S6 Introduction

The First AO Classification System for Fractures

of the Craniomaxillofacial Skeleton: Rationale,
Methodological Background, Developmental
Process, and Objectives
Laurent Audigé, DVM, PhD1,2 Carl-Peter Cornelius, MD, DDS3 Antonio Di Ieva, MD, PhD4
Joachim Prein, MD, DDS5 CMF Classification Group6

1 AO Clinical Investigation and Documentation, AO Foundation, Address for correspondence Laurent Audigé, DVM, PhD, AO
Dübendorf, Switzerland Foundation, AO Clinical Investigation and Documentation,
2 Research and Development Department, Schulthess Clinic, Zürich, Stettbachstrasse 6, CH-8600 Dübendorf, Switzerland
Switzerland (e-mail: laurent.audige@aofoundation.org).
3 Department of Oral and Maxillofacial Surgery, Ludwig Maximilians
Universität München, Germany
4 Department of Systematic Anatomy and Department of
Neurosurgery, Medical University of Vienna, Wien, Austria
5 Clinic for Oral and Craniomaxillofacial Surgery, University Hospital
Basel, Basel, Switzerland
6 CMF Classification Group

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Craniomaxillofac Trauma Reconstruction 2014;7(Suppl 1):S6–S14

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 discrep-
ancies 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,
Keywords achieving an almost individual mapping of the fracture pattern. This introductory article
► fracture describes the rationale for the comprehensive AO CMF classification system, discusses
► classification system the methodological framework, and provides insight into the experiences and inter-
► craniomaxillofacial actions during the evaluation process within the core groups. The details of this system
► diagnostic process in terms of anatomy and levels are presented in a series of focused tutorials illustrated
► reliability with case examples in this special issue of the Journal.

Copyright © 2014 by AO Foundation DOI http://dx.doi.org/

AOCMF 10.1055/s-0034-1389556.
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Tel: +41 44 200 24 20.
 Introduction to the First Comprehensive AOCMF Classification System Audigé et al. S7

Cranial vault, skull base, and face fractures have often been Table 1 References of most common fracture classifications of
described separately, even though they may be combined. the craniomaxillofacial skeleton
These fractures in the different locations are assigned to
different specialist competencies, which leads to the need Location References
for several distinct specialists to discuss their views among Midface Guérin,56 Le Fort,5–7
each other, for example, traumatologists, oral and maxillofa- Wassmund,57 Donat et al16
cial surgeons, plastic surgeons, ENT surgeons, neurosurgeons, Zygoma Zingg et al58
ophthalmologists. These professionals have specific expertise
Orbitozygomatic and Jackson59
regarding craniomaxillofacial (CMF) injuries, yet these com- orbitoethmoid region
petencies can vary across countries and their educational
Nasoethmoid region Markowitz et al60
systems. The lack of borderlines between the specialties may
also be due to the lack of clear guidelines or the lack of a Orbit Hammer,61 Carinici,62
Jacquiéry et al63
universally validated classification system. Classification sys-
tems are important because they offer a structured frame- Medial orbital wall Nolasco and Mathog64
work to communicate effectively about clinical cases, and Palate Chen et al,65 Park and
support the treatment decision process (i.e., conservative vs. Ock66
surgical management, type of surgical intervention, type of Midface in conjunction Buitrago-Téllez et al,8
specialist required). An integral modular classification system with skull base Bächli et al,26 Manson et al67
validated by all involved medical disciplines might be an Frontal base Madhusdan et al68
essential cornerstone to improve synergies and mutual
Temporal bone Rafferty et al69
acceptance.
Mandible Spiessl,70 Roth et al,71
In biomedical sciences, classification systems are omni-
Buitrago-Téllez et al,21

