprinted with permission from Audigé et al.

Figure 3

Unified classification system for fractures of the human skeleton. Adapted from Marsh et al.