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How to Simplify the CT Diagnosis of Le Fort Fractures

¹ Department of Radiology, Harvard Medical School, Massachusetts General Hospital, Fruit St., FH 210, Boston, MA 02114.
² Present address: Department of Radiology, University of California San Francisco and San Francisco General Hospital, 1001 Potrero Ave., Rm. 1x55, San Francisco, CA 94110.

View larger version (48K): [in a new window]   Fig. 1A. —Le Fort I fracture. (Reprinted with permission from [2]) Drawings in lateral (A) and frontal (B) projections show Le Fort I fracture runs horizontally above maxillary alveolar process. Pterygoid plates are broken, as is true in all types of Le Fort fracture. Walls of maxillary sinuses in this plane are broken, including point at anterolateral margin of nasal fossa. Maxillary teeth would be movable on physical examination relative to remainder of face.

View larger version (50K): [in a new window]   Fig. 1B. —Le Fort I fracture. (Reprinted with permission from [2]) Drawings in lateral (A) and frontal (B) projections show Le Fort I fracture runs horizontally above maxillary alveolar process. Pterygoid plates are broken, as is true in all types of Le Fort fracture. Walls of maxillary sinuses in this plane are broken, including point at anterolateral margin of nasal fossa. Maxillary teeth would be movable on physical examination relative to remainder of face.

View larger version (41K): [in a new window]   Fig. 2A. —Le Fort II fracture. (Reprinted with permission from [2]) Drawings show plane of Le Fort II fracture in lateral (A) and frontal (B) projections. Le Fort II fracture is pyramidal in shape with teeth at base of pyramid and nasofrontal suture at apex of pyramid. Pterygoid plates are broken, as is true in all types of Le Fort fracture. Posterior and lateral walls of maxillary sinus are broken as fracture skirts inferior in relation to body of zygoma. Fracture then crosses inferior orbital rim, orbital floor, and medial wall of orbit before crossing midline near nasofrontal suture. Maxillary teeth and nose as a unit would be movable relative to zygomata and rest of skull.

View larger version (46K): [in a new window]   Fig. 2B. —Le Fort II fracture. (Reprinted with permission from [2]) Drawings show plane of Le Fort II fracture in lateral (A) and frontal (B) projections. Le Fort II fracture is pyramidal in shape with teeth at base of pyramid and nasofrontal suture at apex of pyramid. Pterygoid plates are broken, as is true in all types of Le Fort fracture. Posterior and lateral walls of maxillary sinus are broken as fracture skirts inferior in relation to body of zygoma. Fracture then crosses inferior orbital rim, orbital floor, and medial wall of orbit before crossing midline near nasofrontal suture. Maxillary teeth and nose as a unit would be movable relative to zygomata and rest of skull.

View larger version (47K): [in a new window]   Fig. 3A. —Le Fort III fracture. (Reprinted with permission from [2]) Drawings show plane of Le Fort III fracture in lateral (A) and frontal (B) projections. Le Fort III fracture separates bones of face from rest of skull. Pterygoid plates are broken, as is true in all types of Le Fort fracture. Upper posterior margins of maxillary sinuses fracture, as does zygomatic arch, lateral orbital wall, and lateral orbital rim. There is fracture near junction of frontal bone and greater wing of sphenoid in posterior aspect of orbit, fracture along medial orbital wall, and fracture across nasofrontal suture. Maxillary teeth, nose, and zygomata as a unit would be movable on physical examination relative to rest of skull.

View larger version (46K): [in a new window]   Fig. 3B. —Le Fort III fracture. (Reprinted with permission from [2]) Drawings show plane of Le Fort III fracture in lateral (A) and frontal (B) projections. Le Fort III fracture separates bones of face from rest of skull. Pterygoid plates are broken, as is true in all types of Le Fort fracture. Upper posterior margins of maxillary sinuses fracture, as does zygomatic arch, lateral orbital wall, and lateral orbital rim. There is fracture near junction of frontal bone and greater wing of sphenoid in posterior aspect of orbit, fracture along medial orbital wall, and fracture across nasofrontal suture. Maxillary teeth, nose, and zygomata as a unit would be movable on physical examination relative to rest of skull.

View larger version (52K): [in a new window]   Fig. 4A. —Drawings show unique components of each type of Le Fort fracture. (Reprinted with permission from [2]) In Le Fort I fracture, anterolateral margin of nasal fossa (arrow) is broken. This structure is intact in both Le Fort II and III fractures.

View larger version (48K): [in a new window]   Fig. 4B. —Drawings show unique components of each type of Le Fort fracture. (Reprinted with permission from [2]) In Le Fort II fracture, inferior orbital rim (arrow) is broken. This structure is intact in both Le Fort I and III fractures.

View larger version (46K): [in a new window]   Fig. 4C. —Drawings show unique components of each type of Le Fort fracture. (Reprinted with permission from [2]) In Le Fort III fracture, zygomatic arch (arrow) is broken. This structure is intact in both Le Fort I and II fractures.

