Classifications Third Molar

Nerves
Classification of axons – conduction speed Erlanger & Gasser 1937

A 70 – 120 m/sec.
A 30 –70 m /sec.
A
A Large sensory fibres
B Autonomic fibres
C Unmyelinated fibres 0.5 – 2 m / sec. (C fibers)
Classification of axons – size of axon Lloyd 1943

Group I A 6 – 20  m. diameter
Group II A 6 – 20  m.
Group III A 1 – 6  m.
Group IV C and B fibres smaller diameter fibres
Size of fibres in decreasing order

A  A  A  A  B  C
The conduction speed of a nerve fibre is approximately 6 times the diameter of the fibre. Thus a 15 m. nerve fibre
conducts impulse at 90 m/s.
Classification of nerve fibres based on number of fascicles

Monofascicular pattern one large fascicle. E.g. Intra-cranial part of facial nerve.
Oligofascicular pattern 2 – 10 fascicles.
Polyfascicular pattern > 10 fascicles. E.g. Inferior alveolar nerve, Lingual nerve. ( 18 – 21 fascicles )
Physiologic conduction block ( focal conduction block) Lundborg 1988

( Controversies in Oral & Maxillofacial surgery. Page 279.)
Type A Intraneural circulatory arrest or metabolic (ionic) block with no nerve fibre pathology. Reversible
immediately. Managed by therapies to improve the circulation to the nerve trunk, decrease oedema
or reverse vasospasm.
Type B Intraneural oedema resulting in increased endoneurial fluid pressure or metabolic block with little
or no nerve fibre pathology. Reversible within days or weeks. Therapies to decrease oedema and
promote venous drainage.
Intra-operative grading of peripheral nerve lesions Samii 1980

1 Divided peripheral nerve
a) Injury to examination interval < 3 weeks
b) Injury to examination interval > 3 weeks
2 Lesion in continuity
c) Injury to examination interval < 3 months
d) Injury to examination interval > 3 months
3 Mixed 1 and 2
Classification of nerve injuries Seddon 1943

Neuropraxia Local conduction block at the site of injury without Wallerian degeneration
Axonotmesis Complete interruption of axon and myelin sheath with preservation of connective tissue stroma
Neurotmesis Complete anatomic severance of the nerve
Classification of nerve injuriesSunderland 1951
1st degree Corresponds to Seddon’s neurapraxia

Type I Conduction block due to anoxia from interruption of the segmental or epineural blood
vessels, but there is no axonal degeneration or demyelination. Resulting from nerve trunk
manipulation, mild traction or mild compression. Recovery is rapid following restoration of
sensation.
Type II Conduction block due to intrafascicular oedema following rupture of endoneurial
capillaries as a result of trauma of sufficient magnitude. Recovery of senses within 1 – 2 days
following resolution in the intrafascicular oedema.
Type III Segmental demyelination or mechanical disruption of the myelin sheaths following
severe manipulation, traction or compression. Recovery takes 1 – 2 months
2nd degree Axon and myelin are interrupted, but the endoneural sheath and other supporting connective tissue
stroma including epineurium and perineurium are preserved. Wallerian degeneration distal to the
lesion and complete loss of motor, sensory and autonomic inervation.
3rd degree Disruption of axon, myelin sheath; damage to internal structures of the fascicles with loss of
endoneural integrity. Epineurium and perineurium are preserved
4th degree Interruption of all neural and supporting connective tissue stroma, except for epineurium. The
fascicular pattern is lost, and the nerve may appear as a thin strand of connective or as a neuroma
in continuity.
5th degree Loss of continuity of nerve trunk with complete loss of motor, sensory and autonomic function.
Pathologic overgrowth of regenerating axons might result in neuroma formation.
6th degree Mixed combinations of previous five levels of injury. (Added lately by MacKinnon & Dellon
1988.) (Controversies in Oral & Maxillofacial surgery. Page 279.)
Classification of nerve injuriesSymptomatic classification Controversies

in Oral & Maxillofacial surgery. Page 279.)
Anaesthesia. Complete loss any stimulus detection and perception including mechanoreceptors and nociceptor
stimuli.
Paresthesia. Alteration in sensibility with abnormal or normal stimulus detection and perception which may be
perceived as unpleasant but not painful.
Dyesthesia. Alteration in sensibility with abnormal stimulus detection and perception which may be perceived
as unpleasant and painful.
Types : Allodynia, Hyperpathia.
Classification of nerve injuriesAnatomic classification

Intraosseous nerve injury
Soft tissue nerve injury
Classification of nerve injuriesHistopathologic classification (Controversies

Neuroma
Amputation or stump neuroma
Central or neuroma in continuity
Eccentric : Lateral exophytic
Stellate neuroma
Fibrosis
Classification of nerve injuries by location of fibrosis Millesi et al 1989.

Designation Location Prognosis
A Epifascicular epineurium Good prognosis
B Prognosis depends on
Interfascicular epineurium original damage
C Endoneurium Poor.
N In a Sunderland class IV
injury, the epineural
connective tissue that Poor
maintains continuity can be
infiltrated by neuroma.
S
Continuity in class IV injury
maintained only by scar
tissue.
Poor.
Grade A, B & C are used in combination with Sunderland’s classification : I A & I B; II A & II B and III A, III B &
III C.
Grade C fibrosis occurs only with class III injury.
Classification of nerve injuries Pathophysiologic classification

( Controversies in oral & Maxillofacial surgery. Page 283.)
Compression
Compartment syndrome
Stretch injury
Transection, laceration, rupture and avulsion
Chemical injury
Nerve injection injury
Anatomically maintained pain
Central neuropathy
Grading of sensory recovery Mackinnon Clin Plast. Surg 1989

S0 No recovery
S1 Recovery of deep cutaneous pain
S2 Return of some superficial pain / tactile sensation
S 2+ Return of some superficial pain / tactile sensation with over-reaction
S3 Return of some superficial pain / tactile sensation without over-reaction and the presence of static
two-point discrimination (2pd) >15 mm
S 3+ As per S 3, with good localisation of stimulus (2pd) = 7-15 mm
S4 As per S 3+, (2pd) =2-6 mm
Sensory score equal to or greater than S 3 is defined as useful sensory requirement
Assessment of nerve recovery - British Medical Research Council Classification

Classification Description
Motor Recovery
M0 No contraction
M1 Return of perceptible contraction in proximal muscles.
M2 Return of perceptible contraction in both proximal and distal muscles.
M3 Return of function in both proximal and distal muscles of a degree that all important
muscles are sufficiently powerful to act against resistance
M4 Return of function as in stage 3 with addition that all synergetic and independent
movements are possible.
M5 Complete recovery.
Sensory Recovery
S0 Absence of sensibility in the autonomous area.
S1 Recovery of deep cutaneous pain sensibility within the autonomous area of the nerve.
S2 Recovery of some superficial cutaneous pain and tactile sensibility within the
autonomous area of the nerve.
S3 Recovery of superficial cutaneous pain and tactile sensibility throughout the autonomous
area with disappearance of any previous over response.
S3+ Recovery of sensibility as in S 3 with the addition of some recovery of two-point
discrimination within the autonomous area.
S4 Complete recovery.
Pain
Pain classification IASP (International association for the study of Pain).
Burket Page 327
Categorises pain into various parameters.
Axis I Regions ( the body region or site of the reported pain ).
Axis II Systems ( the body system whose abnormal function produces pain
Axis III Temporal ( temporal characteristics of pain and the pattern of occurrence. )
Axis IV Patient’s statement. ( time since onset and intensity of pain).
Axis V Aetiology. ( the presumed aetiology of the pain problem ).
Classification of chronic orofacial pain.

Burket Page 328
Neuralgias
Primary trigeminal neuralgia (tic douloureux).
Secondary trigeminal neuralgia (central nervous system lesions or facial trauma).
Herpes zoster
Postherpetic neuralgia
Geniculate neuralgia (VII)
Glossopharyngeal neuralgia ( IX)
Superior laryngeal neuralgia ( X)
Occipital neuralgia.
Pain of Musculoskeletal origin
Cervical Osteoarthritis
Temporomandibular disorders
TMJ Rheumatoid arthritis
TMJ Osteoarthritis
Myofacial pain dysfunction
Fibromyalgia
Cervical pain or hyperextension
Stylohyoid (Eagle’s) syndrome.
Primary vascular disorders
Migraine with aura
Migraine without aura
Cluster headache
Tension-type headache
Cysts & Tumours
Clinical and functional staging of oral submucous fibrosis
S. M. Haider, A. T. Merchant, F. F. Fikree, M. H. Rahbar. BJOMS 2000:38: 12-15
Clinical stage
1 Faucial bands only.
2 Faucial and buccal bands.
3 Faucial ,buccal bands and labial bands.
Functional stage
A Mouth opening ≥ 20 mm.
B Mouth opening 11 – 19 mm.
C Mouth opening ≤ 10 mm.
Dermoid cyst classification Rapidis et al. 1981. OOO 1994, 78: 5.

Ronald C. King et al Review of literature of dermoid cysts.
Dysodontogenic cyst types Meyer, Spouge et al
Epidermoid cyst (simple dermoid) Simple stratified squamous epith. with no skin appendages
True dermoid cyst (compound dermoid) Similar epithelial lined lesion with skin appendages
Teratoid cyst (Cystic teratoma – complex dermoid) Contains the three germ layers.
Anatomic types
Median dermoid Develops beneath the lingual frenum or between the genioglossus muscles.
Lateral sublingual Between the genial muscles and the mylohyoid
True lateral Develops deep by the genioglossus & hyoglossus medially, and mylohyoid laterally
Cysts
Numerous classifications have been published of cysts of the jaws. Most of them are perfectly satisfactory
in clinical evaluation and practise.
Robinson’s classification (1945)

Developmental cysts
A) from odontogenic tissue
1. Periodontal cyst
(a) radicular or root apex type
(b) lateral type
(c) residual type
2. Dentigerous cyst
3. Primordial cyst
B) from non-dental type of tissue
1. Median cyst (median palatal cyst)
2. Incisive canal cyst
3. Globulomaxillary cyst
Kruger’s classification (1964)

A) Congenital cyst
1. Thyroglossal
2. Branchiogenic
3. Dermoid
B) Developmental cyst
1. non-dental origin
a) fissural type
i. Naso-alveolar
ii. Median
iii. Incisive canal cyst (Naso-palatine)
iv. Globulomaxillary
b) retention type
i. mucocoele
ii. ranula
2. dental origin
a) periodontal
i. periapical
ii. lateral
iii. residual
b) primordial
c) dentigerous
Lucas’ classification (1964)

Intra-osseous cysts
A) Fissural cysts
a) median mandibular
b) median palatal
c) naso-palatine
d) globulomaxillary
e) naso-labial
B) Odontogenic cysts
a) Developmental
i. primordial
ii. dentigerous
b) inflammatory
c) radicular
C) Non-epithelial bone cysts
a) solitary bone cyst
b) aneurysmal bone cyst
Gorlin’s classification (1970)

A) Odontogenic cysts
1. dentigerous cyst
2. eruption cyst
3. gingival cyst of the new-born infants
4. lateral periodontal and gingival cyst
5. keratinising and calcifying odontogenic cysts
(cystic keratinising tumour)
6. radicular (periapical cyst)
7. odontogenic keratocyst
a) primordial cyst
b) Gorlin-Goltz syndrome
B) Non-odontogenic and fissural cysts
1. globulomaxillary (premaxilla-maxillary) cyst
2. naso-alveolar (naso-labial / Klestadt’s) cyst
3. naso-palatine (median anterior maxillary) cyst
4. median mandibular cyst
5. anterior lingual cyst
6. dermoid and epidermoid cyst
7. palatal cysts of new-born infants
C) Cysts of neck, oral floor and salivary glands
1. thyroglossal duct cyst
2. lymphoepithelial (branchial cleft) cyst
3. oral cyst with gastric / epithelial epithelium
4. salivary gland cyst – mucocoele and ranula
D) Pseudocysts of jaws
1. aneurysmal bone cyst
2. static (developmental / lateral) bone cyst
3. traumatic (haemorrhagic / solitary) bone cyst
WHO classification published in ‘Histologic typing of odontogenic tumours’ (Kramer, Pindborg, Shear –
1992)
I. Cysts of the jaws
A) Epithelial
1. developmental
a) odontogenic
i. gingival cysts of infants
ii. odontogenic keratocyst (primordial cyst)
iii. dentigerous (follicular) cyst
iv. eruption cyst
v. lateral periodontal cyst
vi. gingival cyst of the adults
vii. botryoid odontogenic cysts
viii. glandular odontogenic (sialo-odontogenic / mucoepidermoid-
odontogenic) cyst
ix. calcifying odontogenic cyst
b) non-odontogenic
i. naso-palatine duct (incisive canal) cyst
ii. naso-labial (naso-alveolar) cyst
iii. midpalatine raphae cyst of infants
iv. median palatine, median alveolar and median mandibular cysts
v. globulomaxillary cyst
2. inflammatory
i. radicular cyst (apical / lateral)
ii. residual cyst
iii. paradental (mandibular infected buccal) cyst
iv. inflammatory collateral cyst
B) Non-epithelial
i. solitary (traumatic/simple/haemorrhagic) bone cyst
ii. aneurysmal bone cyst
II. Cysts associated with the maxillary antrum
a) benign mucosal cyst of the maxillary antrum
b) post-operative maxillary cyst (surgical ciliated cyst of the maxilla)
III.Cysts of the soft tissues of the mouth, face and neck
a) dermoid and epidermoid cyst
b) lymphoepithelial (branchial cleft) cyst
c) thyroglossal duct cyst
d) anterior median lingual cyst (intralingual cyst of fore-gut origin)
e) oral cyst with gastric / intestinal epithelium (oral alimentary tract cyst)
f) cystic hygroma
g) naso-pharyngeal cysts
h) thymic cysts
i) cysts of the salivary glands
i. mucous extravasation cyst
ii. mucous retention cyst
iii. ranula
iv. polycystic (degenerative) disease of parotid
j) parasitic cysts
i. hydatid cyst
ii. cysticerus cellulosae
iii. trichinosis
Fibro-osseous lesions Charles A Waldron (JOMS 1989, 1993)

1. Fibrous dysplasia
a a. Polyostotic
b. Monostotic.
2. Fibro-osseous (Cemental ) lesions. Reactive (dysplastic ) lesion arising in the tooth bearing area. They are
presumably arising from periodontal ligament. They are divided into three types based on their radiologic
features although they represent the same pathologic process.
b a. Periapical cemental (Cemento-osseous )dysplasia.
c b. Focal (local) cemento-osseous lesions (dysplasia). – probably reactive in nature.
d c. Florid cemento-osseous dysplasia (gigantiform cementoma).
3. Fibro-osseous neoplasms. They are of uncertain or debatable relationship to those arising in the periodontal
ligament. They are widely designated as cementifying fibroma, ossifying fibroma or cemento-ossifying
fibroma.
e a. Cementoblatoma, Osteoblastoma and Osteoid osteoma.
f b. ‘Juvenile active ossifying fibroma’ and other so called “ aggressive”, “active” ossifying / cementifying
fibromas.
TNM classification
The TNM system is used to describe the anatomical extent of a malignant disease. It is based on the
assessment of three components
T – the extent of primary tumour
T – primary tumour
N – the absence or presence and extent of regional lymph node metastasis
M – the absence or presence of distant metastases.
Head and neck cancer
T Primary tumor size
Lip and oral cavity
Tx - Primary tumour cannot be assessed
T0 - No evidence of primary tumour
Tis - Carcinoma in situ
T1 - Tumour 2 cm or less in greatest dimension
T2 - Tumour more than 2 cm but not more than 4 cm in greatest dimension
T3 - Tumour more than 4 cm in greatest dimension
T4 Lip: Tumour invades adjacent structures, e.g. through cortical bone, tongue, skin of neck.
Oral cavity: Tumour invades adjacent structures, e.g. through cortical bone, into deep (extrinsic) muscles
of tongue, maxillary sinus, skin
Pharynx (oropharynx)
T4 - Tumour invades adjacent structures, e.g. through cortical bone, soft tissues of neck, deep (extrinsic)
muscles of tongue
Pharynx (nasopharynx)
T1 - Tumour limited to one subsite of nasopharynx
T2 - Tumour invades more than one subsite of nasopharynx
T3 - Tumour invades nasal cavity and/or oropharynx
T4 - Tumour invades skull and/or cranial nerves
Maxillary sinus
T1 - Tumour limited to the antral mucosa with no erosion or destruction of bone
T2 - Tumour with erosion or destruction of the infrastructure including the hard palate and/or the middle
meatus.
T3 - Tumour invades any of the following: skin of cheek, posterior wall of the maxillary sinus, floor or medial
wall of the orbit, anterior ethmoid sinus
T4 - Tumour invades the orbital contents and/or any of the following: cribriform plate, posterior ethmoid or
sphenoid sinuses, nasopharynx, soft palate, pterygomaxillary or temporal fossae, base of skull
Salivary glands
T4 - Tumour more than 6 cm in greatest dimension.
The classification applies only to carcinoma of the major salivary glands: parotid, submandibular and
sublingual glands. Tumours arising in minor salivary glands (mucous secreting glands in the lining membrane of the
upper aerodigestive tract) are not included in this classification.
N – Regional lymph nodes

The definitions of the N categories for all head and neck sites except thyroid gland are:
Nx - Regional nodes cannot be assessed.
N0 - No regional node metastasis
N1 - Metastasis in a single ipsilateral lymph node, 3cm or less in greatest dimension
N2 - Metastasis in a single ipsilateral lymph node, more than 3cm but not more than 6 cm in greatest
dimension, or in multiple ipsilateral lymph nodes, none more than 6cm in greatest dimension, or in bilateral
or contralateral lymph nodes, none more than 6cm in greatest dimension
N2a – Metastasis in a single ipsilateral lymph node, more than 3cm but not more than 6 cm in greatest
dimension
N2b – Metastasis in multiple ipsilateral lymph nodes, none more than 6cm in greatest dimension
N2c – Metastasis in bilateral or contralateral lymph nodes, none more than 6cm in greatest dimension
N3 - Metastasis in a lymph node more than 6 cm in greatest dimension
N 3 ba – Clinically positive ipsilateral node(s), one more than6 cm in diameter.
N 3b – Bilateral clinically positive nodes( in this situation, each side of the neck should be staged separately)
N 3c – contralateral clinically positive node(s) only.
Note: Midline nodes are considered ipsilateral nodes.
M – Distant metastasis
Metastasis in any lymph node other than regional is classified as distant metastasis. The definition of M-
Distant Metastasis is the same for all types of cancer.
Mx - Presence of distant metastasis cannot be assessed
M0 - No distant metastasis
M1 - Distant metastasis
The category M1 may be further specified according to the following notation:
Pulmonary(PUL) Bone marrow(MAR) Osseous(OSS)
Lymph nodes(LYM) Hepatic (HEP) Peritoneum(PER)
Brain(BRA) Skin(SKI) Pleura(PLE) Other(OTH)
Other tumours
Osteosarcoma
T – Primary tumour
T1 - Tumour confined within the cortex
T2 - Tumour invades beyond the cortex
The classification applies to all primary malignant bone tumours except multiple myeloma, juxtacortical
osteosarcoma and juxtacortical chondrosarcoma
Soft tissue sarcomas

Skin tumours
T4 - Tumour invades deep extradermal structures, i.e. cartilage, skeletal muscle or bone
Note: In the case of multiple simultaneous tumours, the tumour with the highest T category will be classified and the
number of separate tumours will be indicated in parenthesis e.g. T2 (5)
Melanoma
The extent of tumour is classified after excision. This is a pathological tumour classification.
Tis - Melanoma in situ (Clark’s level I) (atypical melanocytic hyperplasia, severe melanocytic dysplasia, not
an invasive malignant lesion)
T1 - Tumour 0.75 mm or less in thickness and invading the papillary dermis (Clark’s level II)
T2 - Tumour more than 0.75 mm but not more than 1.5 mm in thickness and/or invading the papillary-
reticular dermal interface (Clark’s level III)
T3 - Tumour more than 1.5 mm but not more than 4.0 mm in thickness and/or invading the reticular dermis
(Clark’s level IV)
T3a – Tumour more than 1.5 mm but not more than 3.0 mm in thickness
T3b – Tumour more than 3.0 mm but not more than 4.0 mm in thickness
T4 - Tumour more than 4.0 mm in thickness and/or invading subcutaneous tissue (Clark’s level V) and/or
satellites within 2cm of the primary tumour.
T4a – Tumour more than 4.0 mm in thickness and/or invading subcutaneous tissue
T4b – Satellites within 2cm of the primary tumour
Note: In case of discrepancy between tumour thickness and level, the T category is based on the less favourable
finding.

