The “challenging” fractures of the odontoid process: a review of the classification schemes

  • Dimitrios S. Korres
  • Dimitrios G. Chytas
  • Konstantinos N. Markatos
  • Nicolaos E. Efstathopoulos
  • Vasileios S. NikolaouEmail author
General Review • SPINE - CERVICAL


Fractures of the odontoid process seem to have an unclear and not well-understood behavior. This is well demonstrated in the literature as there is a disagreement in many fields, including the patterns of fractures, the percentage of pseudarthrosis or the appropriate treatment that is required. This situation makes the fracture itself a “challenging” one. Indeed, despite the existence of extensive literature, there are still many unresolved problems concerning these fractures. We recognize six main classification schemes of the odontoid process fractures which clearly demonstrate the presence of differences but, also, the disadvantages that these classifications are related to. The most important factors that render these fractures “enigmatic” are the anatomy of the odontoid, the diversity of fractures encountered, the radiological evaluation, the stability and the inability to incorporate the whole spectrum of fractures in one classification. The progress made the last decades in the field of the radiology and their follow-up permitted to better analyze these lesions and to extract useful conclusions.


Odontoid process Dens Fractures Classifications 


Compliance with ethical standards

Conflict of interest

The authors declare that there is no conflict of interest related to this publication.


  1. 1.
    Korres DS (2013) Fractures of the odontoid process. In: Korres DS (ed) The axis vertebra, chap. 6. Springer, Rome, pp 45–59CrossRefGoogle Scholar
  2. 2.
    Korres DS, Karachalios Th et al (2004) The structural properties of the axis studied in cadaveric specimens. Clin Orthop Relat Res 418:134–140CrossRefGoogle Scholar
  3. 3.
    Gadaifis N (2014) Study of the periosteum and its vascularity as a possible factor for the incidence of pseudarthrosis in different types of fracture of the odontoid process of the axis vertebra. Dissertation. Medical School, University of Athens (in Greek) Google Scholar
  4. 4.
    Roy-Camille R, Lepresie PH, Mazel C (1986) Les fractures del’ odontoid. In: Roy-Camille (ed) Rachis cervical supérieur Masson Cie Paris. Masson, Paris, pp 99–118Google Scholar
  5. 5.
    Korres DS, Lazaretos J, Papailiou Kyriakopoulos E, Chytas D, Efstathopoulos NE, Nikolaou VS (2015) Morphometric analysis of the odontoid process: using computed tomography—in the Greek population. Eur J Orthop Surg Traumatol 26(2):119–125CrossRefPubMedGoogle Scholar
  6. 6.
    Gebauer M, Lohse C, Barvencik F, Pogoda P, Rueger JM, Püschel K, Amling M (2006) Subdental synchondrosis and anatomy of the axis in aging: a histomorphometric study on 30 autopsy cases. Eur Spine J 15(3):292–298CrossRefPubMedGoogle Scholar
  7. 7.
    Gebauer M, Amling M (2008) The development of the axis vertebra: the key to a topographic classification of dens fractures. Eur Spine J 17Q:1775–1778CrossRefGoogle Scholar
  8. 8.
    Wang XP, Deng ZC, Liang ZI, Tu YM (2008) Response to reply to the letter to the editor concerning “Gebauer et al subdentale sychondrosie and anatomy of the axis in the aging: a histomorphometric study on 30 autopsy cases”. Eur Spine J 15:292–298, the base of the dens axis. Where is it located? Eur Spine J 17:1771–1774Google Scholar
  9. 9.
    O’Brien WT, Shen P, Lee P (2015) The dens: normal development, developmental variants and anomalies, and traumatic injuries. J Clin Imaging Sci 2015(5):38CrossRefGoogle Scholar
  10. 10.
    Roy-Camille R, Saillant G, Judet Th, De Bollon G, Michel C (1980) Elements de pronostic des fractures de l’ odontoide. Rev Chir Orthop 66:183–186PubMedGoogle Scholar
  11. 11.
    Schatzker J et al (1971) Fractures of the dens (odontoid process): an analysis of thirty-seven cases. J Bone Joint Surg Br 53:392–405PubMedGoogle Scholar