View larger version (134K): [in a new window]   Fig. 5A. —Le Fort I fracture. To classify this Le Fort fracture, look at the following four facial segments: pterygoid processes (fractured in this case: Le Fort fracture is most likely present), anterolateral margins of nasal fossa above maxillary alveolar ridge (fractured: Le Fort I is likely present), inferior orbital rims (intact: Le Fort II is excluded), and zygomatic arches (intact: Le Fort III is excluded). Le Fort I fracture is confirmed by noting other expected fractures in plane of Le Fort I fracture. Coronal CT image shows bilateral fractures of pterygoid processes (arrows).

View larger version (113K): [in a new window]   Fig. 5B. —Le Fort I fracture. To classify this Le Fort fracture, look at the following four facial segments: pterygoid processes (fractured in this case: Le Fort fracture is most likely present), anterolateral margins of nasal fossa above maxillary alveolar ridge (fractured: Le Fort I is likely present), inferior orbital rims (intact: Le Fort II is excluded), and zygomatic arches (intact: Le Fort III is excluded). Le Fort I fracture is confirmed by noting other expected fractures in plane of Le Fort I fracture. Sagittal CT image shows fractures (arrows) in horizontal plane of walls of maxillary sinus.

View larger version (158K): [in a new window]   Fig. 5C. —Le Fort I fracture. To classify this Le Fort fracture, look at the following four facial segments: pterygoid processes (fractured in this case: Le Fort fracture is most likely present), anterolateral margins of nasal fossa above maxillary alveolar ridge (fractured: Le Fort I is likely present), inferior orbital rims (intact: Le Fort II is excluded), and zygomatic arches (intact: Le Fort III is excluded). Le Fort I fracture is confirmed by noting other expected fractures in plane of Le Fort I fracture. Three-dimensional image in lateral projection shows fracture of anterolateral margin of nasal fossa (white arrow), which indicates that Le Fort I fracture is present. Zygomatic arch (black arrows) is intact, thus excluding Le Fort III fracture.

View larger version (130K): [in a new window]   Fig. 5D. —Le Fort I fracture. To classify this Le Fort fracture, look at the following four facial segments: pterygoid processes (fractured in this case: Le Fort fracture is most likely present), anterolateral margins of nasal fossa above maxillary alveolar ridge (fractured: Le Fort I is likely present), inferior orbital rims (intact: Le Fort II is excluded), and zygomatic arches (intact: Le Fort III is excluded). Le Fort I fracture is confirmed by noting other expected fractures in plane of Le Fort I fracture. Coronal CT image shows fractures of lateral margins of nasal fossa (solid arrows) and lateral wall of maxillary sinuses (open arrows).

View larger version (189K): [in a new window]   Fig. 5E. —Le Fort I fracture. To classify this Le Fort fracture, look at the following four facial segments: pterygoid processes (fractured in this case: Le Fort fracture is most likely present), anterolateral margins of nasal fossa above maxillary alveolar ridge (fractured: Le Fort I is likely present), inferior orbital rims (intact: Le Fort II is excluded), and zygomatic arches (intact: Le Fort III is excluded). Le Fort I fracture is confirmed by noting other expected fractures in plane of Le Fort I fracture. Three-dimensional image in frontal projection shows intact inferior orbital rims (black arrows), thus excluding Le Fort II fracture. Horizontally oriented fractures across maxillary sinuses and nasal fossa (white arrows) are seen.

View larger version (132K): [in a new window]   Fig. 6A. —Le Fort II fracture. To classify this Le Fort fracture, look at the following four facial segments: pterygoid processes (fractured in this case: Le Fort fracture is most likely present), anterolateral margins of nasal fossa above maxillary alveolar ridge (intact: Le Fort I is excluded), inferior orbital rims (fractured: Le Fort II is likely present), and zygomatic arches (intact: Le Fort III is excluded). Le Fort II fracture is confirmed by noting other expected fractures in plane of Le Fort II fracture. Coronal CT image shows bilateral fractures of pterygoid processes (arrows).

View larger version (135K): [in a new window]   Fig. 6B. —Le Fort II fracture. To classify this Le Fort fracture, look at the following four facial segments: pterygoid processes (fractured in this case: Le Fort fracture is most likely present), anterolateral margins of nasal fossa above maxillary alveolar ridge (intact: Le Fort I is excluded), inferior orbital rims (fractured: Le Fort II is likely present), and zygomatic arches (intact: Le Fort III is excluded). Le Fort II fracture is confirmed by noting other expected fractures in plane of Le Fort II fracture. Coronal CT image shows that anterolateral margins of nasal fossa (solid arrows) are intact, thus excluding Le Fort I fracture. Inferior orbital rims (open arrows) are broken, indicating that Le Fort II fracture is present. As expected in Le Fort II fracture, lateral walls of maxillary sinuses inferior in relation to the body of zygomata are broken.