N1 - Metastasis 3 cm or less in greatest dimension in any regional lymph node(s)
N2 - Metastasis more than 3 cm or less in greatest dimension in any regional lymph node(s) and/or in-transit
metastasis
N2a - Metastasis more than 3 cm or less in greatest dimension in any regional lymph node(s)
N2b - In-transit metastasis
N2c – Both
Note: In-transit metastasis involves skin or subcutaneous tissue more than 2cm from the primary tumour but beyond the regional lymph nodes
M1 a - Metastasis in skin or subcutaneous tissue or lymph node(s) beyond the regional lymph nodes
M1 b - Visceral metastasis
Salivary gland disease
Classification of echo patterns of palatal salivary gland tumours OOO 1999 Jan
Junichi Ishii et al
Type I Mixed pattern; cystic patterns within echogenic solid pattern
Type II Nodules are seen in the tumour echo
Type III Acoustic shadow is seen in the tumour echo
Type IV Hypo-echoic pattern with homogenous internal echoes
Sialographic grading of sialadenitis

Zou et al – 1992; Wang et al – 1992).
Score Definition
0 Normal
1 Mild; slight irregular dilation of the main duct, often with areas of local stenosis. No disease
within the gland
2 Moderate; more ductal changes than in the mild disease with dilated branching ducts and some
punctate sialectasis
3 Severe; more widespread changes than in moderate disease, spreading to most of the ducts with
complete sialectasis and formation of cavities.
Histologic grading of sialadenitis

Isacsson et al – 1981; Seifert et al – 1977, 1986).
Score Definition
1. Normal
2. Slight focal and periductal lymphocytic infiltration and slight increase in the diameter of the duct
3. Moderate periductal inflammation and formation of lymphoid follicles; interstitial fibrosis; localised
destruction of acini and moderated changes to ductal epithelium.
4. Reduced lymphocytic infiltration; formation of periductal and interlobular lymphoid follicles; periductal
hyalinisation; reduced ductal metaplastic changes and acinar destruction
Classification of salivary gland disease

The diseases of salivary glands may be divided into
1. Developmental anomalies
2. Infections acute
chronic
systemic
3. Neoplasms benign
malignant
4. Auto-immune
5. Miscellaneous necrotising sialometaplasia
cystic fibrosis
mucocele and ranula
Classification of sialadenitis
Sialadenitis, infection of salivary gland tissue is a relatively common tissue. It may be classified as
(I) Bacterial and viral
a) Mumps (viral parotitis)
b) Bacterial parotitis (sialadenitis)i. Acute
ii. chronic
c) Recurrent parotitis of childhood
(II) Obstructive sialadenitis
a) Sialolithiasis
b) Mucous plugs
c) Stricture – stenosis
d) Foreign body
(III) Systemic granulomatous diseases
a) Tuberculosis
b) Actinomycosis
c) Fungal infection
d) Uveoparotid fever
Defects and clefts
Classification of mid-facial defects
Type I Loss of midfacial skin only ; buttress of the maxilla, orbital floor and palate intact
Type II Partial maxillectomy with intact palate and orbital floor
Type III Partial maxillectomy with resection of a portion of palate ; orbital floor and Lockwood’s ligament
remain intact
Type IV Total maxillectomy and palatectomy ; orbital support remains intact
Type V Total maxillectomy and palatectomy with loss of orbital support or eye
Classification of cleft lip and palate.

Various classifications systems have been proposed, but only a few have found wide acceptance.
I. In the classification of David and Ritchie (1922), congenital clefts were divided into three groups
according to the position of the clefts in relation to the alveolar process.
Group I – Pre-alveolar clefts – unilateral (right or left), bilateral or median
Group II – Post-alveolar clefts – involving soft palate only
involving soft and hard palates
submucous cleft
Group III – Alveolar clefts – unilateral (right or left), bilateral or median.
II. Veau (1931) suggested a classification that divides cleft palates into four groups.
Group I – Cleft of soft palate only.
Group II – Cleft of hard and soft palate extending no further than incisive foramen, thus involving
secondary palate alone.
Group III – Complete unilateral cleft, extending from the uvula to the incisive foramen in the midline, then
deviating to one side and usually extending through the alveolus at the position of the future
lateral incisor tooth.
Group IV – Complete bilateral cleft, resembling Group III with two clefts extending forwards from the
incisive foramen through the alveolus.
III. Kernahan and Stark (1958) recognised the need for a classification based on embryology rather than
morphology.
A. Incomplete cleft of secondary palate
B. Complete cleft of secondary palate
C. Incomplete cleft of primary and secondary palates
D. Unilateral complete cleft of primary and secondary palates
E. Bilateral complete cleft of primary and secondary palates
IV. Kernahan (1971) subsequently proposed a striped ‘Y’ classification. The incisive foramen, which is the
dividing line between primary and secondary palate, is taken as the reference, and forms the junction of the ‘Y’.
With stippling of the involved portion of the ‘Y’, the system provides rapid graphic representation of the
original pathologic condition and renders itself to computer-graphic presentation.
V. American Association of Cleft Palate Rehabilitation Classification (AACPR). The classification

suggested by Harkins and associates (1962) and endorsed by the American Association of Cleft Palate
Rehabilitation Classification (AACPR) is based on the same principles used by Kernahan and Stark.
I. Cleft of primary palate
a) Cleft lip – unilateral, bilateral, median, prolabium, congenital scar
b) Alveolar cleft – unilateral, bilateral, median
II. Cleft of palate proper
a) Involving soft palate
b) Involving hard palate
III. Mandibular process cleft
(i) Mandibular cleft lip
(ii) Mandibular cleft
(iii) Lower lip pits
IV. Naso-ocular cleft – extending from narial region to the medial canthal region
V. Oro-ocular cleft – extending from the angle of the mouth towards the palpebral fissure
VI. Oro-aural cleft – extending from the angle of the mouth towards the ear.
VI. Spina (1974) modified the David and Ritchie classification.

Group I – Pre-incisive foramen clefts
A. Unilateral B. Bilateral C. Median
Group II – Trans-incisive foramen clefts (involving lip, alveolus and palate)
A. Unilateral B. Bilateral
Group III – Post-incisive foramen clefts
A. Total B. Partial
Group IV – Rare facial clefts
VII. Tessier (1973) introduced a classification system for the more complex orbito-facial clefts. Detailed
descriptions of the classification were subsequently published by Tessier (1976) and Kawamoto (1976). The
classification successfully integrates the clinical examination findings with direct observations of the underlying
skeletal deformity at the time of reconstructive surgery.
The system classifies the clefts in circumferential manner around the orbit with cranial extensions. The
clefts are numbered from 0 to 14 and follow constant lines, or axes, through the eyebrows or eyelid, the maxilla,
the nose and the lip. All components of an individual cleft combination add up to 14. The orbit is regarded as
the reference landmark, since it is common to both the cranium and the face. The common cleft lip is part of
clefts 2 and 3.
Median clefts of the lower lip and mandible coincide with the caudal extension of number 0 cleft, but
Tessier has labelled them number 30 clefts.
Preprosthetic surgery
Alveolar ridge classification Cawood & Howell

Class I Dentate
Class II Immediate post extraction
Class III Convex ridge form with adequate height and width
Class IV Knife edge ridge form, inadequate height and width
Class V Loss of basal bone that may be extensive and follows no predictable pattern.
Bone quality classification Lekholm and Zarb 1985 AJOMS 1997

Q1 Dense homogenous cortical bone with a small trabecular bone
Q2 Large, dense layer of cortical bone surrounding dense trabecular core
Q3 Thinner layer of cortical bone around dense trabecular core
Q4 Thin cortical layer surrounding low density trabecular bone.
Alveolar ridge deficiency-Classification and treatment Tucker 1997

( Modified from Kent JN et al . J. Oral Maxillofac Surg 1983 : 41 : 629. )
Principles of oral & Maxillofacial surgery. Vol. II. Page 1108.
Class I Alveolar ridge is adequate in height, inadequate in width, usually with lateral deficiencies or
undercut areas. Patient receives HA alone 2 – 4 gms. For each anterior / posterior area, 6 – 8 gms
for local ridge.
Class II Alveolar ridge is deficient both in height and width and presents a knife edge appearance. Patient
receives HA alone 3 - 5 gms. For each anterior / posterior area, 8 - 10 gms for local ridge.
Class III Alveolar ridge is resorbed to the level of basilar bone, producing a concave form in the posterior
areas of the mandible and a sharp bony ridge form with bulbous mobile soft tissue in the maxilla. .
Patient receives HA alone 8 - 12 gms or HA in combination with autogenous iliac cancellous bone
( 1g HA : !cc bone ).
Class IV There is resorption of the basilar bone, producing thin pencil-thin, flat mandible or maxilla.
Patients receive HA, 10 –15 g, mixed with autogenous bone in a 1:1 ratio. Patient unable to permit
harvesting of iliac bone may have HA alone to increase ridge heights modestly. HA combined with
bone is recommened for larger augumentation and to strengthen the mandible.
Division of available bone

Contemporary implant dentistry Carl E. Misch Page 94
Division Dimension Treatment options
A > 5mm width Division A root form.

> 10-13 mm height
> 7 mm length
< 30 degree angulation
Crown / implant ratio < 1
B 2.5 – 5 mm width Osteoplasty

> 10 – 13 mm height Division A root form.
> 12mm length Augumentation
< 20 degree angulation Demanding aesthetics.
Crown / implant ratio < 1 Great force factors
Narrow Implants
Division B root form
Plate form.
C Unfavourable in :
Width
Bone density classification Misch 1988

Bone Density
D1 Dense cortical bone. ( Anterior mandible)
D2 Thick dense to porous cortical bone on crest and coarse trabecular bone within
( Anterior maxilla)
D3 Thin porous cortical bone on crest and fine trabecular bone within
( Anterior Maxilla & Posterior mandible)
D4 Fine trabecular bone ( Posterior maxilla)
D5 Immature, nonmineralized bone.
D1 bone is similar to drilling into Oak or maple wood, D2 bone is similar to the tactile sensation
of drilling into white pine or spruce, D3 bone is similar to drilling into balsa wood, D4 bone is imilar to
drilling into styrofoam.
CT determination of bone density

D1 > 1250 Hounsfield units
D2 850 – 1250 Hounsfield units
D4 150 –350 Hounsfield units
D5 < 150 Hounsfield units
Partially and edentulous arches class’n Misch and Judy

(Modification of Kennedy-Applegate system)
Contemporary implant dentistry Carl E. Misch Page 163-74
Healing times for treatment categoriesMisch

Mandibular overdenture treatment options Misch

Time course of interface development in cortical bone

Prosthodontic options in implantology Misch 1989

Type Definition
FP1 Fixed prosthesis, replaces only the crown, looks like normal teeth.
FP2 Fixed prosthesis, replaces the crown and a portion of root, crown contour appears normal in the
occlusal half but is elongated or hypercontoured in the gingival half.
FP3 Fixed prosthesis, replaces missing crowns and gingival colour and portion of the edentulous site,
prosthesis most often uses denture teeth and acrylic gingiva, but may be porcelain to metal.
RP4 Removable prosathesis, overdenture supported completely by implant.
RP5 Removable prosthesis, overdenture supported by both soft tissue and by implant.
Clinical implant mobility scale

Scale Description
0 Absence of clinical mobility with 500 g in any direction.
1 Slight detectable horizontal movement.
2 Moderate visible horizontal mobility up to 0.5 mm.
3 Severe horizontal movement greater than 0.5 mm.
4 Visible moderate to severe horizontal and any visible vertical movement.
Implant quality scale Misch 1993

Trauma
Trauma score & Basics
Classification of operative wounds in relation to contamination and increasing risk of infection.
Altemeier, Burke and Pruitt AJOMS 1997
Class I Clean (non-traumatic, uninfected, GIT & Resp. tract not involved
Class II Clean – contaminated (involving GIT and RT under controlled conditions)
Class III Contaminated (gross spillage from GIT, genito-urinary tract involvement with infected urine
and bile.
Class IV Dirty and infected (traumatic wound with devitalised tissue, foreign bodies, faecal contamination
or from a dirty source
Classification of hemorrhagic shock by American College of surgeons committee on trauma 1984

Peterson – Principles of oral & Maxillofacial surgery. Page 290.
Class I Acute blood loss ≤ 15 % of total blood volume. Pulse & respiration increased. BP not significantly
affected.
Class II Acute blood loss of 20 – 25 % of total blood volume. Increased pulse & respiration. Decreased BP.
No decrease in urine output.
Class III Blood loss of 30 –40 % of total blood volume. Increased pulse & respiration. Decreased BP &
Urine output.
Class IV 40 –50 % loss of total blood volume. Lack of vital signs. Decreased urine output. Obtunded
mental status.
For 70 kg man (Peterson, Principles of Oral & Maxillofacial surgery) Page 291
Class I Class II Class III Class IV
Blood Loss 750 ml 750 - 1500 1500 - 2000 2000 or more
% loss 15 % 15 – 30 % 30 –40 % 40 % or more
Pulse rate < 100 > 100 > 120 140 or higher
BP Normal normal decreased Decreased

Normal or
Pulse pressure (mm Hg ) increased
decreased decreased decreased
Capillary blanch test Normal positive positive positive
Respiratory rate 14 – 20 20 – 30 30 - 40 > 35
Urine output (ml / hr ) 30 or more 20- 30 5 - 15 Negligible

Anxious and Confused &
CNS mental status Slightly anxious Mild anxious
confused lethargic
Fluid replacement (3:1 Crystalloid + Crystalloid +
Crystalloid crystalloid
rule ) blood blood
Glasgow Coma scale Jennet & Teasdale
Oral & Maxillofacial trauma Vol I ( Fonseca). Page 181.
Eye Opening ( E )
Spontaneous 4
To voice 3
To pain 2
None 1
Verbal response (V )
Oriented 5
Confused 4
Inappropriate words 3
Incomprehensible sounds 2
None 1
Motor response ( M )
Obeys commands 6
Localises pain 5
Withdraws on pain 4
Flexion on pain 3
Extension on pain 2
None 1
Trauma score scale Champion et al 1981
Peterson ( Principles of Oral & Maxillofacial surgery) Page 272
Rate Code Score
Respiratory rate 10 – 24 4
25 – 35 3
≥ 36 2
1–9 1
0 0
A: _____
Respiratory effort
Normal 1
Reactive Use of accessory muscles or intercostal retraction Reactive / none 0
B: _____
Systolic Blood pressure
≥ 90 4
Systolic cuff pressure Either arm, auscultate or palpate 70 –89 3
50 – 69 2
0 - 49 1
0 0
No carotid pulse.
C: _____
Capillary refill
Normal - forehead / lip mucosa colour refill in 2 secs. Normal 2
Delayed – More than 2 sec refill. Delayed 1
None - No capillary refill. None 0
D: ______
Glasgow Coma Scale ( GCS )
14 – 15 5
11 – 13 4
8 – 10 3
5- 7 2
3 -4 1
E: ______
Trauma score = A + B + C + D + E
Revised trauma Score

Indian journal of OMFS Vol. XII : No : 4 Page. 5 – 9.
Glasgow Coma Scale Systolic B.P. Respiratory rate Coded value
13-15 > 89 10 – 29 4
9 – 12 76 – 89 > 29 3
6 –8 50 – 75 6–9 2
4–5 1 – 49 1–5 1
3 0 0 0
It is a modification of Trauma score rating. It eliminated capillary refill assessment and respiratory
movement.
Injury Severity score
Developed to deal with multiple traumatic injuries and compare the death rates from blunt trauma using the
data that rated the severity of injury in each of the three most severely injured organ systems.
Organ systems evaluated include - - Respiratory, Central nervous system, cardiovascular, abdominal,
extremities and skin.
The grading is
1 Minor
2 Moderate
3 Severe, non life threatening
4 Life threatening, survival probable
5 Survival non probable
6 Fatal cardiovascular, CNS, or burn injuries.
The three highest scores are squared and added to give the ISS. The lowest possible ISS is 3 and highest
ISS score is 108. Mortality rates increases with increase in ISS and age.
The CRAMS scale Gornican 1982, Clemmer et al 1985.

Peterson – Principles of oral & maxillofacial surgery. Page 271 - 273.
Circulation
Normal capillary refill and BP > 100 2
Delayed capillary refill or BP<100, >85 1
No capillary refill or BP < 85 0
Respiration
Normal 2
Abnormal (laboured or shallow) 1
Absent 0
Abdomen
Abdomen and thorax nontender 2
Abdomen or thorax tender 1
Abdomen rigid or flail chest 0
Motor
Normal 2
Responds only to pain (other than decerebrate) 1
No response (or decerebrate) 0
Speech
Normal 2
Confused 1
No intelligble words 0
Score ≤ 8 = Major trauma
Score ≥ 9 = Minor trauma.
Classification of open fractures based on extent of soft tissue injury. Gustilo & Anderson 1976
Grade I Open fracture with a wound less than 1 cm long & clean.
Grade II Open fracture with a laceration more than 1 cm long without extensive soft tissue damage, flaps or
avulsions.
Grade III Either an open segmental fracture or an open fracture with extensive soft tissue damage or
traumatic amputation.
Grade III A Adequate soft tissue coverage of a fractured bone despite extensive soft tissue laceration of flaps or
high energy trauma irrespective of the size of the wound.
Grade III B Extensive soft tissue injury loss with periosteal stripping and bone exposure. This is usually
associated with massive contamination.
Grade III C Open fracture associated with arterial injury requiring repair.
Midface fractures
Classification of midface fractures Réné Le Fort 1901
Killey fractures of middle third of face Page 11
Le Fort I Low-level fracture
Le Fort II Pyramidal or Subzygomatic Fracture
Le Fort III High Traverse or Suprazygomatic Fracture
Classification of midface fractures Wassmund 1927

Krüger & Schilli. Page 107 - 113.
Wassmund I Pyramidal fracture of maxilla without involvement of nasal bones
Wassmund II Pyramidal fracture of maxilla with involvement of nasal bones
Wassmund III Total displacement of midface from cranial base without involvement of nose.
Wassmund IV Total displacement of midface (visecrocranium) from cranial base with involvement of nose.
Classification of midface fractures Schwenzer 1967

Krüger & Schilli. Page 107.
1. Central midface fractures (≠ from root of nose to alveolar process without involvement of cheek bones)
a) Alveolar process fracture
b) Transverse (horizontal) fracture of maxilla (Le Fort I)
c) Sagittal fracture of maxilla (median or paramedian)
d) Pyramidal fracture with separation of entire maxilla with involvement of nasal bones (Le Fort II)
e) Fracture of nasal bones and naso-ethmoid complex.
2. Centrolateral midface (separation of entire facial skeleton from base of skull)
a) Total displacement of visecrocranium with involvement of nasal bones (Le Fort III / Wassmund IV)
b) Total displacement without involvement of nasal bones (Wassmund III)
c) Combination fractures characterised by central and centrolateral fractures with atypical fractures.
3. Lateral midface
a) Fractures of Zygoma
b) Fractures of zygomatic arch
c) Zygomatico-maxillary fracture
d) Zygomatico-mandibular fracture
e) Fracture of the floor of the orbit (Blow out fracture).
Classification of midface fractures Rowe & Williams 1985
A. Fractures not involving the occlusion
1. Central region
2. Lateral region
B. Fractures involving the occlusion
1. Dento-alveolar
2. Subzygomatic
a. Le Fort I (low level or Guérin)
b. Le Fort II (pyramidal)
3. Suprazygomatic
a. Le Fort III (high level or craniofacial dysjunction)
Simpler classification of midface fracturesPeter Banks 1987