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present. Almost every advent of a new technology or novel Carinci et al72
diagnostic/therapeutic regimen is publicized together with
Condylar process of Spiessl and Schroll,73
the urge to reconsider former systematization and concep- the mandible Loukota et al74,75
tions. This is reflected in headlines and titles containing
Panfacial injuries and Clark et al76
vocabulary such as grouping, coding, rating, grading, scaling,
avulsions
scoring, and typifying, which is indicative for a classifying
process. A classification scheme is the “descriptive informa-
tion for an arrangement or division of objects into groups
based on characteristics which the objects have in common.”1 simple distinction of three Le Fort type fractures is considered
Medical classification is “the process of transforming descrip- as a prototype of a classification system for midface fractures.
tions of medical diagnoses and procedures into universal Notably, Buitrago-Téllez et al8 found that only 45% of midface
medical code numbers.”2 Known examples of such diagnoses fractures could be adequately classified according to the Le
and procedure codes are the WHO Family of International Fort classification in practice. The Le Fort classification has
Classifications3 including the International Classification of often been criticized as obsolete by later authors, since it is
Diseases, the Medical Dictionary for Regulatory Activities, confined to the subcranial facial skeleton and does not display
and the Medical Subject Headings. the full variety of possible fracture types in all details. To his
In the making of a classification scheme, a key issue is to credit, Rene Le Fort did not have conventional radiography at
determine the most relevant “common characteristics” men- his disposal and would not have even dreamed of computed
tioned above. The extreme heterogeneity of human skeletal tomography (CT), magnetic resonance imaging, or the use of
fractures makes it difficult to identify appropriate parameters optoelectronic navigational tools in the management of skull
and standardization for assigning a clinical series of unique fractures.
cases into a fixed number of possible classes using a struc-
tured mode.
Rationale for a New Comprehensive CMF
Classification
A Multitude of Existing CMF Classification
Despite the existence of many classification systems
Systems
(►Table 1), a comprehensive and structured classification
Over more than a century, a multitude of classifications were of the whole CMF skeleton that has undergone a structured
created to detail site-specific fracture entities of the cranio- validation process has not been proposed until now. A
facial skeleton (►Table 1). Till date, midface fractures are clinically relevant, well-structured, and agreed-upon classifi-
referred to worldwide by the name of Le Fort.4 His experi- cation provides a universal language and coding that
mental cadaver studies led to an understanding of the hon- facilitates global communication and collaboration. The con-
eycomb construction of the midfacial skeleton and of the duction and comparison of clinical studies is not possible
major lines of weakness. The relation between bony architec- without clear descriptors of the trauma patients and their
ture and the predictable course of the fractures served to injuries. Coding and indexing is a prerequisite to use present-
describe a limited number of well-defined patterns.5–7 The day information and computing media for web-based

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S8 Introduction to the First Comprehensive AOCMF Classification System Audigé et al.

exchange and storage of records on fractures in trauma

databases. A structured classification system enables large-
scale documentation (e.g., registries), interinstitutional com-
parisons, quality control, and performance evaluation of
treatment modalities,9 and the adoption of benchmarking
methods to possibly optimize the surgical procedures and
economic analysis. After all, CMF surgeons could soon be
required by health authorities to document patient care and
treatment performance to justify the increasing costs of
healthcare.10
In clinical settings, injury classification systems ideally
help surgeons in making their decision on the most appro-
priate treatment modality; classification categories reflect
injury severity and include prognostic factors for clinically Figure 1 Multiple patient and injury factors influencing treatment
relevant patient outcomes.11 A comprehensive CMF fracture decision and outcomes. Note: The fracture pattern described by
classification will provide a sound basis to evaluate treatment location and morphology is only one of the many factors influencing
modalities and outcomes thoroughly and help to integrate the treatment decision and outcomes.
results into the daily routines of decision making for evi-
dence-based CMF management.12–15 Based on scientific data, fracture pattern is only one of these factors, it is still the most
CMF surgeons will be in a stronger position to advise their relevant clinical feature for establishing a diagnosis and thus
patients on the best course of action to treat their respective supporting a treatment decision.
conditions. In the development of a classification system, it is therefore