  12. 12.
    Anderson LD, D’Alonzo R (1974) Fractures of the odontoid process of the axis. J Bone Joint Surg Am 56:1663–1674CrossRefPubMedGoogle Scholar
  13. 13.
    Althoff B, Bardholm H (1979) Fractures of the odontoid process. An experimental and clinical study. Acta Orthop Scan Suppl 177:1–91CrossRefGoogle Scholar
  14. 14.
    De Mourgues G, Fischer LP, Bejui J, Carret JP, Gonon GP, Subasi H, Amoa J, Herzberg G, Massardier J (1981) Fractures of the odontoid process. Rev Chir Orthop Repara Appar Mot 67:783–790 (in French) Google Scholar
  15. 15.
    Roy-Camille R, De La Caffiniere JH, Saillant G (1973) Traumatisme du rachis cervical supérieur C1–C2. Masson, Paris, pp 51–55Google Scholar
  16. 16.
    Korres DS, Mavrogenis AF, Gratsias P, Lyritis GP, Papagelopoulos PJ (2008) It is time to reconsider the classification of dens fractures. Eur J Orthop Surg Traumatol 18:189–195CrossRefGoogle Scholar
  17. 17.
    Bergenheim T, Forssel A (1991) Vertical odontoid fracture-case report. J Neurosurg 74:665–667CrossRefPubMedGoogle Scholar
  18. 18.
    Korres DS, Mavrogenis AF, Gratsias P, Posantzis MP, Giannakopoulos EA, Efstathopoulos NE (2010) Type D fractures of the odontoid process. Eur J Orthop Surg Traumatol 20:597–601CrossRefGoogle Scholar
  19. 19.
    Korres DS, Stamos KG, Andreakos AG, Chr Hardouvelis, Kouris A (1989) Fractures of the dens and risk of pseudarthrosis. Arch Orhop Trauma Surg 2:373–376CrossRefGoogle Scholar
  20. 20.
    Benzel E, Hart BL et al (1994) Fractures of the C2 vertebral body. J Neurosurg 81:206–212CrossRefPubMedGoogle Scholar
  21. 21.
    Hadley MN, Brown CM et al (1988) New subtype of acute odontoid fractures (type IIA). Neurosurgery 22:67–71CrossRefPubMedGoogle Scholar
  22. 22.
    Gauer JN, Shaft B et al (2005) Proposal of a modified, treatment-oriented classification of odontoid fractures. Spine J 5:123–129CrossRefGoogle Scholar
  23. 23.
    Reihold M, Bellabarba C et al (2011) Radiographic analysis of type II odontoid fractures in a geriatric patient population: description and pathomechanism of the “Geier”–deformity. Eur Spine J 20:1928–1939CrossRefGoogle Scholar
  24. 24.
    Jea A, Tatsui C, Hamad F, Vanni S, Levi A (2006) Vertically unstable type III odontoid fractures: case report. Neurosurgery 58(4):E797CrossRefGoogle Scholar
  25. 25.
    Adam D, Cergan R, Iftimie D, Moisescu C (2016) Odontoid fracture that is not listed in the existing classifications A new subtype of odontoid fracture: case report. Rom Neurosurg XXX(1):57–64Google Scholar
  26. 26.
    Koller H, Kammermeier V et al (2006) Spinal stenosis C1–C2 following redo surgery for failed odontoid screw fixation-scrutinizing the odontoid fracture classification. Internet J Spine Surg 3:1–11Google Scholar
  27. 27.
    Marra MA (2013) Study of dens fracture in the elderly and the role of osteoporosis with a finite element model. Master of Science Thesis in Medical Engineering. Stockholm, 2013Google Scholar
  28. 28.
    Denaro V, Papalia R, Di Martino A, Denaro L, Maffulli N (2011) The best surgical treatment for type II fractures of the dens is still controversial. Clin Orthop Relat Res 469(3):742–750CrossRefPubMedGoogle Scholar
  29. 29.
    Falavigna A (2016) Management of type II odontoid process fracture in octogenarians (editorial). J Neurosurg Spine 19:1–2Google Scholar

Copyright information

© Springer-Verlag France 2017

Authors and Affiliations

  • Dimitrios S. Korres
    • 1
  • Dimitrios G. Chytas
    • 2
  • Konstantinos N. Markatos
    • 3
  • Nicolaos E. Efstathopoulos
    • 2
  • Vasileios S. Nikolaou
    • 2
    Email author
  1. 1.3rd Orthopaedic DepartmentNational and Kapodistrian University of AthensAthensGreece
  2. 2.2nd Orthopaedic DepartmentNational and Kapodistrian University of AthensAthensGreece
  3. 3.Henry Dynan HospitalAthensGreece

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