1. Dento-alveolar fractures
2. Zygomatic complex fractures
3. Nasal complex fractures
4. Le Fort I, Guérin, or low level fractures
5. Le Fort II, pyramidal or infrazygomatic fractures.
6. Le Fort III or suprazygomatic fractures.
Modified Le Fort Classification Marciani R D 1993

Dental secrets.Page 161 / Fonseca. Oral & Maxillofacial surgery. Vol. 3. Page- 251
Le Fort I Low maxillary fractures
Ia Low maxillary fractures / multiple segments.
Le Fort II Pyramidal fractures
II a Pyramidal and nasal fractures
II b Pyramidal and nasoorbitoethmoidal (NOE) fracture.
Le Fort III Craniofacial dysjunction.
III a Craniofacial dysjunction and nasal fracture
III b Craniofacial dysjunction and NOE
Le Fort IV Le Fort II or III fracture and cranial base fracture
IV a Supraorbital fracture
IV b Anterior cranial fossa and supraorbital rim fracture
IV c Anterior cranial fossa and orbital wall fracture.
Classification of palatal fractures Paul N. Manson et al PSR 1998

Type I Alveolar fractures
Type II Sagittal fractures
Type III Para-sagittal fractures
Type IV Para-alveolar fractures
Type V Complex fractures
Type VI Transverse fractures
Zygomatic complex & orbital fractures
Classification of Zygomatic complex fractures Knight & North 1961
Based on direction of displacement in waters view radiograph.
Peterson. (Principles of Oral & Maxillofacial surgery, Vol. I. Page 495).
Group I Nondisplaced fractures – cases in which there is no clinical or radiographic evidence of
displacement; no treatment required.
Group II Arch fractures – A pure fracture of the zygomatic arch. The classical three fracture lines produce
a ‘V’ shaped deformity.
Group III Unrotated body fractures – Caused by a direct blow to the zygomatic prominence. Zygoma is
driven posteriorly and medially, producing a flattening of the cheek. Water’s view shows a
displaced infra orbital rim inferiorly and medially at the buttress.
Group IV Medially rotated body fractures – Caused by a blow from above the horizontal axis of the
zygoma. Bone is driven medially, inferiorly and posteriorly with rotation. The X rays shows
displacement inferiorly at the infraorbital rim and either outward at the malar buttress or inward at
the frontozygomatic suture.
Group V Laterally rotated body fractures – Caused by a blow below the horizontal axis of the bone.
Zygoma is displaced medially and posteriorly with lateral rotation. The radiograph indicates
upward displacement at the infraorbital rim and lateral displacement at the frontozygomatic suture.
Group VI Complex fractures – these have additional fractures across the body of zygoma.
Classification of Zygomatic complex fractures Rowe & Kiley 1968

Modified North & Knight classification by giving consideration to the periosteal envelope of the bone and
adequacy of the bony apposition at the fracture interface.
Classification of Zygomatic complex fractures Yanagisawa 1973

Group I Nondisplaced fractures – no treatment required.
Group II Arch fractures – A pure fracture of the zygomatic arch.
Group III Medial or lateral rotation around a vertical axis.
Group IV Medial or lateral rotation around a longitudinal axis.
Group V Medial or lateral displacement without rotation.
Group VI Isolated rim fracture.
Group VII All Complex fractures.
Classification of malar fractures Spiessl & Schroll 1972

Kruger & Schilli ( traumatology Vol II ). Page 158.
Type I Zygomatic arch fracture
Type II Zygomatic complex fracture - - no significant displacement
Type III Zygomatic complex fracture - - partial medial displacement (kinking at the FZ suture)
Type IV Zygomatic complex fracture - - total medial displacement. (Complete ≠ of FZ suture).
Type V Zygomatic complex fracture - - dorsal displacement. (2 ≠ sites in zygomatic arch).
Type VI Zygomatic complex fracture - - inferior displacement.
Type VII Zygomatic complex fracture - - Comminuted fracture
Classification of Zygomatic complex fractures Larsen & Thompson 1978

Group I Nondisplaced fractures requiring no treatment – During the initial evaluation, if there is any
doubt about stability, revaluation should occur 1 week after injury.
Group II All fractures requiring treatment – This is further subdivided into fractures that are stable and
fractures that are unstable after reduction.
Classification of malar fractures Eberhard Krüger 1986

1. Fractures of Zygoma
a. No significant displacement
b. Partial medial displacement
c. Total medial displacement
d. Dorsal displacement
e. Inferior displacement
f. Comminuted fractures
2. Fractures of Zygomatic arch
3. Complex fractures
a. Centrolateral midface fractures
b. Zygomatico-maxillary fractures
c. Zygomatico-mandibular fractures.
Classification of Orbital fracturesRowe & Williams 1985
Rowe & Williams. Maxillofacial injuries. Vol. I Page 502- 506.
Zygomatic complex fractures
1. Fractures stable after elevation
a. Arch only (medially displaced).
b. Rotation around vertical axis
i) Medially
ii) Laterally
2. Fractures unstable after elevation
a. Arch only (inferiorly displaced).
b. Rotation around horizontal axis
i) Medially
ii) Laterally
c. Dislocation en bloc
i) Inferiorly
ii) Medially
iii) Postero-laterally
d. Comminuted fractures
Isolated fractures of the orbital rim
1. Superior rim
a. Lateral third (lacrimal recess)
b. Central third (supraorbital nerve)
c. Medial third (frontal sinus)
2. Inferior rim
a. Central third (infraorbital nerve)
b. Medial third (inferior oblique margin)
3. Medial rim
a. Medial canthal ligament
b. Lacrimal passage
4. Lateral rim
a. Lateral canthal ligament
b. Suspensory ligament
Isolated fractures of the orbital wall
1. Roof
a. Anterior fossa
b. Levator palpebrae superioris / superior rectus
c. Frontal sinus
2. Floor
a. Antrum
b. Infraorbital nerve & vessels
c. Inferior rectus / inferior oblique
3. Medial wall
a. Lacrimal sac & nasolacrimal canal
b. Ethmoidal sinus
c. Medial rectus
d. Suspensory ligament
4. Lateral wall
Superior orbital fissure & related structures.
Complex comminuted fracture
Classification of zygomatic fractures Zingg et al 1992.

AJOMS 1997:55: 253 – 258.
Type A Incomplete fractures
Isolated lateral orbital rim
Isolated inferior orbital rim
Type B Monofragment malar or classic tetrapod fractures
Type C Multifragmented fractures
Nasal, Nasoethmoid and Orbital fractures

Classification of Naso-Orbito-Ethmoid complex fractures.
Type I one portion of medial orbital rim involved with attached medial canthal ligament.
Type II fractured large fragments, medial canthal tendon attached to the fractured segment.
Type III fracture involving the central fragment of bone where the medial canthus attaches.
Classification of Nasal fractures

Schwenzer (1967) classified central mid-face fractures into
1. Alveolar fractures of the maxilla
2. LeFort I fracture
3. Sagittal fracture of the maxilla
4. Pyramidal fracture of the maxilla (LeFort II)
(a) Wassmund I
(b) Wassmund II (involving the nasal bone)
5. Fractures of the nasal bone and naso-ethmoidal region.
A simple classification based on severity of injury was proposed by Haug and Prather (1991) who
suggested an anatomically based system. Most of the existing classification schema are based on the direction of
applied force. Thus in 1968, Rowe and Killey described lateral and anterior nasal injuries resulting from impact
either from lateral or anterior direction. This forms the basis of the most popular classification of nasal injuries
described by Stranc and Robertson (1979). They divided the less common frontal type of injuries into 3 categories,
depending on the depth of injury.
Plane I injury
These do not extent beyond a line joining the lower end of the nasal bones to the anterior nasal spine. The
major part of impact is transmitted to the lower cartilaginous vault. Separation or avulsion injuries of the lateral
cartilages or septum may be seen.
Plane II injury
Limited to the external nose, these may involve the nasal septum and the anterior nasal spine. More
extensive deviation of the nasal bones and septal fractures, segmental over-riding etc. may be seen in this case.
Plane III injury
These extend to involve the orbital and possibly cranial structures. These injuries typically involve
comminution of nasal bones and extent to adjacent bony structures viz. Frontal process of maxilla, ethmoid labyrinth
and lacrimal bones. Upward extensions may involve the cribriform plate of ethmoid and orbital plates of frontal
bones.
The levels of injury resulting from lateral or latero-oblique forces are as follows
Level I – involving ipsilateral nasal bone
Level II – Level I + contra-lateral nasal bone and septum
Level III – Level II + frontal process of maxilla and lacrimal bones.
Many other classification systems are subclasses to include the nasal tip and ANS, fractures of the dorsum with
or without septal deflection, and comminuted nasal fractures (Harrison-1978). Courtiss (1978) described specific
additional combinations of depression and twisting of nasal structures. Holt (1978) classified septal injuries into
dislocation, fractures and fracture-dislocations.
One classification based on fracture severity is by Manson P. (1986)
A. Fracture of one nasal bone with infero-lateral displacement
B. Separation of nasal bone from the frontal process of maxilla, but the nasal septum is intact
C. Fracture of septum, permitting flattening and spreading of nasal bones (open book fracture)
D. Fracture of the two nasal bone with postero-lateral displacement
E. Comminuted fracture of the nasal bones, frontal processes and nasal septum – displacement is
posterior and inferior
F. Fracture of nasal septum with separation of nasal bones from the frontal process of the
maxilla, and elevation of the nasal bridge
G. Extensive comminuted nasal fractures extending to involve the naso-ethmoidal region (naso-
ethmoidal fractures)
In 1986, Murray and Maran described a pathological classification of nasal fractures following experiments
on fifty embalmed cadavers. They found seven different patterns of nasal fracture with varying degrees of septal
involvement. They emphasised the deviation of nasal pyramid from midline as the clinical predictor of the
management outcome.
Classification of naso-ethmoid fractures

Facial fractures are characterised as naso-ethmoid fractures when they isolate a central bone fragment to
which the medial canthal tendon is attached (Paskert et al –1988, Markovitz –1991). Instability and displacement of
this central fragment creates the naso-ethmoidal injury characterised by telecanthus, central globe displacement and
shortened palpebral fissure.
The literature consists of many classifications of varied nature. An elaborate, but complicated classification
was given by Gruss (1985), who divided naso-ethmoidal fractures into five types. Manson in 1985 proposed a
simple classification of naso-ethmoid fractures, dividing them into ‘isolated or extended’ and ‘unilateral or bilateral’,
the patterns of extension being superior (frontal), lateral (zygomatic) and LeFort and combinations of any or all.
Bowerman et al (1985) classified naso-ethmoid fractures into
1. Isolated naso-ethmoid and frontal nerve injury without other fractures of the mid-face
a) Bilateral
b) Unilateral
2. Combined naso-ethmoid and frontal region injury with other fractures of the mid-face
(a) Bilateral
(b) Unilateral
This is essentially the same as Manson’s classification in content.

Three distinct patterns of naso-ethmoid injury have been identified and described by Markovitz, Manson
and Sargent in 1991. The fractures are typically noted to be unilateral or bilateral and simple or comminuted.
Type I naso-ethmoid fractures
This is the simplest form of naso-ethmoid fractures involving only one portion of the medial orbital rim
with its attached medial canthal tendon. It may be unilateral or bilateral. In bilateral Type I fractures, there is no
medial canthal tendon displacement, and trans-nasal wiring is not required. Stabilisation of the osseous mono-block
is enough.
Type II naso-ethmoid fractures
These also may occur unilaterally or bilaterally and may produce large segments or comminution. Most
commonly, the canthus remains attached to the large central fragment. Reduction is usually accomplished by
positioning and controlling this bony segment which is associated with the medial canthal tendon.
Type III naso-ethmoid fractures
This type involves comminution involving the central fragment of bone where the medial canthal tendon
attaches. The canthus is rarely avulsed completely, but is attached to bone fragments that are too small to be utilised
in reconstruction. In this circumstance, trans-nasal wiring of the canthus is required, as is osseous reconstruction.
Variants of types I. II and III fractures may occur on one side or the other in conjunction with each other. If
such is the case, the type of injury and its severity guides the treatment.
Condylar fractures
Classification of injuries to the TMJ region Helmut Schüle 1986
Oral & Maxillofacial traumatology Vol 2 . Kruger & schilli. Page 45 – 47.
1.1.1 Contusion of the TMJ
1.1.2 Fractures of the condylar process without displacement of the fragments
1.1.2.1 Fractures of the condyle
Transcapitular.
Subcapitular.
1.1.2.2 Fractures of the condylar neck
1.1.2.3 Basal fracture of the condylar process.
1.1.3 Fractures of the condylar process with displacement of the fragments.
Displacement of the small fragments.
Ventrally.
Dorsally.
Medially.
Laterally.
Torsion of fragments
Displacement with contraction
Compression fracture of the condyle.
1.1.4 Sprains of the TMJ
1.1.5 Dislocation (subluxation) of the TMJ.
Dislocation of the condylar head ( condyle).
Anteriorly.
Posteriorly
Cranially ( central dislocation).
Medially
Laterally.
1.1.6 Fracture dislocations of the condylar process.
Anteriorly
Medially
Laterally.
Dorsally.
Classification of condylar fractures MacLennan system (1952)

Fonseca. Vol. I, Page 537
Type I Nondisplaced fracture
Type II Fracture deviation
Type III Fracture displacement
Type IV Fracture dislocation.
Classification of condylar fractures Spiessl and Schroll (1972) Int.JOMS 1999

1. non-displaced fracture
2. low-neck fracture with displacement, mostly with contact between fragments
3. high-neck fracture with displacement, mostly without contact between fragments
4. low-neck fracture with dislocation
5. high-neck fracture with dislocation
6. intracapsular fracture of condylar head
Classification of condylar fractures Lindahl system (1977)

Fonseca. Vol. I, Page 536.
Level of condylar fracture
Condylar head
Condylar neck
Subcondylar
Relationship of condylar segment to mandibular fragment.
Nondisplaced
Deviated
Displacement with medial or lateral overlap
Displacement with anterior or posterior overlap
No contact between fractured segments
Relationship between condylar head & Glenoid fossa
Nondisplaced
Displacement
Dislocation
Mandibular fractures
Classification of mandibular fractures Kazangia and Converse
Clinics in plastic surgery 1992, advances in craniofacial  management. Page62.
Class I Teeth present on both sides fracture line
Class II Teeth present on only one side.
Class III fracture occurs in an area without dentition
Classification of mandibular fractures based on type of fracture

Simple fracture Single fracture line that does not communicate with the exterior.
Compound fracture These fractures have communication with the external environment, usually by
periodontal ligament of a tooth or
Greenstick fracture This type frequently occurs in children with incomplete loss of continuity of bone.
Usually one cortex is fractured and the other is bent, leading to distortion without
complete section. There is no mobility between distal and proximal segment.
Comminuted fractures Multiple fragmentation of bone at one fracture site. Usually as a result of greater force.
Complex or complicated ≠ Damage to adjacent structures of bone like vessels, nerves or joint structures.
Telescoped or impacted ≠ one bone is driven into another. Rare in mandible.
Direct fractures Fractures at the site of impact
Indirect fracture Fractures at a point away from site of impact.
Pathological fracture ≠ occurring as a result normal force or minimal trauma as a result of bone weakened by
pathology.
Classification of mandibular fractures based on site of fracture Kelly & Harrigan1975

Condylar process
Ascending ramus
Angle fracture
Body fracture
Symphysis fracture
Classification of mandibular fractures based on muscular pull Frye et al 1942

Horizontally favourable  directed downward and forward.
Horizontally unfavourable  directed downward and backward
Vertically favourable  extends from posterior laterally to anterior medially.
Vertically unfavourable  extends from anterior laterally to posterior medially.
Classification of mandibular fractures AO Classification.

Internal fixation of mandible. Bernd Spiessl. 1989.
F Number of fractures.
L Location ( site).
O Occlusion
S Soft tissue involvement
A Associated fractures.
The combination of the components results in :
Right / Left
1. Fracture formula : FLO
2. Soft tissue formula : FS
3. Grade of severity : I – V.
E.g. F1L2O3S2A1
Categories of fractures. ( F ).
F1 : Single fracture.
F2 : Multiple Fractures ( segmental fractures).
F3 : Comminuted Fracture.
F4 : Fracture with bone defect.
Categories of localisation ( L )
L1 : Precanine.
L2 : Canine.
L3 : Postcanine
L4 : Angular
L5 : Supra angular
L6 : Processus articularis
L7 : Processus muscularis
L8 : Alveolar process
Categories of Occlusion ( O ).
O0 : No malocclusion.
O1 : Malocclusion.
O2 : Nonexistent occlusion ( edentulous mandible )
Categories of soft tissue involvement ( S )

S0 : Closed.
S1 : Open intraorally.
S2 : Open extraorally.
S3 : Open intraextraorally.
S4 : Soft tissue defect.
Categories of associated fracture ( A )

A None
A1 : Fracture and / or loss of tooth.
A2 : Nasal bone.
A3 : Zygoma.
A4 : Le Fort I
A5 : Le Fort II
A6 : Le Fort III
Grade of severity ( I - V )
Grade of severity Soft tissue formula Clinical presentation
I A F0S0
I B F1S0
Closed fracture
II A F2S0
II B F3S0
III A F0S1 / F1S1 / F2S1 / F0S2 / F1S2 / F2S2
III B F0S3 / F1S3 / F2S3 Open fracture
IV A F3S1 / F3S2
IV B F3S3
VA F4S1 / F4S2 / F4S3 Open fracture with bone defect.
VB F4S4 Gun shot wound
Classification of frontal sinus fractures

Anterior table fracture Linear
Displaced
Posterior table fracture Linear
Displaced
Outflow tract injury
Infection
ORN Marx 1983 AJOMS
Type I Develops shortly after radiation; is due to synergistic effects of surgical trauma and radiation
injury
Type II Develops years after radiation and follows a traumatic event; rarely occurs before 2 years after
treatment; most commonly occurs after 6 years; due to progressive endarteritis and vascular
effusion.
Type III Occurs spontaneously without a preceding traumatic event; usually occurs between 6 months and
3 years after radiation. ; due to immediate cellular damage and death due to radiation treatment.
Osteonecrosis Epstein et al 1987 AJOMS

Oct 2000 AJOMS Page 1093
1. Resolved healed osteonecrosis
No pathologic fracture
Pathologic fracture
2. Chronic, persistent and non-progressive osteonecrosis
Pathologic fracture
3. Active progressive osteonecrosis
Pathologic fracture
Orbital cellulitis (Chandler – 1970)

Principles of OMFS Vol. 1 Page 181
Group 1 Obstructive non-tender oedema contrasted with inflammation and cellulitis
Group 2 Inflammatory oedema and orbital cellulitis
Group 3 Sub-periosteal pus
Group 4 Pus in orbital tissue
Group 5 Cavernous sinus thrombosis
Osteomyelitis Hudson 1993

Fonseca. Vol 5. Page 485
I) Acute forms of osteomyelitis (Suppurative or nonsuppurative)
A. Contiguous focus.
1. Trauma.
2. Surgery.
3. Odontogenic infection
B. Progressive
1. Burns.
2. Sinusitis.
3. Vascular insufficiency.
C. Hematogenous (metastatic)
1. Developing skeleton (children).
2. Developing dentition
II) Chronic forms of osteomyelitis
A) Recurrent multifocal
2. Escalated osteogenic activity (<age 25).
B) Garrés osteomyelitis
1. Unique proliferative subperiosteal reaction.
2. Developing skeleton (children to adult).
C) Suppurative or nonsuppurative.
1. Inadequate treated forms.
2. Systemically compromised forms
3. Refractory forms (chronic refractory osteomyelitis CROM).
D) Sclerosing
1. Diffuse
a. Fastidious micro-organisms.
b. Compromised host and pathogen interface.
2. Focal
a. Predominantly odontogenic
b. Chronic localised injury.
Osteomyelitis : Classification and Staging Cierny, Mader, Pennick 1985

I) Anatomic type.
Stage 1: Medullary osteomyelitis – involved medullar bone without cortical involvement, usually
hematogenous.
Stage 2: Superficial osteomyelitis – less than 2-cm bony defect without cancellous bone.
Stage 3: Localised osteomyelitis – less than 2-cm bony defect on radiograph, which does not appear
to involve both cortices.
Stage 4: Diffuse osteomyelitis – defect larger than 2 cm, pathologic fracture, infection, nonunion.
II) Physiologic class
III) Systemic or local factors that affect immune surveillance, metabolism and local vascularity
Temporomandibular Joint
TMJ disorders classifications
Moore Page 566
Structural disorders
Inflammation
Acute
Chronic
Infection
Ankylosis
True
False
Trauma
Neoplasia
Developmental
Degenerative
Functional
Pain dysfunction syndrome
TMJ osteo-arthritis - Clinical classification criteria Int. JOMS 1999

1. TMJ pain for most days
2. Functional impairment
3. Restricted joint mobility / disturbed movement
4. Radiographic degenerative changes
Chondromalacia : Grading Outerbridge RE

Grade I Softening of articular cartilage – Collagenases causes degradation of proteoglycans in
fibrocartilage.
Grade II Rupture of deep fibrils attached to the subchondral bone – Loss of proteoglycans & Ability to
withstand compressive & shearing forces.
Grade III Rupture of parallel articular fibres of fibrocartilage producing fibrillated and frayed cartilage
strands and resulting in increased frictional surface.
Grade IV Degeneration of fibrocartilage with exposure of subchondral bone.
Acute synovitis index based on arthroscopic finding

Stage I Dilation of superficial synovial blood vessels
Stage II Superficial vascular dilation within synovial membrane hyperemia
Stage III Superficial vascular dilation with moderate synovial membrane hyperemia
Stage IV Advanced generalised synovial membrane hyperemia.
Synovial chondromatosis based on developmental stages Milgram 1977

1 Metaplasia is found in the synovial membrane without presence of detached particles.
2 Metaplasia is found in the synovial membrane with presence of detached particles in the joint that
are nourished by the diffusion of synovial fluid.
3 Only detached particles are found in the joint.
Internal derangement of TMJ Wilke’s staging, 1989.