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of utmost importance to identify the most relevant items that
will support the treatment decision.17,18 The resulting cate-
Expected Attributes of a Valuable CMF
gories might be indicative of some specific injury character-
Classification
istics such as severity, that is, they can reliably distinguish
Reflecting on a few essential diagnostic and classification groups of injuries that differ regarding the complexity of their
issues allows one to identify the most important attributes treatment, or the quality of their outcome(s).18 Most impor-
which are necessary to achieve the objective of the tantly, a fracture classification system should be based on
classification. their essential biological characteristics, that is, fracture
As pointed out by Donat et al,16 a classification system for topography and morphology,19 and not explicitly include
midfacial/craniofacial fractures should be “logically struc- treatment-based criteria to ensure universality of the system.
tured, systematic, accurate, comprehensive, it should provide
information regarding the severity of the injury and a guidance User Friendliness and Discernibility
to the therapeutical options.” A fracture classification system should be simple to use and
therefore limited to a few pertinent parameters. must not
Comprehensiveness allow for complete individualized fracture mapping. The
Fractures of the human skeleton are particularly varied, thus necessary process of abstraction in the development of the
rendering it a major challenge to identify appropriate param- system is always a tradeoff between detailed individualized
eters and standardization to assign a clinical series of unique information and the use of restricted categories associated
cases into a fixed number of possible classes in a structured with loss of information.
and clinically useful process. While many classification sys-
tems have been proposed (►Table 1), the link between Reliability/Accuracy
mandible, midfacial, cranial vault, and skull base fractures In addition to clinical relevance, a good fracture classification
is often missing. A comprehensive classification would ad- should provide a reliable and accurate means of communica-
dress the whole CMF skeleton in a uniform scheme. In tion. Different observers presented with the same diagnostic
addition, the classification should be all inclusive, that is, images (e.g., CT scan series) must agree on the classification of
all CMF injuries should be classifiable using the proposed a fracture most of the time (reliability of the diagnosis). The
system as well as mutually exclusive (such that these injuries classification should also reflect the true injury status of the
cannot be classified in more than one classification category patient (accuracy of the diagnosis), that is, observers should
in the system). accurately identify the most clinically relevant fracture pat-
terns. If this is not the case, the classification has failed in its
Clinically Relevant Diagnosis and Treatment Decision fundamental goal—a means to communicate information
Initially, it may seem reasonable to include all conceivable based on agreed similarities and differences.
factors and patient details into the classification. However, In traumatology, most published reliability studies gener-
this would become unmanageable in routine clinical use. ally showed poor interobserver reliability of commonly used
These pertinent factors all contribute to the daily treatment classifications.20 In the CMF field in particular, reliability
decisions made by surgeons (►Fig. 1). Although, the observed studies were rarely conducted. Recently, Buitrago-Tellez

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 Introduction to the First Comprehensive AOCMF Classification System Audigé et al. S9

et al21 reported on one of our initial evaluation sessions Tellez et al,8 and adapted the same approach to the mandi-
regarding a proposed classification system for mandibular ble.21 However, after several evaluation sessions, consensus
fractures. In orthopedics, it has become a standard that injury could not be achieved among evaluating surgeons. An alter-
classification systems be formally validated before their native classification concept was required. As a consequence,
approval for clinical and research purposes.20,22–24 a critical step toward the development of the present system
was done. The CMCG was reorganized in 2007 with a
smaller core membership of five experienced CMF surgeons
Fracture Classification versus Injury Severity
(J.P., CP.C., C.K., J.F., R.R.), one radiologist (C.B.), and a scientific
Score
coordinator (L.A.). In addition, two specifically focused Classi-
The use of an injury severity score implies that the magnitude fication Groups (CGs) were established to develop part of the
of the injuries can be graded on a continuous or ordinal scale system addressing skull base fractures (C.M., A.D., K.S., B.K.)
and that this score has some predictive value for treatment and condylar process fractures (M.R., A.N., CP.C).
options and/or outcome(s). Various attempts were made to Broad international acknowledgment and changeover as
build up fracture severity scores for the CMF region21,25–30 standard application of the comprehensive CMF system in
based on several diagnostic parameters. The final severity clinical institutions worldwide was a key objective of this
scores are calculated by adding points allocated to each of project. The involvement of experienced surgeons from vari-
these diagnostic parameters and anatomical region found to ous geographical and clinical backgrounds (e.g., CMF sur-
be relevant in guiding treatment decisions. The actual point geons, ENT surgeons, plastic surgeons, neurosurgeons) in
systems, however, were elicited by the authors or expert classification groups facilitates identification of cross-cultural
opinion without solid scientific basis, leading to some uncer- differences in training and understanding of basic clinical
tainty pertaining to the validity of the actual numeric final concepts and definitions.
score. For instance, Catapano et al31 proposed a new severity