I Early Stage
A) Clinical : No significant mechanical symptoms other than opening reciprocal clicking, no pain or limitation of
motion.
B) Radiologic : Slight forward displacement, good anatomic contour of the disk, negative tomograms.
C) Anatomic/ pathologic : Excellent anatomic form, slight anterior displacement, passive incoordination
demonstrable.
II Early Intermediate stage
A) Clinical : One or more episodes of pain, beginning major mechanical problems consisting of mid to late opening
loud clicking, transient catching and locking.
B) Radiologic : Slight forward displacement, beginning disk deformity of slight thickening of posterior edge,
negative tomograms.
C) Anatomic/ pathologic : Anterior disk displacement, early anatomic disk deformity, good central articulating
area.
III Intermediate Stage.

A) Clinical : Multiple episodes of pain, major mechanical symptoms consisting of locking (intermittent or fully
closed ), restriction of motion, and difficulty with function.
B) Radiologic : Anterior disk displacement with significant deformity or prolapse of disk ( increased thickening of
posterior edge), negative tomograms.
C) Anatomic/ Pathologic : Marked anatomic disk deformity with anterior disk displacement, no hard tissue
changes.
IV Late Intermediate stage.
A) Clinical : Slight increase in severity over intermediate stage
B) Radiologic : Increase in severity over intermediate stage, positive tomograms showing early to moderate
degenerative changes – flattening of eminence, deformed condylar head, sclerosis
C) Anatomic/ Pathologic : Increase in severity over intermediate stage, Hard tissue degenerative remodelling of
both bearing surfaces (osteophytosis), multiple adhesions in anterior and posterior recesses, no perforation of
disk or attachments
V Late Stage.
A) Clinical : Characterised by crepitus, variable and episodic pain, chronic restriction of motion and difficulty with
function
C) Radiologic : Disk or attachment perforation, filling defects, gross anatomic deformity of disk and hard tissues,
positive tomograms with essentially degenerative arthritic changes
C) Anatomic/ Pathologic : Gross degenerative changes of disk and hard tissues, perforation of posterior
attachment, multiple adhesions, osteophytosis, flattening of condyle and eminence, subcortical cyst formation.
Variations of fibrosis & fibrous adhesions in TMJ Kamanishi & Davis, 1989
Bell: Modern Practice of Orthognathic Surgery, 1992, Page 651.
1. Fibrous bands.
2. Fibrosynovial bands.
3. Intracapsular fibrosis.
4. Capsular fibrosis.
5. Discal osseous bands.
6. Variations of pseudowalls.
TMJ ankylosis Kazanjian 1938

Moore
True ankylosis Intra articular ankylosis
False ankylosis Extra articular ankylosis
False ankylosis Miller et al 1975

Moore
Myogenic
Neurogenic
Psychogenic
Bone impingement
Fibrous adhesions
Tumours
Temporomandibular joint ankylosis Rowe & Williams Page 457
Fibrous Short / Long
Bony Intracapsular / Extracapsular
Histologic variations
Fibrous
Fibro-osseous
Osseous
Osteocartilaginous
TMJ ankylosis Raveh et al

( Controversies in oral& Maxillofacial surgery. Page 181.)
Class I Ankylotic bone tissue limited to the condylar process and articular fossa.
Class II The bone extends out of the fossa involving the medial aspect of the skull base up to the carotid-
jugular vessel.
Class III Extension and penetration into the middle cranial fossa.
Class IV Combination of class II and III.
TMJ ankylosis Topazian 1966

Type I Condyle only involved
Type II Intermediate
Type III Entire condyle, sigmoid notch and coronoid.
TMJ ankylosis Shashi Aggarwal, Manorama Berry 1990

OOO 1990 : 69 : 1 : 128 – 132.
Type I Condyle could be identified – flattened, irregular sclerosed or partially resorbed. Condyle
usually medially angulated. The articular fossa has corresponding irregular, shallow or deep and
usually sclerosed, the sclerosis extending to the adjacent areas of the temporal bone. Mild to
moderate new bone formation which extends from the neck of the condyle or lateral superior
aspect of the ramus to the squamous temporal bone and or zygomatic arch, frequently
enchroaching on the lateral aspect of the articular fossa. Etiology specific
– trauma associated.
Type II Joint architecture completely disrupted with no recognisable condyle or articular fossa.there are large mass
of new bone, funnel shaped, extending from the thickened ramus to the grossly sclerosed and
irregular base of the skull. Sequlae of both trauma & non trauma cases.
Bony ankylosis (TMJ ankylosis ) Sawhney 1986

Kenneth S. Rotskoff. – Management of hypomobility & hypermobility disorders of TMJ (
Principles of oral & maxillofacial surgery. Vol III. Page 1996.)
Type I Condylar head is flattened or deformed in close approximation to the upper joint space. Dense
fibrous adhesion is present within. Restricted motion is due to fibrosis in and around the joint.
Type II Flattened condyle in close approximation to the glenoid fossa, bony fusion of the outer aspect of
the articular surface either anteriorly or posteriorly and limited to a small area.
Type III Ankylosis usually results from a medially displaced fracture dislocation of the condyle with bone
bridging the ramus of the mandible to the zygomatic arch. The atrophic condylar head is either
free or fused to the medial aspect of the superior portion of the ramus.
Type IV A wider bony block bridges the mandibular ramus and zygomatic arch, extending and
obliterating the upper joint space and completely replacing the architecture of the joint.
Syngnathia ( maxillomandibular fusion ) Dowson et al 1997 / 1996
IJOMS Feb 2001:30:1 ( page 75 – 79)
Type 1 Simple syngnathia – no other congenital anomalies in head & neck.
Type 2 Complex syngnathia
Type 2 a Syngnathia co-existent with aglossia
Type 2 b Syngnathia co-existent with agenesis or hypoplasia of the proximal mandible.
Syngnathia ( maxillomandibular fusion ) Laster et al 2000 / 2001

IJOMS Feb 2001:30:1 ( page 75 – 79)
Type 1 Anterior syngnathia
Type 1a Simple anterior syngnathia -- Bony fusion of alveolar ridges only without other
congenital deformities
Type 1b Complex anterior syngnathia -- Bony fusion of alveolar ridges only, associated
with other congenital deformities
Type 2 Zygomatico-mandibular syngnathia
Type 2a Simple Zygomatico-mandibular syngnathia – Bony fusion of mandible to
zygomatic complex – causing mandibular micrognathia.
Type 2b Complex Zygomatico-mandibular syngnathia – Bony fusion of mandible to
zygomatic complex – associated with clefts or TMJ ankylosis.
General
American Society of Anaesthesiologist physical status classification system Schiender 1983
Principles of oral & Maxillofacial Surgery. Vol. I. Page 126.
ASA I A patient without systemic disease, normal healthy patient.
ASA II A patient with mild systemic disease, no functional limitation.
ASA III A patient with severe systemic disease, definite functional limitation.
ASA IV A patient with a severe systemic disease that is a constant threat to life.
ASA V A moribund patient unlikely to survive 24 hours with or without operation.
ASA E Emergency operation of any variety; the "E" precedes the patient’s physical status.
Arteriovenous malformation clinical staging Schobinger

Grabb & Smith.
Stage I Blush/ stain, warmth and AV shunting by continuos Doppler or 20 MHz colour Doppler
Stage II Same as stage I + enlargement, tortuous tense veins, pulsation, thrill and bruit.
Stage III Same as stage II + either dystrophic changes, ulceration, bleeding, persistent pain or destruction
Stage IV Same as stage II + cardiac failure.
Dental treatments – classification

Type 1 Examinations, radiographs, study model impressions, oral hygiene instruction, supragingival
prophylaxis, simple restorative dentistry.
Type 2 Scaling, root planing, endodontics, simple extractions, curettage, simple gingivectomy, advanced
restorative procedures, simple implants.
Type 3 Multiple extractions, gingivectomy, quadrant periosteal reflections, impacted teeth extractions,
apicocetomy, plate form implants, multiple root form implants, ridge augumentation,unilatral
sinus grafting, unilateral subperiosteal implants.
Type 4 Full arch implant (complete subperiosteal implants, ramus frame implants, full-arch endosteal
implants), orthognathic surgery, autogenous bone grafting, bilateral sinus grafting.
Impacted teeth
Winter’s classification 1926.
Based on the relation of long axis of impacted tooth to the 2nd molar.
Vertical
Mesioangular
Distoangular
Horizontal
Inverted
Buccoangular
Linguoangular
Pell & Gregory 1933.

Relationship of 3rd molar to ramus.
Class I There is sufficient amount of space between ramus and the distal side of the second molar for the
accommodation of the mesiodistal diameter of the third molar.
Class II The space between the ramus and the distal side of the second molar is less than the mesiodistal
diameter of the crown of the third molar
Class III All or most of the third molar is located within the ramus.
Relative depth of 3rd molar in bone.
Position A The highest portion of the 3rd molar tooth is on a level with or above the occlusal line.
Position B. The highest portion of the 3rd molar tooth is below the occlusal plane but above the cervical line
of the 2nd molar.
Position C. The highest portion of the 3rd molar tooth is below the cervical line of the 2nd molar.
Based on the long axis of the 3rd molar to that of 2nd molar (from Winter’s classification).
Horizontal with Buccoversion
Vertical Linguoversion
Mesioangular Torsoversion
Distoangular
Inverted
Buccoangular
Linguoangular
Difficulty index for removal of impacted mandibular 3rd molar Pedersen G W 1988
Oral surgery Pedersen G W
This index is based on Pell & Gregory classification and aids in assessing difficulty in surgical removal of
third molar
Classification Value
Spatial relationship
Mesioangular 1
Horizontal / Transverse 2
Vertical 3
Distoangular 4
Depth
Level A 1
Level B 2
Level C 3
Ramus relationship / Space available
Class I 1
Class II 2
Class III 3
Total score out of 10.
Difficulty index:
Very difficult 7 – 10.
Moderately difficult 5 –7.
Minimal difficult 3 – 4.
WHARFE assessment of difficulty in surgical removal of impacted 3 rd molars.

Srinivasan textbook of oral surgery Page 73
Category Score
Winter’s classification Vertical 0
Mesioangular 1
Distoangular 2
____________________________________Horizontal 2
Height of mandible 35 – 39 mm 0
31 – 34 mm 1
1 – 30 mm 2
Angulation of third molars 1o – 50o 0
51o – 69o 1
70o – 79o 2
80o – 89o 3
90o + 4
Root shape Conical 1
Favourable curvature 2
Unfavourable curvature 3
Follicles Enlarged 0
Possibly enlarged 1
Normal 2
Path of Exit Space available 0
Mesial cusp covered 1
Distal cusp covered 2
Both covered 3
_______________
Total score for out of 33
Higher score indicates difficult extraction
Canine impactions Field and Ackerman 1935
Oral and Maxillofacial Surgery Vol. II Daniel M. Laskin Page 83
Maxillary canines
a. labial position
i. crown in intimate relationship with incisors
ii. crown well above the apices of incisors
b. palatal position
i. crown near surface in close relationship with the roots of incisors
ii. crown deeply embedded in close relationship to the apices of incisors
c. intermediate position
i. crown between lateral incisor and first premolar roots
ii. crown above these teeth with crown labially placed and root palatally placed and
vice versa.
d. unusual position
i. nasal or antral
ii. infra-orbital region.
Mandibular canines
a. labial position
i. vertical
ii. oblique
iii. horizontal
b. unusual position
i. at inferior border
ii. in the mental protuberance
iii. migrated to the opposite side
Maxillary canine impactions

Oral and Maxillofacial Surgery Vol. I Archer Page 325
Class I Impacted tooth located in the palate

1. Horizontal.
2. Vertical
3. Semivertical
Class II Impacted tooth in the labial or buccal surface of the maxilla.
1. Horizontal.
2. Vertical
3. Semivertical
Class III Impacted tooth located in both the palatal and labial or buccal maxillary bone. E.g. crown is on
the palatal aspect and the root passes between the roots of the adjacent teeth in the alveolar
process, ending in a sharp angle on the labial or buccal surface of the maxilla.
Class IV Impacted cuspids located in the alveolar process, usually vertically between the incisor and first
bicuspid.
Class V Impacted cuspids located in an edentulous maxilla.
Supernumerary teeth impaction classification
(J. Canadian Dental Association, Dec 99) Gravey et al
1. Single
 Conical
 Composite odontoma
1. Complex
2. Compound
 Tuberculate
 Supplemental
2. Multiple
 Non-Syndrome
1. Tuberculate
2. Supplemental
 Syndrome
1. Cleft Lip/Palate
2. Cleidocranial Dysplasia
3. Gardner Syndrome
Maxillary third molar impactions

A classification based on the anatomic position

A Based on relative depth of the impacted maxillary third molar in bone.
Class A The lowest portion of the crown of the impacted maxillary third molar is on line with the occlusal
plane of second molar
Class B The lowest portion of the crown of the impacted maxillary third molar is between the occlusal
plane of second molar and the cervical line
Class C The lowest portion of the crown of the impacted maxillary third molar is at or above the cervical
line of the second molar
B Based on the long axis of the third molar in relation to the long axis of second molar
1. Vertical
2. Horizontal These may also occur simultaneously in
3. Mesioangular a) Buccal version.
4. Distoangular b) Lingual version
5. Inverted c) Torsoversion
6. Buccoangular
7. Linguoangular
C Based on the relationship of impacted third molar and maxillary sinus.

SA (Sinus approximation): No bone or thin portion of bone between the maxillary third molar and the
maxillary sinus.
NSA (No sinus approximation): 2mm or more thickness of bone between the impacted maxillary third molar and
the maxillary sinus.
Medicaments
Carnoy’s solution
Killey & Kay part II page.
Absolute alcohol 6 parts

Chloroform 3 parts
Glacial acetic acid 1 part
Bone wax (Horsley’s)

Killey & Kay part II page. 42.
Beeswax (yellow) 7 parts by weight

Olive oil 2 parts
Phenol 1part
Whitehead’s varnish
Benzoin 10 parts
Storax 7.5 parts
Balsam of Tolu 5 parts
Iodoform 10 parts
Solvent ether to make 100 parts.
Bonney’s blue
McGregor principles of Plastic Surgery. Page
Gentian violet 10 g
Brilliant green 10 g
Alcohol 95% 950 ml
Water to make 2000 ml.
Eusol
Local anaesthetic
Anaesthetic Lignocaine 2% (20 mg / ml)
Vasoconstrictor Adrenaline
1: 50,000 (0.02 mg/ml)
1: 80,000 (0.0125 mg/ml)
1: 1,00,000 (0.01 mg/ml)
1: 2,00,000 (0.005 mg/ml)
Preservative for local anaesthetic Methyparaben
Reducing agent Sodium bisulphite
Antifungal Thymol
Vehicle Ringer lactate
Tumescent solution
Grab & Smith
Allogenic bone
Os purum
Bone in which some of the organic elements have been removed
Anorganic bone
This is prepared by boiling bone in ethylenediamine for several days. This can be stored without
refrigeration. This can be trimmed with scalpel and cut into chips.
Kiel bone
Bovine bone treated with hydrogen peroxide and a de-fattening agent.
Boplant bone
Bovine bone treated with β propiolactone to sterilise it and de-fattening is by detergents and organic
solvents.
AAA bone (antigen

Nerves
Classification of axons – conduction speed Erlanger & Gasser 1937
A 70 – 120 m/sec.
A 30 –70 m /sec.
A
A Large sensory fibres
B Autonomic fibres
C Unmyelinated fibres 0.5 – 2 m / sec. (C fibers)
Classification of axons – size of axon Lloyd 1943

Group I A 6 – 20  m. diameter
Group II A 6 – 20  m.
Group III A 1 – 6  m.
Group IV C and B fibres smaller diameter fibres
Size of fibres in decreasing order

A  A  A  A  B  C
The conduction speed of a nerve fibre is approximately 6 times the diameter of the fibre. Thus a 15 m. nerve fibre
conducts impulse at 90 m/s.
Classification of nerve fibres based on number of fascicles

Monofascicular pattern one large fascicle. E.g. Intra-cranial part of facial nerve.
Oligofascicular pattern 2 – 10 fascicles.
Polyfascicular pattern > 10 fascicles. E.g. Inferior alveolar nerve, Lingual nerve. ( 18 – 21 fascicles )
Physiologic conduction block ( focal conduction block) Lundborg 1988

Type A Intraneural circulatory arrest or metabolic (ionic) block with no nerve fibre pathology. Reversible
immediately. Managed by therapies to improve the circulation to the nerve trunk, decrease oedema
or reverse vasospasm.
Type B Intraneural oedema resulting in increased endoneurial fluid pressure or metabolic block with little
or no nerve fibre pathology. Reversible within days or weeks. Therapies to decrease oedema and
promote venous drainage.
Intra-operative grading of peripheral nerve lesions Samii 1980

2 Divided peripheral nerve
e) Injury to examination interval < 3 weeks
f) Injury to examination interval > 3 weeks
2 Lesion in continuity
g) Injury to examination interval < 3 months
h) Injury to examination interval > 3 months
3 Mixed 1 and 2
Classification of nerve injuries Seddon 1943

Neuropraxia Local conduction block at the site of injury without Wallerian degeneration
Axonotmesis Complete interruption of axon and myelin sheath with preservation of connective tissue stroma
Neurotmesis Complete anatomic severance of the nerve
Classification of nerve injuriesSunderland 1951
1st degree Corresponds to Seddon’s neurapraxia

Type I Conduction block due to anoxia from interruption of the segmental or epineural blood
vessels, but there is no axonal degeneration or demyelination. Resulting from nerve trunk
manipulation, mild traction or mild compression. Recovery is rapid following restoration of
sensation.
Type II Conduction block due to intrafascicular oedema following rupture of endoneurial
capillaries as a result of trauma of sufficient magnitude. Recovery of senses within 1 – 2 days
following resolution in the intrafascicular oedema.
Type III Segmental demyelination or mechanical disruption of the myelin sheaths following
severe manipulation, traction or compression. Recovery takes 1 – 2 months
2nd degree Axon and myelin are interrupted, but the endoneural sheath and other supporting connective tissue
stroma including epineurium and perineurium are preserved. Wallerian degeneration distal to the
lesion and complete loss of motor, sensory and autonomic inervation.
3rd degree Disruption of axon, myelin sheath; damage to internal structures of the fascicles with loss of
endoneural integrity. Epineurium and perineurium are preserved
4th degree Interruption of all neural and supporting connective tissue stroma, except for epineurium. The
fascicular pattern is lost, and the nerve may appear as a thin strand of connective or as a neuroma
in continuity.
5th degree Loss of continuity of nerve trunk with complete loss of motor, sensory and autonomic function.
Pathologic overgrowth of regenerating axons might result in neuroma formation.
6th degree Mixed combinations of previous five levels of injury. (Added lately by MacKinnon & Dellon
1988.) (Controversies in Oral & Maxillofacial surgery. Page 279.)
Classification of nerve injuriesSymptomatic classification Controversies

Anaesthesia. Complete loss any stimulus detection and perception including mechanoreceptors and nociceptor
stimuli.
Paresthesia. Alteration in sensibility with abnormal or normal stimulus detection and perception which may be
perceived as unpleasant but not painful.
Dyesthesia. Alteration in sensibility with abnormal stimulus detection and perception which may be perceived
as unpleasant and painful.
Types : Allodynia, Hyperpathia.
Classification of nerve injuriesAnatomic classification

Intraosseous nerve injury
Soft tissue nerve injury
Classification of nerve injuriesHistopathologic classification (Controversies

Neuroma
Amputation or stump neuroma
Central or neuroma in continuity
Eccentric : Lateral exophytic
Stellate neuroma
Fibrosis
Classification of nerve injuries by location of fibrosis Millesi et al 1989.
Designation Location Prognosis
A Epifascicular epineurium Good prognosis
B Prognosis depends on original

Interfascicular epineurium damage
C Endoneurium Poor.
N In a Sunderland class IV injury,

the epineural connective tissue
that maintains continuity can be Poor
infiltrated by neuroma.
S Continuity in class IV injury Poor.

maintained only by scar tissue.
Grade A, B & C are used in combination with Sunderland’s classification : I A & I B; II A & II B and III A,
III B & III C.
Grade C fibrosis occurs only with class III injury.
Classification of nerve injuries Pathophysiologic classification

( Controversies in oral & Maxillofacial surgery. Page 283.)
Compression
Compartment syndrome
Stretch injury
Transection, laceration, rupture and avulsion
Chemical injury
Nerve injection injury
Anatomically maintained pain
Central neuropathy
Grading of sensory recovery Mackinnon Clin Plast. Surg 1989

S0 No recovery
S1 Recovery of deep cutaneous pain
S2 Return of some superficial pain / tactile sensation
S 2+ Return of some superficial pain / tactile sensation with over-reaction
S3 Return of some superficial pain / tactile sensation without over-reaction and the presence
of static two-point discrimination (2pd) >15 mm
S 3+ As per S 3, with good localisation of stimulus (2pd) = 7-15 mm
S4 As per S 3+, (2pd) =2-6 mm
Sensory score equal to or greater than S 3 is defined as useful sensory requirement
Assessment of nerve recovery - British Medical Research Council Classification

Classification Description
Motor Recovery
M0 No contraction
M1 Return of perceptible contraction in proximal muscles.
M2 Return of perceptible contraction in both proximal and distal muscles.
M3 Return of function in both proximal and distal muscles of a degree that all
important muscles are sufficiently powerful to act against resistance
M4 Return of function as in stage 3 with addition that all synergetic and independent
movements are possible.
M5 Complete recovery.
Sensory Recovery
S0 Absence of sensibility in the autonomous area.
S1 Recovery of deep cutaneous pain sensibility within the autonomous area of the
nerve.
S2 Recovery of some superficial cutaneous pain and tactile sensibility within the
autonomous area of the nerve.
S3 Recovery of superficial cutaneous pain and tactile sensibility throughout the
autonomous area with disappearance of any previous over response.
S3+ Recovery of sensibility as in S 3 with the addition of some recovery of two-point
discrimination within the autonomous area.
S4 Complete recovery.
Pain
Pain classification IASP (International association for the study of Pain).
Burket Page 327
Categorises pain into various parameters.
Axis I Regions ( the body region or site of the reported pain ).
Axis II Systems ( the body system whose abnormal function produces pain
Axis III Temporal ( temporal characteristics of pain and the pattern of occurrence. )
Axis IV Patient’s statement. ( time since onset and intensity of pain).
Axis V Aetiology. ( the presumed aetiology of the pain problem ).
Classification of chronic orofacial pain.

Burket Page 328
Neuralgias
Primary trigeminal neuralgia (tic douloureux).
Secondary trigeminal neuralgia (central nervous system lesions or facial trauma).
Herpes zoster
Postherpetic neuralgia
Geniculate neuralgia (VII)
Glossopharyngeal neuralgia ( IX)
Superior laryngeal neuralgia ( X)
Occipital neuralgia.
Pain of Musculoskeletal origin
Cervical Osteoarthritis
Temporomandibular disorders
TMJ Rheumatoid arthritis
TMJ Osteoarthritis
Myofacial pain dysfunction
Fibromyalgia
Cervical pain or hyperextension
Stylohyoid (Eagle’s) syndrome.
Primary vascular disorders
Migraine with aura
Migraine without aura
Cluster headache
Tension-type headache
Cysts & Tumours
Clinical and functional staging of oral submucous fibrosis
S. M. Haider, A. T. Merchant, F. F. Fikree, M. H. Rahbar. BJOMS 2000:38: 12-15
Clinical stage
4 Faucial bands only.
5 Faucial and buccal bands.
6 Faucial ,buccal bands and labial bands.
Functional stage
A Mouth opening > 20 mm.
B Mouth opening 11 – 19 mm.
C Mouth opening < 10 mm.
Dermoid cyst classification Rapidis et al. 1981. OOO 1994,

78: 5. Ronald C. King et al Review of literature of dermoid cysts.
Dysodontogenic cyst types Meyer, Spouge et al
Epidermoid cyst (simple dermoid) Simple stratified squamous epith. with no skin appendages
True dermoid cyst (compound dermoid) Similar epithelial lined lesion with skin appendages
Teratoid cyst (Cystic teratoma – complex dermoid) Contains the three germ layers.
Anatomic types
Median dermoid Develops beneath the lingual frenum or between the genioglossus muscles.
Lateral sublingual Between the genial muscles and the mylohyoid
True lateral Develops deep by the genioglossus & hyoglossus medially, and mylohyoid
laterally
Cysts
Numerous classifications have been published of cysts of the jaws. Most of them are perfectly
satisfactory in clinical evaluation and practise.
Robinson’s classification (1945)

Developmental cysts
C) from odontogenic tissue
4. Periodontal cyst
(d) radicular or root apex type
(e) lateral type
(f) residual type
5. Dentigerous cyst
6. Primordial cyst
D) from non-dental type of tissue
4. Median cyst (median palatal cyst)
5. Incisive canal cyst
6. Globulomaxillary cyst
Kruger’s classification (1964)

C) Congenital cyst
4. Thyroglossal
5. Branchiogenic
6. Dermoid
D) Developmental cyst
3. non-dental origin
c) fissural type
v. Naso-alveolar
vi. Median
vii. Incisive canal cyst (Naso-palatine)
viii. Globulomaxillary
d) retention type
iii. mucocoele
iv. ranula
4. dental origin
d) periodontal
iv. periapical
v. lateral
vi. residual
e) primordial
f) dentigerous
Lucas’ classification (1964)

Intra-osseous cysts
D) Fissural cysts
f) median mandibular
g) median palatal
h) naso-palatine
i) globulomaxillary
j) naso-labial
E) Odontogenic cysts
d) Developmental
iii. primordial
iv. dentigerous
e) inflammatory
f) radicular
F) Non-epithelial bone cysts
c) solitary bone cyst
d) aneurysmal bone cyst
Gorlin’s classification (1970)

E) Odontogenic cysts
8. dentigerous cyst
9. eruption cyst
10. gingival cyst of the new-born infants
11. lateral periodontal and gingival cyst
12. keratinising and calcifying odontogenic cysts (cystic keratinising tumour)
13. radicular (periapical cyst)
14. odontogenic keratocyst
c) primordial cyst
d) Gorlin-Goltz syndrome
F) Non-odontogenic and fissural cysts
8. globulomaxillary (premaxilla-maxillary) cyst
9. naso-alveolar (naso-labial / Klestadt’s) cyst
10. naso-palatine (median anterior maxillary) cyst
11. median mandibular cyst
12. anterior lingual cyst
13. dermoid and epidermoid cyst
14. palatal cysts of new-born infants
G) Cysts of neck, oral floor and salivary glands
5. thyroglossal duct cyst
6. lymphoepithelial (branchial cleft) cyst
7. oral cyst with gastric / epithelial epithelium
8. salivary gland cyst – mucocoele and ranula
H) Pseudocysts of jaws
4. aneurysmal bone cyst
5. static (developmental / lateral) bone cyst
6. traumatic (haemorrhagic / solitary) bone cyst
WHO classification published in ‘Histologic typing of odontogenic tumours’ (Kramer, Pindborg,
Shear – 1992)
I. Cysts of the jaws
C) Epithelial
3. developmental
c) odontogenic
x. gingival cysts of infants
xi. odontogenic keratocyst (primordial cyst)
xii. dentigerous (follicular) cyst
xiii. eruption cyst
xiv. lateral periodontal cyst
xv. gingival cyst of the adults
xvi. botryoid odontogenic cysts
xvii. glandular odontogenic (sialo-odontogenic / mucoepidermoid-
odontogenic) cyst
xviii. calcifying odontogenic cyst
d) non-odontogenic
vi. naso-palatine duct (incisive canal) cyst
vii. naso-labial (naso-alveolar) cyst
viii. midpalatine raphae cyst of infants
ix. median palatine, median alveolar and median mandibular
cysts
x. globulomaxillary cyst
4. inflammatory
v. radicular cyst (apical / lateral)
vi. residual cyst
vii. paradental (mandibular infected buccal) cyst
viii. inflammatory collateral cyst
D) Non-epithelial
iii. solitary (traumatic/simple/haemorrhagic) bone cyst
iv. aneurysmal bone cyst
II. Cysts associated with the maxillary antrum
c) benign mucosal cyst of the maxillary antrum
d) post-operative maxillary cyst (surgical ciliated cyst of the maxilla)
III.Cysts of the soft tissues of the mouth, face and neck
k) dermoid and epidermoid cyst
l) lymphoepithelial (branchial cleft) cyst
m) thyroglossal duct cyst
n) anterior median lingual cyst (intralingual cyst of fore-gut origin)
o) oral cyst with gastric / intestinal epithelium (oral alimentary tract cyst)
p) cystic hygroma
q) naso-pharyngeal cysts
r) thymic cysts
s) cysts of the salivary glands
v. mucous extravasation cyst
vi. mucous retention cyst
vii. ranula
viii. polycystic (degenerative) disease of parotid
t) parasitic cysts
iv. hydatid cyst
v. cysticerus cellulosae
vi. trichinosis
Fibro-osseous lesions Charles A Waldron (JOMS 1989, 1993)
4. Fibrous dysplasia
g a. Polyostotic
b. Monostotic.
5. Fibro-osseous (Cemental ) lesions. Reactive (dysplastic ) lesion arising in the tooth bearing area. They
are presumably arising from periodontal ligament. They are divided into three types based on their
radiologic features although they represent the same pathologic process.
h a. Periapical cemental (Cemento-osseous )dysplasia.
i b. Focal (local) cemento-osseous lesions (dysplasia). – probably reactive in nature.
j c. Florid cemento-osseous dysplasia (gigantiform cementoma).
6. Fibro-osseous neoplasms. They are of uncertain or debatable relationship to those arising in the
periodontal ligament. They are widely designated as cementifying fibroma, ossifying fibroma or
cemento-ossifying fibroma.
k a. Cementoblatoma, Osteoblastoma and Osteoid osteoma.
l b. ‘Juvenile active ossifying fibroma’ and other so called “ aggressive”, “active” ossifying /
cementifying fibromas.
TNM classification
The TNM system is used to describe the anatomical extent of a malignant disease. It is based on
the assessment of three components
T – the extent of primary tumour
T – primary tumour
N – the absence or presence and extent of regional lymph node metastasis
M – the absence or presence of distant metastases.
Head and neck cancer
T Primary tumor size
Lip and oral cavity
T4 Lip: Tumour invades adjacent structures, e.g. through cortical bone, tongue, skin of neck.
Oral cavity: Tumour invades adjacent structures, e.g. through cortical bone, into deep (extrinsic)
muscles of tongue, maxillary sinus, skin
Pharynx (oropharynx)
T4 - Tumour invades adjacent structures, e.g. through cortical bone, soft tissues of neck, deep
(extrinsic) muscles of tongue
Pharynx (nasopharynx)
T1 - Tumour limited to one subsite of nasopharynx
T2 - Tumour invades more than one subsite of nasopharynx
T3 - Tumour invades nasal cavity and/or oropharynx
T4 - Tumour invades skull and/or cranial nerves
Maxillary sinus
T1 - Tumour limited to the antral mucosa with no erosion or destruction of bone
T2 - Tumour with erosion or destruction of the infrastructure including the hard palate and/or the
middle meatus.
T3 - Tumour invades any of the following: skin of cheek, posterior wall of the maxillary sinus, floor
or medial wall of the orbit, anterior ethmoid sinus
T4 - Tumour invades the orbital contents and/or any of the following: cribriform plate, posterior
ethmoid or sphenoid sinuses, nasopharynx, soft palate, pterygomaxillary or temporal fossae, base
of skull
Salivary glands
T4 - Tumour more than 6 cm in greatest dimension.
The classification applies only to carcinoma of the major salivary glands: parotid, submandibular
and sublingual glands. Tumours arising in minor salivary glands (mucous secreting glands in the lining
membrane of the upper aerodigestive tract) are not included in this classification.

The definitions of the N categories for all head and neck sites except thyroid gland are:
N1 - Metastasis in a single ipsilateral lymph node, 3cm or less in greatest dimension
N2 - Metastasis in a single ipsilateral lymph node, more than 3cm but not more than 6 cm in greatest
dimension, or in multiple ipsilateral lymph nodes, none more than 6cm in greatest dimension, or in
bilateral or contralateral lymph nodes, none more than 6cm in greatest dimension
N2a – Metastasis in a single ipsilateral lymph node, more than 3cm but not more than 6 cm in greatest
dimension
N2b – Metastasis in multiple ipsilateral lymph nodes, none more than 6cm in greatest dimension
N2c – Metastasis in bilateral or contralateral lymph nodes, none more than 6cm in greatest dimension
N3 - Metastasis in a lymph node more than 6 cm in greatest dimension
N 3 ba – Clinically positive ipsilateral node(s), one more than6 cm in diameter.
N 3b – Bilateral clinically positive nodes( in this situation, each side of the neck should be staged
separately)
N 3c – contralateral clinically positive node(s) only.
Note: Midline nodes are considered ipsilateral nodes.
Metastasis in any lymph node other than regional is classified as distant metastasis. The definition
of M-Distant Metastasis is the same for all types of cancer.
The category M1 may be further specified according to the following notation:
Pulmonary(PUL) Bone marrow(MAR) Osseous(OSS)
Lymph nodes(LYM) Hepatic (HEP) Peritoneum(PER)
Brain(BRA) Skin(SKI) Pleura(PLE) Other(OTH)
Other tumours
Osteosarcoma
T1 - Tumour confined within the cortex
T2 - Tumour invades beyond the cortex
The classification applies to all primary malignant bone tumours except multiple myeloma, juxtacortical
osteosarcoma and juxtacortical chondrosarcoma
Soft tissue sarcomas

Skin tumours
T4 - Tumour invades deep extradermal structures, i.e. cartilage, skeletal muscle or bone
Note: In the case of multiple simultaneous tumours, the tumour with the highest T category will be
classified and the number of separate tumours will be indicated in parenthesis e.g. T2 (5)
Melanoma
The extent of tumour is classified after excision. This is a pathological tumour classification.
Tis - Melanoma in situ (Clark’s level I) (atypical melanocytic hyperplasia, severe melanocytic dysplasia,
not an invasive malignant lesion)
T1 - Tumour 0.75 mm or less in thickness and invading the papillary dermis (Clark’s level II)
T2 - Tumour more than 0.75 mm but not more than 1.5 mm in thickness and/or invading the papillary-
reticular dermal interface (Clark’s level III)
T3 - Tumour more than 1.5 mm but not more than 4.0 mm in thickness and/or invading the reticular dermis
(Clark’s level IV)
T3a – Tumour more than 1.5 mm but not more than 3.0 mm in thickness
T3b – Tumour more than 3.0 mm but not more than 4.0 mm in thickness
T4 - Tumour more than 4.0 mm in thickness and/or invading subcutaneous tissue (Clark’s level V) and/or
satellites within 2cm of the primary tumour.
T4a – Tumour more than 4.0 mm in thickness and/or invading subcutaneous tissue
T4b – Satellites within 2cm of the primary tumour
Note: In case of discrepancy between tumour thickness and level, the T category is based on the less favourable
finding.
N1 - Metastasis 3 cm or less in greatest dimension in any regional lymph node(s)
N2 - Metastasis more than 3 cm or less in greatest dimension in any regional lymph node(s) and/or
in-transit metastasis
N2a - Metastasis more than 3 cm or less in greatest dimension in any regional lymph node(s)
N2b - In-transit metastasis
N2c – Both
Note: In-transit metastasis involves skin or subcutaneous tissue more than 2cm from the primary tumour but beyond the regional
lymph nodes
M1 a - Metastasis in skin or subcutaneous tissue or lymph node(s) beyond the regional lymph
nodes
M1 b - Visceral metastasis
Classification of Burkitt’s lymphoma
Several classification systems have been used to stage non-Hodgkin's lymphoma (Ultmann and Jacobs,
1985; Kearns et al., 1986). They include that of Lukes and Collins (1974), of Murphy (1980) and that of
Ann Arbor (Ultman and Jacobs, 1985), which carry some prognostic relevance.
A separate staging system for Burkitt's lymphoma has been developed by Ziegler (1981), while
Levine et al. (1982) classified the cases of the American Burkitt's Lymphoma Registry as follows:
Stage I single tumour mass (extra abdominal 1A or abdominal 2A).
Stage II two separate tumour masses on the same side of the diaphragm.
Stage III involvement of more than two separate masses, or disease on both sides of the
diaphragm
Stage IV pleural effusion, ascites, or involvement of the central nervous system (malignant cells in
the cerebrospinal fluid) or bone marrow.
Salivary gland disease
Classification of echo patterns of palatal salivary gland tumours OOO 1999 Jan Junichi
Ishii et al
Type I Mixed pattern; cystic patterns within echogenic solid pattern
Type II Nodules are seen in the tumour echo
Type III Acoustic shadow is seen in the tumour echo
Type IV Hypo-echoic pattern with homogenous internal echoes
Sialographic grading of sialadenitis Zou et al – 1992; Wang et al – 1992).