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scoring of facial fractures which sums a grade of 0 (no
Classification Development and Validation
fracture) to 3 (bone loss) across 41 anatomical regions.
Pathway
Because all regions received equal weighting, an increased
severity of some fracture patterns may not be systematically According to the AOCMF and its CMF classification groups, a
associated with an increased score. Also, the final score may list of expected properties for the classification system was
not be handled on a continuous scale. The weighting of drawn up (►Table 2).
diagnostic categories and regions to generate severity scores
should have a sound scientific basis, that is, the score calcu- Table 2 Targeted properties of the CMF classification system
lation algorithm requires clinical data to create prognostic
models. This process has been applied in the context of 1 Address only traumatic CMF fractures
outcome analysis systems to provide norms for trauma 2 Be comprehensive, including the whole CMF skeleton
care.32–34 3 Be applicable to the mature skeletona
A typical limitation of severity scores is that the score itself
4 Consider a hierarchical system from very simple for all
cannot be reversed into the fracture pattern and, stand-alone, surgeons to more detailed and focused for specific
only provides prognostic information. For that reason, after locations and specialist surgeons
having considered the potential value of a CMF injury severity 5 Describe fracture location and morphology based
score at the initial development stages,21 the objective of this essentially on CT scans (or for mandibular fractures,
project was strictly focused on the development of a clinically Panorex and/or conventional radiographs in two
meaningful classification system allowing intelligible pictur- planes)
ing of the fracture patterns. This system may be subsequently 6 Be consistent with well-accepted systems such as
translated into a severity score following appropriate clinical the Le Fort classification in the midfacial skeleton5–7
documentation. 7 Be perceived by CMF surgeons as simple, practical,
and clinically meaningful
8 Demonstrate a reasonable level of reliability and
AOCMF Classification Group—A Brief History accuracy for most common fractures
An international Craniomaxillofacial Classification Group 9 Provide a rational basis for prospective (functional
(CMCG) including an extended company of multispecialty and patient reported) treatment outcome studies,
surgeons experienced in the management of CMF fractures from which algorithms for clinical decision making
was established in 2004 with the task of developing a can be derived
clinically relevant and valid CMF comprehensive fracture 10 Reach international acceptance
classification system. Scientific coordination and organiza- 11 Be incorporated into an electronic database, such as
tional support to the group were provided by AO Clinical a specialized software solution to facilitate teaching,
Investigation and Documentation. The list of participating classification, and documentation of CMF cases
surgeons involved in the initial classification activities is Abbreviation: CMF, craniomaxillofacial.
presented in the Acknowledgment section. This group ini- a
Maxillofacial trauma in pediatric patients requires different consider-
tially followed on the craniofacial fracture work of Buitrago- ations from those of adults, with different therapeutic approaches.77

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S10 Introduction to the First Comprehensive AOCMF Classification System Audigé et al.

In the development and validation of classification sys- surgeons evaluated the proposed or revised system by con-
tems, Audigé et al35 suggested implementing a methodologi- ducting classification sessions using imaging series (conven-
cal pathway with three successive research phases (►Fig. 2). tional radiographs and CT scans) of up to 150 consecutive
The first phase involves clinical experts developing a blue- cases. Overall, the image documentation of 494 consecutive
print for the classification system, as well as defining the CMF fracture cases collected from 6 European centers was
assessment technique (e.g., clinical information, image mo- anonymized and centralized at AOCID for use in successive
dalities, measurement aids). Precise definitions and instruc- evaluation sessions. Cases were sent to surgeons on digital
tions need to be worked out to define a common language by video disks together with a DICOM viewer. They classified the
which surgeons should be able to understand, identify, and cases independently each time according to the most updated
describe injuries in a uniform way. Successive pilot agreement version. Classification data were collected either on paper
studies are conducted to evaluate the reproducibility of the forms or electronically using MS Excel (Microsoft Corpora-
classification performed by clinical experts. The natural ten- tion, Redmont, WA) or specifically designed AOCOIAC soft-
dency of all CGs was to initiate the development by proposing ware (AO Comprehensive Injury Automatic Classifier, AO
a very detailed system to address all injury patterns. Partic- Foundation, Dübendorf, Switzerland; www.aofoundation.
ipants realized after a few evaluation sessions that simplifi- org/aocoiac). The datasets were analyzed for classification
cation is only warranted, along with the clarification of reliability and accuracy as well as for identification of cases
definitions for terms that are commonly used (e.g., “fragmen- showing most coding discrepancies between surgeons. These
tation” or “comminution”). This process is not easy and latter cases were discussed during the subsequent face-to-
involves translating clinical experience (pattern recognition) face meetings to identify the probable reasons for the inter-
into a set of standardized definitions. At this stage, the observer disparities in order for adjustments and clarification
predictive clinical value of any proposed system is evaluated of the actual version. Group members also had to agree that
by expert opinion (concept of face validity, that is, the the proposed system would meet initial expectations

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classification should look good on clinical ground). The (►Table 2); further evaluation is to come and should involve
second phase involves a multicenter agreement study to a wider circle of CMF surgeons (phase 2 validation process) to
ensure that future users with less clinical experience can support the current consensus, and allow final adaptations of
understand and agree on the classification system. This the system.
creates the basis for a classification tool to be used for
documentation and evaluation of treatment options. Only
Consensus, Challenges, Strength, and
after these first two phases have been completed can a third
Limitations
phase involving prospective clinical documentation be im-
plemented to support future recommendations for patient The development of this comprehensive CMF fracture classi-
care based on the classification. fication used a strong consensus process among experienced
This methodological pathway has been adopted and im- surgeons aimed at measuring and resolving disagreement
plemented successfully within all classification projects sup- (consensus development). There are many traditional meth-
ported by the AO Foundation and its specialties, in particular ods used to reach group consensus.39–43 In the medical field,
for the development of the established AO pediatric long- the application of group consensus has mainly been used in
bone fracture classification system,36,37 and the development the development of standards and guidelines for diagnosis
of a comprehensive AO-Spine injury classification.38 and treatment,44,45 and has provided relatively consistent
The currently proposed CMF fracture classification is the and reliable results.46–48 Our consensus approach toward
product after completion of phase 1. More specifically, it classification development incorporated an immediate prac-
involved for each CG a series of face-to-face meetings to tical application through classification evaluation sessions.
gradually build up the classification system itself as well as These sessions allowed surgeons to gain experience using the
the prerequisites (e.g., imaging type and quality) under which proposed system, and after considering the classification
it can be reliably used. In the period between the meetings, discrepancies, review meetings could be focused on the
essential issues to improve the system.
Experienced surgeons are busy professionals and the
repetition of classification sessions on a series of 50 to 150
cases required a high level of dedication and investing
personal time from the participants. It was a great challenge
to maintain the CGs motivation and commitment throughout
the consensus process. A phase 1 development project often
requires 3 to 4 years to reach a solid and scientifically
supported consensus.36,49
Some limitations should be mentioned. Initially, surgeons
classified cases during meetings; however, the process was
changed to reserve meetings for case discussion based on
Figure 2 Methodological pathway for the development and validation of coding disagreements. Classification sessions were then con-
injury classification systems. Reprinted with permission from Audigé et al.35 ducted at home. There was always a tradeoff between

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 Introduction to the First Comprehensive AOCMF Classification System Audigé et al. S11

methodological concerns and practical issues. The number of numerical coding of the bones and anatomical regions of the
consecutive cases that can be classified in any session is human skeleton, with fractures of the CMF skeleton being
limited by the surgeon’s time and thus only the most frequent coded with the number 9 (►Fig. 3).18 The presented AO CMF
fracture patterns were examined. To address rare fractures, classification system is anchored within a global and uniform
subsequent follow-up evaluation projects should be system to support surgeons documenting their fractures
implemented. similarly.
The present classification system and evaluation sessions
were limited by the type and quality of the images made New Hierarchical Classification System
available. Cases with images considered insufficient for clas- The first classification evaluation sessions and review meet-
sification purposes were excluded from the series. It should ings led to the realization that the initial system was not
be noted that some part of the CMF classification system will intuitive enough to achieve consensus among surgeons in-
require more advanced imaging for a thorough evaluation volved in the evaluation process. An agreement concerning
process, such as craniomidfacial fractures documented by the definitions using the AO triad system8,21 could not be
multidetector CT.50 We must also accept that imperfections in achieved in the evaluation meetings to continue the imple-
the system will be detected by further technological advances mentation of this system. One of the reasons may be hypo-
resulting in improved (computer-assisted) diagnosis pro- thetically due to the adoption of the AO-Müller triad scheme,
cesses and classification, by means of new algorithms and well accepted for long bones,17 but not very familiar among
imaging sequences such as those using high-resolution multi- CMF specialties.
planar reformations.51 So the triad system was not considered mandatory for the
CMF skeleton anymore. A paradigm shift was required toward
the development of a streamlined classification system con-
The Present AOCMF Fracture Classification
sidered as practical, clinically meaningful, and still scientifi-
System—History Outline and Structure