Score Definition
0 Normal
1 Mild; slight irregular dilation of the main duct, often with areas of local stenosis. No disease within the
gland
2 Moderate; more ductal changes than in the mild disease with dilated branching ducts and some punctate
sialectasis
3 Severe; more widespread changes than in moderate disease, spreading to most of the ducts with complete
sialectasis and formation of cavities.
Histologic grading of sialadenitis Isacsson et al – 1981; Seifert et al – 1977,

1986).
Score Definition
5. Normal
6. Slight focal and periductal lymphocytic infiltration and slight increase in the diameter of the duct
7. Moderate periductal inflammation and formation of lymphoid follicles; interstitial fibrosis; localised
destruction of acini and moderated changes to ductal epithelium.
8. Reduced lymphocytic infiltration; formation of periductal and interlobular lymphoid follicles;
periductal hyalinisation; reduced ductal metaplastic changes and acinar destruction
Classification of salivary gland disease

The diseases of salivary glands may be divided into
3. Developmental anomalies
4. Infections acute
chronic
systemic
3. Neoplasms benign
malignant
6. Auto-immune
7. Miscellaneous necrotising sialometaplasia
cystic fibrosis
mucocele and ranula
Classification of sialadenitis
Sialadenitis, infection of salivary gland tissue is a relatively common tissue. It may be classified as
(IV) Bacterial and viral
c) Mumps (viral parotitis)
d) Bacterial parotitis (sialadenitis)i. Acute
ii. chronic
c) Recurrent parotitis of childhood
(V) Obstructive sialadenitis
e) Sialolithiasis
f) Mucous plugs
g) Stricture – stenosis
h) Foreign body
(VI) Systemic granulomatous diseases
e) Tuberculosis
f) Actinomycosis
g) Fungal infection
h) Uveoparotid fever
Defects and clefts
Classification of mid-facial defects
Type I Loss of midfacial skin only ; buttress of the maxilla, orbital floor and palate intact
Type II Partial maxillectomy with intact palate and orbital floor
Type III Partial maxillectomy with resection of a portion of palate ; orbital floor and Lockwood’s
ligament remain intact
Type IV Total maxillectomy and palatectomy ; orbital support remains intact
Type V Total maxillectomy and palatectomy with loss of orbital support or eye
Classification of cleft lip and palate.

Various classifications systems have been proposed, but only a few have found wide acceptance.
VIII. In the classification of David and Ritchie (1922), congenital clefts were divided into three groups
according to the position of the clefts in relation to the alveolar process.
Group I – Pre-alveolar clefts – unilateral (right or left), bilateral or median
Group II – Post-alveolar clefts – involving soft palate only
involving soft and hard palates
submucous cleft
Group III – Alveolar clefts – unilateral (right or left), bilateral or median.
IX. Veau (1931) suggested a classification that divides cleft palates into four groups.
Group I – Cleft of soft palate only.
Group II – Cleft of hard and soft palate extending no further than incisive foramen, thus involving
secondary palate alone.
Group III – Complete unilateral cleft, extending from the uvula to the incisive foramen in the
midline, then deviating to one side and usually extending through the alveolus at the
position of the future lateral incisor tooth.
Group IV – Complete bilateral cleft, resembling Group III with two clefts extending forwards
from the incisive foramen through the alveolus.
X. Kernahan and Stark (1958) recognised the need for a classification based on embryology rather
than morphology.
F. Incomplete cleft of secondary palate
G. Complete cleft of secondary palate
H. Incomplete cleft of primary and secondary palates
I. Unilateral complete cleft of primary and secondary palates
J. Bilateral complete cleft of primary and secondary palates
XI. Kernahan (1971) subsequently proposed a striped ‘Y’ classification. The incisive foramen, which
is the dividing line between primary and secondary palate, is taken as the reference, and forms the
junction of the ‘Y’. With stippling of the involved portion of the ‘Y’, the system provides rapid graphic
representation of the original pathologic condition and renders itself to computer-graphic presentation.
XII. American Association of Cleft Palate Rehabilitation Classification (AACPR). The
classification suggested by Harkins and associates (1962) and endorsed by the American Association
of Cleft Palate Rehabilitation Classification (AACPR) is based on the same principles used by
Kernahan and Stark.
VII. Cleft of primary palate
a) Cleft lip – unilateral, bilateral, median, prolabium, congenital scar
b) Alveolar cleft – unilateral, bilateral, median
VIII. Cleft of palate proper
a) Involving soft palate
b) Involving hard palate
IX. Mandibular process cleft
(i) Mandibular cleft lip
(ii) Mandibular cleft
(iii) Lower lip pits
X. Naso-ocular cleft – extending from narial region to the medial canthal region
XI. Oro-ocular cleft – extending from the angle of the mouth towards the palpebral fissure
XII. Oro-aural cleft – extending from the angle of the mouth towards the ear.
XIII. Spina (1974) modified the David and Ritchie classification.

Group I – Pre-incisive foramen clefts
A. Unilateral B. Bilateral C. Median
Group II – Trans-incisive foramen clefts (involving lip, alveolus and palate)
A. Unilateral B. Bilateral
Group III – Post-incisive foramen clefts
A. Total B. Partial
Group IV – Rare facial clefts
XIV. Tessier (1973) introduced a classification system for the more complex orbito-facial clefts.
Detailed descriptions of the classification were subsequently published by Tessier (1976) and
Kawamoto (1976). The classification successfully integrates the clinical examination findings with
direct observations of the underlying skeletal deformity at the time of reconstructive surgery.
The system classifies the clefts in circumferential manner around the orbit with cranial extensions.
The clefts are numbered from 0 to 14 and follow constant lines, or axes, through the eyebrows or
eyelid, the maxilla, the nose and the lip. All components of an individual cleft combination add up to
14. The orbit is regarded as the reference landmark, since it is common to both the cranium and the
face. The common cleft lip is part of clefts 2 and 3.
Median clefts of the lower lip and mandible coincide with the caudal extension of number 0 cleft,
but Tessier has labelled them number 30 clefts.
Preprosthetic surgery
Alveolar ridge classification Cawood & Howell

Class I Dentate
Class II Immediate post extraction
Class III Convex ridge form with adequate height and width
Class IV Knife edge ridge form, inadequate height and width
Class V Loss of basal bone that may be extensive and follows no predictable pattern.
Bone quality classification Lekholm and Zarb 1985 AJOMS 1997

Q1 Dense homogenous cortical bone with a small trabecular bone
Q2 Large, dense layer of cortical bone surrounding dense trabecular core
Q3 Thinner layer of cortical bone around dense trabecular core
Q4 Thin cortical layer surrounding low density trabecular bone.
Alveolar ridge deficiency-Classification and treatment Tucker 1997

( Modified from Kent JN et al . J. Oral Maxillofac Surg 1983 : 41 : 629. )
Principles of oral & Maxillofacial surgery. Vol. II. Page 1108.
Class I Alveolar ridge is adequate in height, inadequate in width, usually with lateral deficiencies
or undercut areas. Patient receives HA alone 2 – 4 gms. For each anterior / posterior area,
6 – 8 gms for local ridge.
Class II Alveolar ridge is deficient both in height and width and presents a knife edge appearance.
Patient receives HA alone 3 - 5 gms. For each anterior / posterior area, 8 - 10 gms for
local ridge.
Class III Alveolar ridge is resorbed to the level of basilar bone, producing a concave form in the
posterior areas of the mandible and a sharp bony ridge form with bulbous mobile soft
tissue in the maxilla. . Patient receives HA alone 8 - 12 gms or HA in combination with
autogenous iliac cancellous bone ( 1g HA : !cc bone ).
Class IV There is resorption of the basilar bone, producing thin pencil-thin, flat mandible or
maxilla. Patients receive HA, 10 –15 g, mixed with autogenous bone in a 1:1 ratio.
Patient unable to permit harvesting of iliac bone may have HA alone to increase ridge
heights modestly. HA combined with bone is recommened for larger augumentation and
to strengthen the mandible.
Division of available bone

Division Dimension Treatment options
A > 5mm width Division A root form.

> 10-13 mm height
> 7 mm length
< 30 degree angulation
Crown / implant ratio < 1
B 2.5 – 5 mm width Osteoplasty

> 10 – 13 mm height Division A root form.
> 12mm length Augumentation
< 20 degree angulation Demanding aesthetics.
Crown / implant ratio < 1 Great force factors
Narrow Implants
Division B root form
Plate form.
C Unfavourable in :
Width
Bone density classification Misch 1988
Bone Density
D1 Dense cortical bone. ( Anterior mandible)
D2 Thick dense to porous cortical bone on crest and coarse trabecular bone within
( Anterior maxilla)
D3 Thin porous cortical bone on crest and fine trabecular bone within
( Anterior Maxilla & Posterior mandible)
D4 Fine trabecular bone ( Posterior maxilla)
D5 Immature, nonmineralized bone.
D1 bone is similar to drilling into Oak or maple wood, D2 bone is similar to the tactile
sensation of drilling into white pine or spruce, D3 bone is similar to drilling into balsa wood, D4
bone is imilar to drilling into styrofoam.
CT determination of bone density

D1 > 1250 Hounsfield units
D4 150 –350 Hounsfield units
D5 < 150 Hounsfield units
Partially and edentulous arches class’n Misch and Judy

(Modification of Kennedy-Applegate system)
Contemporary implant dentistry Carl E. Misch Page 163-74
Healing times for treatment categories Misch

Mandibular overdenture treatment options Misch

Time course of interface development in cortical bone

Prosthodontic options in implantology Misch 1989

Type Definition
FP1 Fixed prosthesis, replaces only the crown, looks like normal teeth.
FP2 Fixed prosthesis, replaces the crown and a portion of root, crown contour appears normal
in the occlusal half but is elongated or hypercontoured in the gingival half.
FP3 Fixed prosthesis, replaces missing crowns and gingival colour and portion of the
edentulous site, prosthesis most often uses denture teeth and acrylic gingiva, but may be
porcelain to metal.
RP4 Removable prosathesis, overdenture supported completely by implant.
RP5 Removable prosthesis, overdenture supported by both soft tissue and by implant.
Clinical implant mobility scale

Scale Description
5 Absence of clinical mobility with 500 g in any direction.
6 Slight detectable horizontal movement.
7 Moderate visible horizontal mobility up to 0.5 mm.
8 Severe horizontal movement greater than 0.5 mm.
9 Visible moderate to severe horizontal and any visible vertical movement.
Implant quality scale Misch 1993
Trauma
Trauma score & Basics
Classification of operative wounds in relation to contamination and increasing risk of infection.
Altemeier, Burke and Pruitt AJOMS 1997
Class I Clean (non-traumatic, uninfected, GIT & Resp. tract not involved
Class II Clean – contaminated (involving GIT and RT under controlled conditions)
Class III Contaminated (gross spillage from GIT, genito-urinary tract involvement with
infected urine and bile.
Class IV Dirty and infected (traumatic wound with devitalised tissue, foreign bodies, faecal
contamination or from a dirty source
Classification of hemorrhagic shock by American College of surgeons committee on trauma 1984

Class I Acute blood loss ≤ 15 % of total blood volume. Pulse & respiration increased. BP not
significantly affected.
Class II Acute blood loss of 20 – 25 % of total blood volume. Increased pulse & respiration.
Decreased BP. No decrease in urine output.
Class III Blood loss of 30 –40 % of total blood volume. Increased pulse & respiration. Decreased
BP & Urine output.
Class IV 40 –50 % loss of total blood volume. Lack of vital signs. Decreased urine output.
Obtunded mental status.
For 70 kg man (Peterson, Principles of Oral & Maxillofacial surgery) Page 291
Class I Class II Class III Class IV
Blood Loss 750 ml 750 - 1500 1500 - 2000 2000 or more
% loss 15 % 15 – 30 % 30 –40 % 40 % or more
Pulse rate < 100 > 100 > 120 140 or higher
BP Normal normal decreased Decreased

Normal or
Pulse pressure (mm Hg ) increased
decreased decreased decreased
Capillary blanch test Normal positive positive positive
Respiratory rate 14 – 20 20 – 30 30 - 40 > 35
Urine output (ml / hr ) 30 or more 20- 30 5 - 15 Negligible

Anxious and Confused &
CNS mental status Slightly anxious Mild anxious
confused lethargic
Fluid replacement (3:1 Crystalloid + Crystalloid +
Crystalloid crystalloid
rule ) blood blood
Glasgow Coma scale Jennet & Teasdale
Oral & Maxillofacial trauma Vol I ( Fonseca). Page 181.
Eye Opening ( E )
Spontaneous 4
To voice 3
To pain 2
None 1
Verbal response (V )
Oriented 5
Confused 4
Inappropriate words 3
Incomprehensible sounds 2
None 1
Motor response ( M )
Obeys commands 6
Localises pain 5
Withdraws on pain 4
Flexion on pain 3
Extension on pain 2
None 1
Trauma score scale Champion et al 1981
Peterson ( Principles of Oral & Maxillofacial surgery) Page 272
Rate Code Score
Respiratory rate 10 – 24 4
25 – 35 3
≥ 36 2
1–9 1
0 0
A: _____
Respiratory effort
Normal 1
Reactive Use of accessory muscles or intercostal retraction Reactive / none 0
B: _____
Systolic Blood pressure
≥ 90 4
Systolic cuff pressure Either arm, auscultate or palpate 70 –89 3
50 – 69 2
0 - 49 1
7 0
No carotid pulse.
C: _____
Capillary refill
Normal - forehead / lip mucosa colour refill in 2 secs. Normal 2
Delayed – More than 2 sec refill. Delayed 1
None - No capillary refill. None 0
D: ______
Glasgow Coma Scale ( GCS )
14 – 15 5
11 – 13 4
8 – 10 3
5- 7 2
3 -4 1
E: ______
Trauma score = A + B + C + D + E
Revised trauma Score

Indian journal of OMFS Vol. XII : No : 4 Page. 5 – 9.
Glasgow Coma Scale Systolic B.P. Respiratory rate Coded value
13-15 > 89 10 – 29 4
9 – 12 76 – 89 > 29 3
6 –8 50 – 75 6–9 2
4–5 1 – 49 1–5 1
3 0 0 0
It is a modification of Trauma score rating. It eliminated capillary refill assessment and respiratory
movement.
Injury Severity score
Developed to deal with multiple traumatic injuries and compare the death rates from blunt trauma
using the data that rated the severity of injury in each of the three most severely injured organ systems.
Organ systems evaluated include - - Respiratory, Central nervous system, cardiovascular,
abdominal, extremities and skin.
The grading is
8 Minor
9 Moderate
10 Severe, non life threatening
11 Life threatening, survival probable
12 Survival non probable
13 Fatal cardiovascular, CNS, or burn
injuries.
The three highest scores are squared and added to give the ISS. The lowest possible ISS is 3 and
highest ISS score is 108. Mortality rates increases with increase in ISS and age.
The CRAMS scale Gornican 1982, Clemmer et al 1985.

Peterson – Principles of oral & maxillofacial surgery. Page 271 - 273.
Circulation
Normal capillary refill and BP > 100 2
Delayed capillary refill or BP<100, >85 1
No capillary refill or BP < 85 0
Respiration
Normal 2
Abnormal (laboured or shallow) 1
Absent 0
Abdomen
Abdomen and thorax nontender 2
Abdomen or thorax tender 1
Abdomen rigid or flail chest 0
Motor
Normal 2
Responds only to pain (other than decerebrate) 1
No response (or decerebrate) 0
Speech
Normal 2
Confused 1
No intelligble words 0
Score ≤ 8 = Major trauma
Score ≥ 9 = Minor trauma.
Classification of open fractures based on extent of soft tissue injury. Gustilo & Anderson
1976
Grade I Open fracture with a wound less than 1 cm long & clean.
Grade II Open fracture with a laceration more than 1 cm long without extensive soft tissue
damage, flaps or avulsions.
Grade III Either an open segmental fracture or an open fracture with extensive soft tissue damage or
traumatic amputation.
Grade III A Adequate soft tissue coverage of a fractured bone despite extensive soft tissue laceration
of flaps or high energy trauma irrespective of the size of the wound.
Grade III B Extensive soft tissue injury loss with periosteal stripping and bone exposure. This is
usually associated with massive contamination.
Grade III C Open fracture associated with arterial injury requiring repair.
Midface fractures
Classification of midface fractures Réné Le Fort 1901
Le Fort I Low-level fracture
Le Fort II Pyramidal or Subzygomatic Fracture
Le Fort III High Traverse or Suprazygomatic Fracture
Classification of midface fractures Wassmund 1927

Krüger & Schilli. Page 107 - 113.
Wassmund I Pyramidal fracture of maxilla without involvement of nasal bones
Wassmund II Pyramidal fracture of maxilla with involvement of nasal bones
Wassmund III Total displacement of midface from cranial base without involvement of nose.
Wassmund IV Total displacement of midface (visecrocranium) from cranial base with involvement of nose.
Classification of midface fractures Schwenzer 1967

Krüger & Schilli. Page 107.
1. Central midface fractures (≠ from root of nose to alveolar process without involvement of cheek bones)
a) Alveolar process fracture
b) Transverse (horizontal) fracture of maxilla (Le Fort I)
c) Sagittal fracture of maxilla (median or paramedian)
d) Pyramidal fracture with separation of entire maxilla with involvement of nasal bones (Le Fort II)
e) Fracture of nasal bones and naso-ethmoid complex.
2. Centrolateral midface (separation of entire facial skeleton from base of skull)
a) Total displacement of visecrocranium with involvement of nasal bones (Le Fort III / Wassmund IV)
b) Total displacement without involvement of nasal bones (Wassmund III)
c) Combination fractures characterised by central and centrolateral fractures with atypical fractures.
3. Lateral midface
a) Fractures of Zygoma
b) Fractures of zygomatic arch
c) Zygomatico-maxillary fracture
d) Zygomatico-mandibular fracture
e) Fracture of the floor of the orbit (Blow out fracture).
Classification of midface fractures Rowe & Williams 1985
A. Fractures not involving the occlusion
1. Central region
2. Lateral region
B. Fractures involving the occlusion
1. Dento-alveolar
2. Subzygomatic
a. Le Fort I (low level or Guérin)
b. Le Fort II (pyramidal)
3. Suprazygomatic
a. Le Fort III (high level or craniofacial dysjunction)
Simpler classification of midface fracturesPeter Banks 1987

7. Dento-alveolar fractures
8. Zygomatic complex fractures
9. Nasal complex fractures
10. Le Fort I, Guérin, or low level fractures
11. Le Fort II, pyramidal or infrazygomatic fractures.
12. Le Fort III or suprazygomatic fractures.
Modified Le Fort Classification Marciani R D 1993

Dental secrets.Page 161 / Fonseca. Oral & Maxillofacial surgery. Vol. 3. Page- 251
Le Fort I Low maxillary fractures
Ia Low maxillary fractures / multiple segments.
Le Fort II Pyramidal fractures
II a Pyramidal and nasal fractures
II b Pyramidal and nasoorbitoethmoidal (NOE) fracture.
Le Fort III Craniofacial dysjunction.
III a Craniofacial dysjunction and nasal fracture
III b Craniofacial dysjunction and NOE
Le Fort IV Le Fort II or III fracture and cranial base fracture
IV a Supraorbital fracture
IV b Anterior cranial fossa and supraorbital rim fracture
IV c Anterior cranial fossa and orbital wall fracture.
Classification of palatal fractures Paul N. Manson et al PSR 1998