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cally sound. Despite the present system being built on all
From Maurice Müller to International Collaboration previous endeavors and published classification work
In 1986, the AO Foundation officially adopted “The Compre- (►Table 1), it had to be accepted a priori that the system
hensive Classification of Fractures of the Long Bones” devel- was not meant to map each and every conceivable combina-
oped by Maurice Müller and his group as a groundwork for
its activities in documentation. This system introduced a
standardized alphanumeric code to indicate the affected
bone and fracture morphology within the specific bone
location, according to three types (A, B, and C), three groups
within each type (A1, A2, and A3), and three subgroups within
each group (A1.1, A1.2, and A1.3) ranging from low (A1.1) to
high (C3.3) “severity.” The latter relates to the complexities of
the fractures, the assumed difficulties inherent in their
treatment, and their perceived prognosis.52 This classification
concept became a standard worldwide for long bone fractures
and was later adopted for fractures of the pelvis/acetabu-
lum,53 the hand54 as well as spine injuries.55
On the same path, the AO Foundation has made persistent
efforts to create a classification of craniofacial injuries. The
project was launched by the work of Buitrago-Téllez et al,8
who initially designed a CT-based diagnostic algorithm for
craniomidfacial fractures to establish a hierarchical classifi-
cation of increasing severity. The elementary concept was to
split craniofacial fracture patterns analogous to the AO triad
system. The craniofacial region was divided into three units:
the lower midface (I), the upper midface (II), and the cranio-
basal-facial unit (III). Lateral and central fractures were also
distinguished. This allowed a standardization of the midfacial
and craniofacial fractures in a special way described with
regard to their severity. With the subsequent establishment
of a first CMF classification expert panel, a classification
system for the mandible differentiating vertical mandibular
compartments and a horizontal subdivision of the body and
parasymphyseal region was proposed on the same princi-
ples.21 At the same time, the AO Classification Advisory group Figure 3 Unified classification system for fractures of the human
and the OTA Classification Committee agreed on a uniform skeleton. Adapted from Marsh et al. 18

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S12 Introduction to the First Comprehensive AOCMF Classification System Audigé et al.

tion of every single fracture line in a CMF injury, and restric- Concluding Notes
tion to the most relevant diagnostic items for clinical practice
was essential. Our consensus approach allowed bringing together the per-
The present AOCMF fracture classification system is based spectives from different CMF specialties toward a common
on a hierarchical structure of three levels from very simple to goal of having a comprehensive classification system.
more focused and complex: As expected and accepted, this system is simplistic and
imperfect. Some CMF surgeons will possibly reject it as being
• Level 1: elementary system for gross fracture location:
not detailed enough for their purpose, or not providing them
mandible (code 91), midface (code 92), skull base (code
the immediate clinical application they look for. Yet, the only
93), cranial vault (code 94)
way to make it a valuable tool for documenting CMF cases at
• Level 2: basic system for refined fracture location in the
a chosen level of details is to install it as a standard and aim
CMF skeleton (outlining the topographic boundaries of the
for continuous improvement. This will promote more valid
anatomical regions within the fundamental units of the
clinical research. With the use of refined diagnostic imaging
CMF skeleton as a basis for a more precise localization)
techniques, the classification system will evolve and incorpo-
• Level 3: focused modular system assessing fracture mor-
rate additional well-thought and validated diagnostic fea-
phology (i.e., fracture lines, level of fragmentation, and
tures we are not even dreaming of at present just as Le Fort at
displacement)
his time.
While levels 1 and 2 serve as approved anatomical Presently, the authors encourage the whole community of
localizers, level 3 describes the fracture morphology in an surgeons involved in the management of CMF trauma to
array of modules representing anatomical regions and embark on the use of the proposed system, apply it in daily
subregions. practice and research, and to push help its limit eventually to
A detailed presentation of each classification level and the benefit of their patients.