Type I Alveolar fractures
Type II Sagittal fractures
Type III Para-sagittal fractures
Type IV Para-alveolar fractures
Type V Complex fractures
Type VI Transverse fractures
Zygomatic complex & orbital fractures
Classification of Zygomatic complex fractures Knight & North 1961
Based on direction of displacement in waters view radiograph.
Group I Nondisplaced fractures – cases in which there is no clinical or radiographic evidence of
displacement; no treatment required.
Group II Arch fractures – A pure fracture of the zygomatic arch. The classical three fracture lines
produce a ‘V’ shaped deformity.
Group III Unrotated body fractures – Caused by a direct blow to the zygomatic prominence.
Zygoma is driven posteriorly and medially, producing a flattening of the cheek. Water’s
view shows a displaced infra orbital rim inferiorly and medially at the buttress.
Group IV Medially rotated body fractures – Caused by a blow from above the horizontal axis of
the zygoma. Bone is driven medially, inferiorly and posteriorly with rotation. The X rays
shows displacement inferiorly at the infraorbital rim and either outward at the malar
buttress or inward at the frontozygomatic suture.
Group V Laterally rotated body fractures – Caused by a blow below the horizontal axis of the
bone. Zygoma is displaced medially and posteriorly with lateral rotation. The radiograph
indicates upward displacement at the infraorbital rim and lateral displacement at the
frontozygomatic suture.
Group VI Complex fractures – these have additional fractures across the body of zygoma.
Classification of Zygomatic complex fractures Rowe & Kiley 1968

Modified North & Knight classification by giving consideration to the periosteal envelope of the
bone and adequacy of the bony apposition at the fracture interface.
Classification of Zygomatic complex fractures Yanagisawa 1973

Group I Nondisplaced fractures – no treatment required.
Group II Arch fractures – A pure fracture of the zygomatic arch.
Group III Medial or lateral rotation around a vertical axis.
Group IV Medial or lateral rotation around a longitudinal axis.
Group V Medial or lateral displacement without rotation.
Group VI Isolated rim fracture.
Group VII All Complex fractures.
Classification of malar fractures Spiessl & Schroll 1972

Type I Zygomatic arch fracture
Type II Zygomatic complex fracture - - no significant displacement
Type III Zygomatic complex fracture - - partial medial displacement (kinking at the FZ suture)
Type IV Zygomatic complex fracture - - total medial displacement. (Complete ≠ of FZ suture).
Type V Zygomatic complex fracture - - dorsal displacement. (2 ≠ sites in zygomatic arch).
Type VI Zygomatic complex fracture - - inferior displacement.
Type VII Zygomatic complex fracture - - Comminuted fracture
Classification of Zygomatic complex fractures Larsen & Thompson 1978

Group I Nondisplaced fractures requiring no treatment – During the initial evaluation, if there is
any doubt about stability, revaluation should occur 1 week after injury.
Group II All fractures requiring treatment – This is further subdivided into fractures that are
stable and fractures that are unstable after reduction.
Classification of malar fractures Eberhard Krüger 1986

1. Fractures of Zygoma
a. No significant displacement
b. Partial medial displacement
c. Total medial displacement
d. Dorsal displacement
e. Inferior displacement
f. Comminuted fractures
2. Fractures of Zygomatic arch
3. Complex fractures
a. Centrolateral midface fractures
b. Zygomatico-maxillary fractures
c. Zygomatico-mandibular fractures.
Classification of Orbital fracturesRowe & Williams 1985
Rowe & Williams. Maxillofacial injuries. Vol. I Page 502- 506.
Zygomatic complex fractures
1. Fractures stable after elevation
a. Arch only (medially displaced).
b. Rotation around vertical axis
i) Medially
ii) Laterally
2. Fractures unstable after elevation
a. Arch only (inferiorly displaced).
b. Rotation around horizontal axis
i) Medially
ii) Laterally
c. Dislocation en bloc
i) Inferiorly
ii) Medially
iii) Postero-laterally
d. Comminuted fractures
Isolated fractures of the orbital rim
1. Superior rim
a. Lateral third (lacrimal recess)
b. Central third (supraorbital nerve)
c. Medial third (frontal sinus)
2. Inferior rim
a. Central third (infraorbital nerve)
b. Medial third (inferior oblique margin)
3. Medial rim
a. Medial canthal ligament
b. Lacrimal passage
4. Lateral rim
a. Lateral canthal ligament
b. Suspensory ligament
Isolated fractures of the orbital wall
1. Roof
a. Anterior fossa
b. Levator palpebrae superioris / superior rectus
c. Frontal sinus
2. Floor
a. Antrum
b. Infraorbital nerve & vessels
c. Inferior rectus / inferior oblique
3. Medial wall
a. Lacrimal sac & nasolacrimal canal
b. Ethmoidal sinus
c. Medial rectus
d. Suspensory ligament
4. Lateral wall
Superior orbital fissure & related structures.
Complex comminuted fracture
Classification of zygomatic fractures Zingg et al 1992.

AJOMS 1997:55: 253 – 258.
Type A Incomplete fractures
Isolated lateral orbital rim
Isolated inferior orbital rim
Type B Monofragment malar or classic tetrapod fractures
Type C Multifragmented fractures
Nasal, Nasoethmoid and Orbital fractures

Classification of Naso-Orbito-Ethmoid complex fractures.
Type I one portion of mpedial orbital rim involved with attached medial canthal ligament.
Type II fractured large fragments, medial canthal tendon attached to the fractured segment.
Type III fracture involving the central fragment of bone where the medial canthus attaches.
Classification of Nasal fractures

Schwenzer (1967) classified central mid-face fractures into
6. Alveolar fractures of the maxilla
7. LeFort I fracture
8. Sagittal fracture of the maxilla
9. Pyramidal fracture of the maxilla (LeFort II)
(c) Wassmund I
(d) Wassmund II (involving the nasal bone)
10. Fractures of the nasal bone and naso-ethmoidal region.
A simple classification based on severity of injury was proposed by Haug and Prather (1991) who
suggested an anatomically based system. Most of the existing classification schema are based on the
direction of applied force. Thus in 1968, Rowe and Killey described lateral and anterior nasal injuries
resulting from impact either from lateral or anterior direction. This forms the basis of the most popular
classification of nasal injuries described by Stranc and Robertson (1979). They divided the less common
frontal type of injuries into 3 categories, depending on the depth of injury.
Plane I injury
These do not extent beyond a line joining the lower end of the nasal bones to the anterior nasal
spine. The major part of impact is transmitted to the lower cartilaginous vault. Separation or avulsion
injuries of the lateral cartilages or septum may be seen.
Plane II injury
Limited to the external nose, these may involve the nasal septum and the anterior nasal spine.
More extensive deviation of the nasal bones and septal fractures, segmental over-riding etc. may be seen in
this case.
Plane III injury
These extend to involve the orbital and possibly cranial structures. These injuries typically involve
comminution of nasal bones and extent to adjacent bony structures viz. Frontal process of maxilla, ethmoid
labyrinth and lacrimal bones. Upward extensions may involve the cribriform plate of ethmoid and orbital
plates of frontal bones.
The levels of injury resulting from lateral or latero-oblique forces are as follows
Level I – involving ipsilateral nasal bone
Level II – Level I + contra-lateral nasal bone and septum
Level III – Level II + frontal process of maxilla and lacrimal bones.
Many other classification systems are subclasses to include the nasal tip and ANS, fractures of the
dorsum with or without septal deflection, and comminuted nasal fractures (Harrison-1978). Courtiss (1978)
described specific additional combinations of depression and twisting of nasal structures. Holt (1978)
classified septal injuries into dislocation, fractures and fracture-dislocations.
One classification based on fracture severity is by Manson P. (1986)
H. Fracture of one nasal bone with infero-lateral displacement
I. Separation of nasal bone from the frontal process of maxilla, but the nasal septum is
intact
J. Fracture of septum, permitting flattening and spreading of nasal bones (open book
fracture)
K. Fracture of the two nasal bone with postero-lateral displacement
L. Comminuted fracture of the nasal bones, frontal processes and nasal septum –
displacement is posterior and inferior
M. Fracture of nasal septum with separation of nasal bones from the frontal process of
the maxilla, and elevation of the nasal bridge
N. Extensive comminuted nasal fractures extending to involve the naso-ethmoidal
region (naso-ethmoidal fractures)
In 1986, Murray and Maran described a pathological classification of nasal fractures following
experiments on fifty embalmed cadavers. They found seven different patterns of nasal fracture with varying
degrees of septal involvement. They emphasised the deviation of nasal pyramid from midline as the clinical
predictor of the management outcome.
Classification of naso-ethmoid fractures

Facial fractures are characterised as naso-ethmoid fractures when they isolate a central bone
fragment to which the medial canthal tendon is attached (Paskert et al –1988, Markovitz –1991). Instability
and displacement of this central fragment creates the naso-ethmoidal injury characterised by telecanthus,
central globe displacement and shortened palpebral fissure.
The literature consists of many classifications of varied nature. An elaborate, but complicated
classification was given by Gruss (1985), who divided naso-ethmoidal fractures into five types. Manson in
1985 proposed a simple classification of naso-ethmoid fractures, dividing them into ‘isolated or extended’
and ‘unilateral or bilateral’, the patterns of extension being superior (frontal), lateral (zygomatic) and
LeFort and combinations of any or all.
Bowerman et al (1985) classified naso-ethmoid fractures into
3. Isolated naso-ethmoid and frontal nerve injury without other fractures of the mid-face
c) Bilateral
d) Unilateral
4. Combined naso-ethmoid and frontal region injury with other fractures of the mid-face
(c) Bilateral
(d) Unilateral
This is essentially the same as Manson’s classification in content.

Three distinct patterns of naso-ethmoid injury have been identified and described by Markovitz,
Manson and Sargent in 1991. The fractures are typically noted to be unilateral or bilateral and simple or
comminuted.
Type I naso-ethmoid fractures
This is the simplest form of naso-ethmoid fractures involving only one portion of the medial
orbital rim with its attached medial canthal tendon. It may be unilateral or bilateral. In bilateral Type I
fractures, there is no medial canthal tendon displacement, and trans-nasal wiring is not required.
Stabilisation of the osseous mono-block is enough.
Type II naso-ethmoid fractures
These also may occur unilaterally or bilaterally and may produce large segments or comminution.
Most commonly, the canthus remains attached to the large central fragment. Reduction is usually
accomplished by positioning and controlling this bony segment which is associated with the medial canthal
tendon.
Type III naso-ethmoid fractures
This type involves comminution involving the central fragment of bone where the medial canthal
tendon attaches. The canthus is rarely avulsed completely, but is attached to bone fragments that are too
small to be utilised in reconstruction. In this circumstance, trans-nasal wiring of the canthus is required, as
is osseous reconstruction.
Variants of types I. II and III fractures may occur on one side or the other in conjunction with each
other. If such is the case, the type of injury and its severity guides the treatment.
Condylar fractures
Classification of injuries to the TMJ region Helmut Schüle 1986
Oral & Maxillofacial traumatology Vol 2 . Kruger & schilli. Page 45 – 47.
1.1.1 Contusion of the TMJ
2.1.2 Fractures of the condylar process without displacement of the fragments
2.1.2.1 Fractures of the condyle
Transcapitular.
Subcapitular.
2.1.2.2 Fractures of the condylar neck
2.1.2.3 Basal fracture of the condylar process.
2.1.3 Fractures of the condylar process with displacement of the fragments.
Displacement of the small fragments.
Ventrally.
Dorsally.
Medially.
Laterally.
Torsion of fragments
Displacement with contraction
Compression fracture of the condyle.
2.1.4 Sprains of the TMJ
2.1.5 Dislocation (subluxation) of the TMJ.
Anteriorly.
Posteriorly
Cranially ( central dislocation).
Medially
Laterally.
2.1.6 Fracture dislocations of the condylar process.
Anteriorly
Medially
Laterally.
Dorsally.
Classification of condylar fractures MacLennan system (1952)

Fonseca. Vol. I, Page 537
Type I Nondisplaced fracture
Type II Fracture deviation
Type III Fracture displacement
Type IV Fracture dislocation.
Classification of condylar fractures Spiessl and Schroll (1972)

Int.JOMS 1999
7. non-displaced fracture
8. low-neck fracture with displacement, mostly with contact between fragments
9. high-neck fracture with displacement, mostly without contact between fragments
10. low-neck fracture with dislocation
11. high-neck fracture with dislocation
12. intracapsular fracture of condylar head
Classification of condylar fractures Lindahl system (1977)

Fonseca. Vol. I, Page 536.
Level of condylar fracture
Condylar head
Condylar neck
Subcondylar
Relationship of condylar segment to mandibular fragment.
Nondisplaced
Deviated
Displacement with medial or lateral overlap
Displacement with anterior or posterior overlap
No contact between fractured segments
Relationship between condylar head & Glenoid fossa
Nondisplaced
Displacement
Dislocation
Mandibular fractures
Classification of mandibular fractures Kazangia and Converse
Class I Teeth present on both sides fracture line
Class II Teeth present on only one side.
Class III fracture occurs in an area without dentition
Classification of mandibular fractures based on type of fracture

Simple fracture Single fracture line that does not communicate with the exterior.
Compound fracture These fractures have communication with the external environment, usually
by periodontal ligament of a tooth or
Greenstick fracture This type frequently occurs in children with incomplete loss of continuity of
bone. Usually one cortex is fractured and the other is bent, leading to
distortion without complete section. There is no mobility between distal
and proximal segment.
Comminuted fractures Multiple fragmentation of bone at one fracture site. Usually as a result of
greater force.
Complex or complicated ≠ Damage to adjacent structures of bone like vessels, nerves or joint structures.
Telescoped or impacted ≠ one bone is driven into another. Rare in mandible.
Direct fractures Fractures at the site of impact
Indirect fracture Fractures at a point away from site of impact.
Pathological fracture ≠ occurring as a result normal force or minimal trauma as a result of bone
weakened by pathology.
Classification of mandibular fractures based on site of fracture Kelly & Harrigan1975

Condylar process
Ascending ramus
Angle fracture
Body fracture
Symphysis fracture
Classification of mandibular fractures based on muscular pull Frye et al 1942

Horizontally favourable  directed downward and forward.
Horizontally unfavourable  directed downward and backward
Vertically favourable  extends from posterior laterally to anterior medially.
Vertically unfavourable  extends from anterior laterally to posterior medially.
Classification of mandibular fractures AO Classification.
Internal fixation of mandible. Bernd Spiessl. 1989.
F Number of fractures.
L Location ( site).
O Occlusion
S Soft tissue involvement
A Associated fractures.
The combination of the components results in :
Right / Left
4. Fracture formula : FLO
5. Soft tissue formula : FS
6. Grade of severity : I – V.
E.g. F1L2O3S2A1
Categories of fractures. ( F ).
F1 : Single fracture.
F2 : Multiple Fractures ( segmental fractures).
F3 : Comminuted Fracture.
F4 : Fracture with bone defect.
Categories of localisation ( L )
L1 : Precanine.
L2 : Canine.
L3 : Postcanine
L4 : Angular
L5 : Supra angular
L6 : Processus articularis
L7 : Processus muscularis
L8 : Alveolar process
Categories of Occlusion ( O ).
O0 : No malocclusion.
O1 : Malocclusion.
O2 : Nonexistent occlusion ( edentulous mandible )
Categories of soft tissue involvement ( S )

S0 : Closed.
S1 : Open intraorally.
S2 : Open extraorally.
S3 : Open intraextraorally.
S4 : Soft tissue defect.
Categories of associated fracture ( A )

A None
A1 : Fracture and / or loss of tooth.
A2 : Nasal bone.
A3 : Zygoma.
A4 : Le Fort I
A5 : Le Fort II
A6 : Le Fort III
Grade of severity ( I - V )
Grade of severity Soft tissue formula Clinical presentation
I A F0S0
I B F1S0
Closed fracture
II A F2S0
II B F3S0
III A F0S1 / F1S1 / F2S1 / F0S2 / F1S2 / F2S2
III B F0S3 / F1S3 / F2S3 Open fracture
IV A F3S1 / F3S2
IV B F3S3
VA F4S1 / F4S2 / F4S3 Open fracture with bone defect.
VB F4S4 Gun shot wound
Classification of frontal sinus fractures

Anterior table fracture Linear
Displaced
Posterior table fracture Linear
Displaced
Outflow tract injury
Infection
ORN Marx 1983 AJOMS
Type I Develops shortly after radiation; is due to synergistic effects of surgical trauma and radiation
injury
Type II Develops years after radiation and follows a traumatic event; rarely occurs before 2 years after
treatment; most commonly occurs after 6 years; due to progressive endarteritis and
vascular effusion.
Type III Occurs spontaneously without a preceding traumatic event; usually occurs between 6 months
and 3 years after radiation. ; due to immediate cellular damage and death due to radiation
treatment.
Osteonecrosis Epstein et al 1987 AJOMS Oct 2000 AJOMS Page 1093

4. Resolved healed osteonecrosis
Pathologic fracture
5. Chronic, persistent and non-progressive osteonecrosis
Pathologic fracture
6. Active progressive osteonecrosis
Pathologic fracture
Orbital cellulitis (Chandler – 1970) Principles of OMFS Vol. 1 Page 181

Group 1 Obstructive non-tender oedema contrasted with inflammation and cellulitis
Group 2 Inflammatory oedema and orbital cellulitis
Group 3 Sub-periosteal pus
Group 4 Pus in orbital tissue
Group 5 Cavernous sinus thrombosis
Osteomyelitis Hudson 1993 Fonseca. Vol 5. Page 485

III) Acute forms of osteomyelitis (Suppurative or nonsuppurative)
D. Contiguous focus.
4. Trauma.
5. Surgery.
6. Odontogenic infection
E. Progressive
4. Burns.
5. Sinusitis.
6. Vascular insufficiency.
F. Hematogenous (metastatic)
2. Developing dentition
IV) Chronic forms of osteomyelitis
E) Recurrent multifocal
4. Escalated osteogenic activity (<age 25).
F) Garrés osteomyelitis
3. Unique proliferative subperiosteal reaction.
4. Developing skeleton (children to adult).
G) Suppurative or nonsuppurative.
4. Inadequate treated forms.
5. Systemically compromised forms
6. Refractory forms (chronic refractory osteomyelitis CROM).
H) Sclerosing
3. Diffuse
c. Fastidious micro-organisms.
d. Compromised host and pathogen interface.
4. Focal
c. Predominantly odontogenic
d. Chronic localised injury.
Osteomyelitis : Classification and Staging Cierny, Mader, Pennick 1985

J) Anatomic type.
Stage 1: Medullary osteomyelitis – involved medullar bone without cortical involvement,
usually hematogenous.
Stage 2: Superficial osteomyelitis – less than 2-cm bony defect without cancellous bone.
Stage 3: Localised osteomyelitis – less than 2-cm bony defect on radiograph, which does not
appear to involve both cortices.
Stage 4: Diffuse osteomyelitis – defect larger than 2 cm, pathologic fracture, infection,
nonunion.
II) Physiologic class
III) Systemic or local factors that affect immune surveillance, metabolism and local vascularity
Temporomandibular Joint
TMJ disorders classifications Moore Page 566
Structural disorders
Inflammation
Acute
Chronic
Infection
Ankylosis
True
False
Trauma
Neoplasia
Developmental
Degenerative
Functional
Pain dysfunction syndrome
TMJ osteo-arthritis - Clinical classification criteria Int. JOMS 1999

5. TMJ pain for most days
6. Functional impairment
7. Restricted joint mobility / disturbed movement
8. Radiographic degenerative changes
Chondromalacia : Grading Outerbridge RE

Grade I Softening of articular cartilage – Collagenases causes degradation of proteoglycans in
fibrocartilage.
Grade II Rupture of deep fibrils attached to the subchondral bone – Loss of proteoglycans &
Ability to withstand compressive & shearing forces.
Grade III Rupture of parallel articular fibres of fibrocartilage producing fibrillated and frayed
cartilage strands and resulting in increased frictional surface.
Grade IV Degeneration of fibrocartilage with exposure of subchondral bone.
Acute synovitis index based on arthroscopic finding

Stage I Dilation of superficial synovial blood vessels
Stage II Superficial vascular dilation within synovial membrane hyperemia
Stage III Superficial vascular dilation with moderate synovial membrane hyperemia
Stage IV Advanced generalised synovial membrane hyperemia.
Synovial chondromatosis based on developmental stages Milgram 1977

4 Metaplasia is found in the synovial membrane without presence of detached particles.
5 Metaplasia is found in the synovial membrane with presence of detached particles in the
joint that are nourished by the diffusion of synovial fluid.
6 Only detached particles are found in the joint.
Internal derangement of TMJ Wilke’s staging, 1989.