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module is presented in the following series of tutorial papers
in this special issue of the Journal along with typical and
difficult case examples according to specific anatomical Acknowledgments
locations: This CMF classification project was funded by the AO
Foundation and its AOCMF Specialty. Buitrago-Tellez C,
• Level 2 craniomidface
Institute of Radiology, Zofingen Hospital, Switzerland,
• Level 2 mandible
initiated this development with support from an AO
• Level 3 mandible (excluding the condylar process)
Research Grant and developed in cooperation with Sauter
• Level 3 condylar process
D and Marschelke H, Ingenieurbüro Marschelke, Reich-
• Level 3 midface (excluding the orbit)
enau, Germany the first software version for semiauto-
• Level 3 orbit
matic classification of craniomaxillofacial fractures
• Levels 2 and 3 skull base and cranial vault
(Buitrago CAFFAC—CrAniomaxillo-Facial-Fracture-Auto-
In addition, practical applications of the present system matic-Classifier). Illustrations were prepared by AO Edu-
are considered with specific regard to radiological and diag- cation (publishing) by Jecca Reichmuth and her colleagues.
nostic issues as well as electronic documentation using a The authors are grateful to all surgeons (as listed below
software solution. A large case collection is made available in alphabetical order) who participated in the successive
electronically on the AOCMF website (www.aocmf.org/clas- classification sessions and provided their fruitful support
sification). Each presented case include selected diagnosis in the development and validation of this craniomaxillo-
images, a description of identified fractures, as well as the facial fracture classification system:
fracture coding using the AOCOIAC (AO Comprehensive Injury Alpert B, Louisville, KY; Brad S, Sacramento, CA; Bui-
Automatic Classifier) software solution. trago-Tellez C, Zofingen, Switzerland; Cornelius CP, Mu-
nich, Germany; Dala Torre D, Innsbruck, Austria; Di Ieva A,
Terminology Vienna, Austria; Ehrenfeld M, Munich, Germany; Figari M,
Routinely used clinical terms sometimes lack definition Buenos Aires, Argentina; Frodel J, Danville, PA; Hirsch J,
and are used in a more ambiguous way in contrast to Uppsala, Sweden; Kellman B, Syracuse NY; Kunz C, Basel,
international anatomical designations which are well Switzerland; Kushner G, Louisville, KY; Lindqvist C, Hel-
illustrated in atlases and clearly referenced in an official sinki, Finland; Manley G, San Francisco, CA; Matula C,
nomenclature (FCAT, Federative Committee of Anatomical Vienna, Austria; Neff A, Marburg, Germany; Patrick L,
Terminology). The clinical terms often relate to important Birmingham, AL; Prein J, Basel, Switzerland; Rasse M,
landmarks or substructures that bear no formal anatomical Innsbruck, Austria; Rudderman R, Alpharetta, GA; Shum-
nameplates. rick K, Cincinnati, OH; Sugar A, Wales, United Kingdom.
Both anatomical nomenclature and clinical terminology
are used to identify the skeletal components. To preclude
errors and misunderstanding in context with the level 2 Notes
CMF Classification, some ambiguous clinical expressions are Laurent Audigé, DVM, PhD and Carl-Peter Cornelius, MD,
presented in an appendix glossary. DDS, have contributed equally to this article and share lead

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 Introduction to the First Comprehensive AOCMF Classification System Audigé et al. S13

authorship. Members of the CMF Classification Group 23 Bono CM, Vaccaro AR, Hurlbert RJ, et al. Validating a newly
were: Core: Prein J. (Chair), Cornelius P., Buitrago-Tellez proposed classification system for thoracolumbar spine trauma:
C. (radiologist), Kunz C., Frodel J., Rudderman R.; Condylar looking to the future of the thoracolumbar injury classification and
severity score. J Orthop Trauma 2006;20(8):567–572
Process: Rasse M. (Chair), Neff A., Cornelius CP.; Skull Base:
24 Brady OH, Garbuz DS, Masri BA, Duncan CP. The reliability and
Matula C. (Chair), Di Ieva A., Shumrick K., Kellman B.; validity of the Vancouver classification of femoral fractures after
Scientific coordinator: Audigé L. hip replacement. J Arthroplasty 2000;15(1):59–62
25 Bagheri SC, Dierks EJ, Kademani D, et al. Application of a facial
injury severity scale in craniomaxillofacial trauma. J Oral Max-
illofac Surg 2006;64(3):408–414
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