I Early Stage
A) Clinical : No significant mechanical symptoms other than opening reciprocal clicking, no pain or
limitation of motion.
C) Radiologic : Slight forward displacement, good anatomic contour of the disk, negative tomograms.
C) Anatomic/ pathologic : Excellent anatomic form, slight anterior displacement, passive incoordination
demonstrable.
II Early Intermediate stage
A) Clinical : One or more episodes of pain, beginning major mechanical problems consisting of mid to late
opening loud clicking, transient catching and locking.
C) Radiologic : Slight forward displacement, beginning disk deformity of slight thickening of posterior
edge, negative tomograms.
C) Anatomic/ pathologic : Anterior disk displacement, early anatomic disk deformity, good central
articulating area.
III Intermediate Stage.

A) Clinical : Multiple episodes of pain, major mechanical symptoms consisting of locking (intermittent or
fully closed ), restriction of motion, and difficulty with function.
C) Radiologic : Anterior disk displacement with significant deformity or prolapse of disk ( increased
thickening of posterior edge), negative tomograms.
C) Anatomic/ Pathologic : Marked anatomic disk deformity with anterior disk displacement, no hard
tissue changes.
IV Late Intermediate stage.
A) Clinical : Slight increase in severity over intermediate stage
D) Radiologic : Increase in severity over intermediate stage, positive tomograms showing early to
moderate degenerative changes – flattening of eminence, deformed condylar head, sclerosis
C) Anatomic/ Pathologic : Increase in severity over intermediate stage, Hard tissue degenerative
remodelling of both bearing surfaces (osteophytosis), multiple adhesions in anterior and posterior
recesses, no perforation of disk or attachments
V Late Stage.
A) Clinical : Characterised by crepitus, variable and episodic pain, chronic restriction of motion and
difficulty with function
E) Radiologic : Disk or attachment perforation, filling defects, gross anatomic deformity of disk and hard
tissues, positive tomograms with essentially degenerative arthritic changes
C) Anatomic/ Pathologic : Gross degenerative changes of disk and hard tissues, perforation of posterior
attachment, multiple adhesions, osteophytosis, flattening of condyle and eminence, subcortical cyst
formation.
Variations of fibrosis & fibrous adhesions in TMJ Kamanishi & Davis, 1989
Bell: Modern Practice of Orthognathic Surgery, 1992, Page 651.
7. Fibrous bands.
8. Fibrosynovial bands.
9. Intracapsular fibrosis.
10. Capsular fibrosis.
11. Discal osseous bands.
12. Variations of pseudowalls.
TMJ ankylosis Kazanjian 1938 (Moore)

True ankylosis Intra articular ankylosis
False ankylosis Extra articular ankylosis
False ankylosis Miller et al 1975 (Moore)

Myogenic
Neurogenic
Psychogenic
Bone impingement
Fibrous adhesions
Tumours
Temporomandibular joint ankylosis Rowe & Williams Page 457

Fibrous Short / Long
Bony Intracapsular / Extracapsular
Histologic variations
Fibrous
Fibro-osseous
Osseous
Osteocartilaginous
TMJ ankylosis Raveh et al

( Controversies in oral& Maxillofacial surgery. Page 181.)
Class I Ankylotic bone tissue limited to the condylar process and articular fossa.
Class II The bone extends out of the fossa involving the medial aspect of the skull base up to the
carotid- jugular vessel.
Class III Extension and penetration into the middle cranial fossa.
Class IV Combination of class II and III.
TMJ ankylosis Topazian 1966

Type I Condyle only involved
Type II Intermediate
Type III Entire condyle, sigmoid notch and coronoid.
TMJ ankylosis Shashi Aggarwal, Manorama Berry 1990

OOO 1990 : 69 : 1 : 128 – 132.
Type I Condyle could be identified – flattened, irregular sclerosed or partially resorbed.
Condyle usually medially angulated. The articular fossa has corresponding irregular,
shallow or deep and usually sclerosed, the sclerosis extending to the adjacent areas of the
temporal bone. Mild to moderate new bone formation which extends from the neck of the
condyle or lateral superior aspect of the ramus to the squamous temporal bone and or
zygomatic arch, frequently enchroaching on the lateral aspect of the articular fossa.
Etiology specific – trauma associated.
Type II Joint architecture completely disrupted with no recognisable condyle or articular fossa.there are
large mass of new bone, funnel shaped, extending from the thickened ramus to the
grossly sclerosed and irregular base of the skull. Sequlae of both
trauma & non trauma cases.
Bony ankylosis (TMJ ankylosis ) Sawhney 1986

Kenneth S. Rotskoff. – Management of hypomobility & hypermobility disorders of TMJ
( Principles of oral & maxillofacial surgery. Vol III. Page 1996.)
Type I Condylar head is flattened or deformed in close approximation to the upper joint space.
Dense fibrous adhesion is present within. Restricted motion is due to fibrosis in and
around the joint.
Type II Flattened condyle in close approximation to the glenoid fossa, bony fusion of the outer
aspect of the articular surface either anteriorly or posteriorly and limited to a small area.
Type III Ankylosis usually results from a medially displaced fracture dislocation of the condyle
with bone bridging the ramus of the mandible to the zygomatic arch. The atrophic
condylar head is either free or fused to the medial aspect of the superior portion of the
ramus.
Type IV A wider bony block bridges the mandibular ramus and zygomatic arch,
extending and obliterating the upper joint space and completely replacing the architecture
of the joint.
Syngnathia ( maxillomandibular fusion) Dowson et al 1997 / 1996 IJOMS Feb 2001:30:1( page 75
– 79)
Type 1 Simple syngnathia – no other congenital anomalies in head & neck.
Type 2 Complex syngnathia
Type 2 a Syngnathia co-existent with aglossia
Type 2 b Syngnathia co-existent with agenesis or hypoplasia of the proximal mandible.
Syngnathia ( maxillomandibular fusion ) Laster et al 2000 / 2001 IJOMS Feb 2001:30:1( page 75 – 79)
Type 1 Anterior syngnathia
Type 1a Simple anterior syngnathia -- Bony fusion of alveolar ridges only without other congenital
deformities
Type 1b Complex anterior syngnathia -- Bony fusion of alveolar ridges only, associated with other
congenital deformities
Type 2 Zygomatico-mandibular syngnathia
Type 2a Simple Zygomatico-mandibular syngnathia – Bony fusion of mandible
to zygomatic complex – causing mandibular micrognathia.
Type 2b Complex Zygomatico-mandibular syngnathia – Bony fusion of
mandible to zygomatic complex – associated with clefts or TMJ
ankylosis.
General
American Society of Anaesthesiologist physical status classification system Schiender 1983
Principles of oral & Maxillofacial Surgery. Vol. I. Page 126.
ASA I A patient without systemic disease, normal healthy patient.
ASA II A patient with mild systemic disease, no functional limitation.
ASA III A patient with severe systemic disease, definite functional limitation.
ASA IV A patient with a severe systemic disease that is a constant threat to life.
ASA V A moribund patient unlikely to survive 24 hours with or without operation.
ASA E Emergency operation of any variety; the "E" precedes the patient’s physical status.
Arteriovenous malformation clinical staging Schobinger

Grabb & Smith.
Stage I Blush/ stain, warmth and AV shunting by continuos Doppler or 20 MHz colour Doppler
Stage II Same as stage I + enlargement, tortuous tense veins, pulsation, thrill and bruit.
Stage III Same as stage II + either dystrophic changes, ulceration, bleeding, persistent pain or
destruction
Stage IV Same as stage II + cardiac failure.
Dental treatments – classification

Type 1 Examinations, radiographs, study model impressions, oral hygiene instruction,

supragingival prophylaxis, simple restorative dentistry.
Type 2 Scaling, root planing, endodontics, simple extractions, curettage, simple gingivectomy,
advanced restorative procedures, simple implants.
Type 3 Multiple extractions, gingivectomy, quadrant periosteal reflections, impacted teeth
extractions, apicocetomy, plate form implants, multiple root form implants, ridge
augumentation,unilatral sinus grafting, unilateral subperiosteal implants.
Type 4 Full arch implant (complete subperiosteal implants, ramus frame implants, full-arch
endosteal implants), orthognathic surgery, autogenous bone grafting, bilateral sinus
grafting.
Impacted teeth
Winter’s classification 1926.
Based on the relation of long axis of impacted tooth to the 2nd molar.
Vertical
Mesioangular
Distoangular
Horizontal
Inverted
Buccoangular
Linguoangular
Pell & Gregory 1933.

Relationship of 3rd molar to ramus.
Class I There is sufficient amount of space between ramus and the distal side of the second
molar for the accommodation of the mesiodistal diameter of the third molar.
Class II The space between the ramus and the distal side of the second molar is less than the
mesiodistal diameter of the crown of the third molar
Class III All or most of the third molar is located within the ramus.
Relative depth of 3rd molar in bone.
Position A The highest portion of the 3rd molar tooth is on a level with or above the occlusal line.
Position B. The highest portion of the 3rd molar tooth is below the occlusal plane but above the
cervical line of the 2nd molar.
Position C. The highest portion of the 3rd molar tooth is below the cervical line of the 2nd molar.
Based on the long axis of the 3rd molar to that of 2nd molar (from Winter’s classification).
Horizontal with Buccoversion
Vertical Linguoversion
Mesioangular Torsoversion
Distoangular
Inverted
Buccoangular
Linguoangular
Difficulty index for removal of impacted mandibular 3rd molar Pedersen G W 1988
Oral surgery Pedersen G W
This index is based on Pell & Gregory classification and aids in assessing difficulty in surgical
removal of third molar
Classification Value
Spatial relationship
Mesioangular 1
Horizontal / Transverse 2
Vertical 3
Distoangular 4
Depth
Level A 1
Level B 2
Level C 3
Ramus relationship / Space available
Class I 1
Class II 2
Class III 3
Total score out of 10.
Difficulty index:
Very difficult 7 – 10.
Moderately difficult 5 –7.
Minimal difficult 3 – 4.
WHARFE assessment of difficulty in surgical removal of impacted 3 rd molars.

Srinivasan textbook of oral surgery Page 73
Category Score
Winter’s classification Vertical 0
Mesioangular 1
Distoangular 2
____________________________________Horizontal 2
Height of mandible 35 – 39 mm 0
31 – 34 mm 1
1 – 30 mm 2
Angulation of third molars 1o – 50o 0
51o – 69o 1
70o – 79o 2
80o – 89o 3
90o + 4
Root shape Conical 1
Favourable curvature 2
Unfavourable curvature 3
Follicles Enlarged 0
Possibly enlarged 1
Normal 2
Path of Exit Space available 0
Mesial cusp covered 1
Distal cusp covered 2
Both covered 3
_______________
Total score for out of 33
Higher score indicates difficult extraction
Canine impactions Field and Ackerman 1935
Oral and Maxillofacial Surgery Vol. II Daniel M. Laskin Page 83
Maxillary canines
e. labial position
iii. crown in intimate relationship with incisors
iv. crown well above the apices of incisors
f. palatal position
iii. crown near surface in close relationship with the roots of incisors
iv. crown deeply embedded in close relationship to the apices of incisors
g. intermediate position
iii. crown between lateral incisor and first premolar roots
iv. crown above these teeth with crown labially placed and root palatally
placed and vice versa.
h. unusual position
iii. nasal or antral
iv. infra-orbital region.
Mandibular canines
c. labial position
iv. vertical
v. oblique
vi. horizontal
d. unusual position
iv. at inferior border
v. in the mental protuberance
vi. migrated to the opposite side
Maxillary canine impactions

Class I Impacted tooth located in the palate

4. Horizontal.
5. Vertical
6. Semivertical
Class II Impacted tooth in the labial or buccal surface of the maxilla.
4. Horizontal.
5. Vertical
6. Semivertical
Class III Impacted tooth located in both the palatal and labial or buccal maxillary bone. E.g.
crown is on the palatal aspect and the root passes between the roots of the adjacent teeth
in the alveolar process, ending in a sharp angle on the labial or buccal surface of the
maxilla.
Class IV Impacted cuspids located in the alveolar process, usually vertically between the incisor
and first bicuspid.
Class V Impacted cuspids located in an edentulous maxilla.
Supernumerary teeth impaction classification
(J. Canadian Dental Association, Dec 99) Gravey et al
3. Single
 Conical
 Composite odontoma
3. Complex
4. Compound
 Tuberculate
 Supplemental
4. Multiple
 Non-Syndrome
3. Tuberculate
4. Supplemental
 Syndrome
4. Cleft Lip/Palate
5. Cleidocranial Dysplasia
6. Gardner Syndrome
Maxillary third molar impactions

A classification based on the anatomic position

A Based on relative depth of the impacted maxillary third molar in bone.
Class A The lowest portion of the crown of the impacted maxillary third molar is on line with the
occlusal plane of second molar
Class B The lowest portion of the crown of the impacted maxillary third molar is between the
occlusal plane of second molar and the cervical line
Class C The lowest portion of the crown of the impacted maxillary third molar is at or above the
cervical line of the second molar
B Based on the long axis of the third molar in relation to the long axis of second molar
8. Vertical
9. Horizontal These may also occur simultaneously in
10. Mesioangular d) Buccal version.
11. Distoangular e) Lingual version
12. Inverted f) Torsoversion
13. Buccoangular
14. Linguoangular
C Based on the relationship of impacted third molar and maxillary sinus.

SA (Sinus approximation): No bone or thin portion of bone between the maxillary third molar and
the maxillary sinus.
NSA (No sinus approximation): 2mm or more thickness of bone between the impacted maxillary third
molar and the maxillary sinus.
Medicaments
Carnoy’s solution
Killey & Kay part II page.
Absolute alcohol 6 parts
Chloroform 3 parts
Glacial acetic acid 1 part
Bone wax (Horsley’s)

Beeswax (yellow) 7 parts by weight
Olive oil 2 parts
Phenol 1part
Whitehead’s varnish
Benzoin 10 parts
Storax 7.5 parts
Balsam of Tolu 5 parts
Iodoform 10 parts
Solvent ether to make 100 parts.
Bonney’s blue
McGregor principles of Plastic Surgery. Page
Gentian violet 10 g
Brilliant green 10 g
Alcohol 95% 950 ml
Water to make 2000 ml.
Paste for placing in dry socket Kiley & Kay Part I

Polyethylene glycol 4000 –510 g
Polyethylene glycol 1500 – 510 g
Lignocaine Hcl 20 g
Domiphen bromide 0.5 g
Distilled water 20 ml
Talbot’s solution G L Howe page 245

Iodine 12 g (183 gr)
Zinc iodide 7 g (110 gr)
Water 4.5 ml (82 minims)
Glycerin to make 28.4 ml (1 fl oz)
Eusol
Local anaesthetic
Anaesthetic Lignocaine 2% (20 mg / ml)
Vasoconstrictor Adrenaline
1: 50,000 (0.02 mg/ml)
1: 80,000 (0.0125 mg/ml)
1: 1,00,000 (0.01 mg/ml)
1: 2,00,000 (0.005 mg/ml)
Preservative for local anaesthetic Methyparaben
Reducing agent Sodium meta bisulphite
Antifungal Thymol iodide
Vehicle Ringer lactate
Tumescent solution
Grab & Smith page 673
2% lignocaine 25 ml
1:1000 epinephrine 1 ml
Lactated Ringer’s solution 1000 ml
-------------------------------------------------------
0.05% lignocaine with 1:1,000,000 epinephrine 1026 ml
Chemical peeling agents

Grabb & Smith page 598
30% TCA (Trichloroacetic acid)
TCA crystals 30 g
Distilled water to make 100 ml / cc.
Jessner’s solution
Salicylic acid 14 g
Resorcinol 14 g
Lactic acid 14 cc
Ethanol to make 100ml solution
Baker’s phenol solution
Phenol liquid U.S.P. 3 ml
Distilled water 2 ml
Septisol 8 gtts
Croton oil 3 gtts
Allogenic bone
Os purum
Bone in which some of the organic elements have been removed
Anorganic bone
This is prepared by boiling bone in ethylenediamine for several days. This can be stored without
refrigeration. This can be trimmed with scalpel and cut into chips.
Kiel bone
Bovine bone treated with hydrogen peroxide and a de-fattening agent.
Boplant bone
Bovine bone treated with β propiolactone to sterilise it and de-fattening is by detergents and
organic solvents.
AAA bone (antigen extracted autolysed allogenic bone)

Cadaver bone is harvested & treated so that the stainable intralacunar bone is enzymatically
digested. Then freeze dried.

Classifications Third Molar

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Nerves

Classification of axons – conduction speed Erlanger & Gasser 1937

Classification of axons – size of axon Lloyd 1943

Size of fibres in decreasing order

Classification of nerve fibres based on number of fascicles

Physiologic conduction block ( focal conduction block) Lundborg 1988

Intra-operative grading of peripheral nerve lesions Samii 1980

Classification of nerve injuries Seddon 1943

1st degree Corresponds to Seddon’s neurapraxia

Classification of nerve injuriesSymptomatic classification Controversies

Classification of nerve injuriesAnatomic classification

Classification of nerve injuriesHistopathologic classification (Controversies

Classification of nerve injuries by location of fibrosis Millesi et al 1989.

A Epifascicular epineurium Good prognosis

Classification of nerve injuries Pathophysiologic classification

Grading of sensory recovery Mackinnon Clin Plast. Surg 1989

Assessment of nerve recovery - British Medical Research Council Classification

Classification of chronic orofacial pain.

Dermoid cyst classification Rapidis et al. 1981. OOO 1994, 78: 5.

Robinson’s classification (1945)

Kruger’s classification (1964)

Lucas’ classification (1964)

Gorlin’s classification (1970)

Fibro-osseous lesions Charles A Waldron (JOMS 1989, 1993)

N – Regional lymph nodes

Soft tissue sarcomas

N – Regional lymph nodes

Sialographic grading of sialadenitis

Histologic grading of sialadenitis

Classification of salivary gland disease

Classification of cleft lip and palate.

V. American Association of Cleft Palate Rehabilitation Classification (AACPR). The classification

VI. Spina (1974) modified the David and Ritchie classification.

Alveolar ridge classification Cawood & Howell

Bone quality classification Lekholm and Zarb 1985 AJOMS 1997

Alveolar ridge deficiency-Classification and treatment Tucker 1997

Division of available bone

A > 5mm width Division A root form.

B 2.5 – 5 mm width Osteoplasty

Bone density classification Misch 1988

CT determination of bone density

Partially and edentulous arches class’n Misch and Judy

Healing times for treatment categoriesMisch

Mandibular overdenture treatment options Misch

Time course of interface development in cortical bone

Prosthodontic options in implantology Misch 1989

Clinical implant mobility scale

Implant quality scale Misch 1993

Classification of hemorrhagic shock by American College of surgeons committee on trauma 1984

Class I Class II Class III Class IV

Blood Loss 750 ml 750 - 1500 1500 - 2000 2000 or more

% loss 15 % 15 – 30 % 30 –40 % 40 % or more

BP Normal normal decreased Decreased

Capillary blanch test Normal positive positive positive

Respiratory rate 14 – 20 20 – 30 30 - 40 > 35

Urine output (ml / hr ) 30 or more 20- 30 5 - 15 Negligible

Revised trauma Score

The CRAMS scale Gornican 1982, Clemmer et al 1985.

Classification of midface fractures Wassmund 1927

Classification of midface fractures Schwenzer 1967

Simpler classification of midface fracturesPeter Banks 1987

Modified Le Fort Classification Marciani R D 1993

Classification of palatal fractures Paul N. Manson et al PSR 1998