View larger version (126K): [in a new window]   Fig. 6C. —Le Fort II fracture. To classify this Le Fort fracture, look at the following four facial segments: pterygoid processes (fractured in this case: Le Fort fracture is most likely present), anterolateral margins of nasal fossa above maxillary alveolar ridge (intact: Le Fort I is excluded), inferior orbital rims (fractured: Le Fort II is likely present), and zygomatic arches (intact: Le Fort III is excluded). Le Fort II fracture is confirmed by noting other expected fractures in plane of Le Fort II fracture. Axial CT image shows that zygomatic arches (arrows) are intact, thus excluding Le Fort III fracture. As is expected in Le Fort II fracture, anterior and posterolateral margins of maxillary sinuses are broken.

View larger version (108K): [in a new window]   Fig. 6D. —Le Fort II fracture. To classify this Le Fort fracture, look at the following four facial segments: pterygoid processes (fractured in this case: Le Fort fracture is most likely present), anterolateral margins of nasal fossa above maxillary alveolar ridge (intact: Le Fort I is excluded), inferior orbital rims (fractured: Le Fort II is likely present), and zygomatic arches (intact: Le Fort III is excluded). Le Fort II fracture is confirmed by noting other expected fractures in plane of Le Fort II fracture. Axial CT image shows fractures of orbital floors (arrows), as is expected in Le Fort II fracture.

View larger version (88K): [in a new window]   Fig. 6E. —Le Fort II fracture. To classify this Le Fort fracture, look at the following four facial segments: pterygoid processes (fractured in this case: Le Fort fracture is most likely present), anterolateral margins of nasal fossa above maxillary alveolar ridge (intact: Le Fort I is excluded), inferior orbital rims (fractured: Le Fort II is likely present), and zygomatic arches (intact: Le Fort III is excluded). Le Fort II fracture is confirmed by noting other expected fractures in plane of Le Fort II fracture. Axial CT image shows fractures of anterior portion of medial orbital walls (arrows), as is expected in Le Fort II fracture.

View larger version (94K): [in a new window]   Fig. 6F. —Le Fort II fracture. To classify this Le Fort fracture, look at the following four facial segments: pterygoid processes (fractured in this case: Le Fort fracture is most likely present), anterolateral margins of nasal fossa above maxillary alveolar ridge (intact: Le Fort I is excluded), inferior orbital rims (fractured: Le Fort II is likely present), and zygomatic arches (intact: Le Fort III is excluded). Le Fort II fracture is confirmed by noting other expected fractures in plane of Le Fort II fracture. Sagittal CT image shows fracture across nasal bone (arrow) that might be seen in either Le Fort II or III fracture.

View larger version (125K): [in a new window]   Fig. 7A. —Combined Le Fort I fracture on right and Le Fort II and III fractures on left. Look at four facial segments one side at a time. First, look at the right side: pterygoid process (fractured in this case: Le Fort fracture is most likely present), right anterolateral margin of nasal fossa above maxillary alveolar ridge (fractured: Le Fort I is likely present), inferior orbital rim on right (intact: Le Fort II is excluded), and zygomatic arch on right (intact: Le Fort III is excluded). Right-sided Le Fort I fracture is confirmed by noting other expected fractures in plane of Le Fort I fracture. Next, look at the left side: pterygoid process (fractured in this case: Le Fort fracture is most likely present), left anterolateral margin of nasal fossa above maxillary alveolar ridge (intact: Le Fort I is excluded), left inferior orbital rim (fractured: Le Fort II is likely present), and left zygomatic arch (fractured: Le Fort III is likely present). Left-sided Le Fort II and III fractures are confirmed by noting other expected fractures in planes of Le Fort II and III fractures. Coronal CT image shows bilateral fractures of pterygoid processes (arrows).

View larger version (141K): [in a new window]   Fig. 7B. —Combined Le Fort I fracture on right and Le Fort II and III fractures on left. Look at four facial segments one side at a time. First, look at the right side: pterygoid process (fractured in this case: Le Fort fracture is most likely present), right anterolateral margin of nasal fossa above maxillary alveolar ridge (fractured: Le Fort I is likely present), inferior orbital rim on right (intact: Le Fort II is excluded), and zygomatic arch on right (intact: Le Fort III is excluded). Right-sided Le Fort I fracture is confirmed by noting other expected fractures in plane of Le Fort I fracture. Next, look at the left side: pterygoid process (fractured in this case: Le Fort fracture is most likely present), left anterolateral margin of nasal fossa above maxillary alveolar ridge (intact: Le Fort I is excluded), left inferior orbital rim (fractured: Le Fort II is likely present), and left zygomatic arch (fractured: Le Fort III is likely present). Left-sided Le Fort II and III fractures are confirmed by noting other expected fractures in planes of Le Fort II and III fractures. Coronal CT image shows fracture of anterolateral margin of nasal fossa on right side only (lower arrow); Le Fort I fracture is present on right. Note also that there is separation at nasofrontal suture on left (upper arrow). This could be seen in either Le Fort II or III fracture.

View larger version (134K): [in a new window]   Fig. 7C. —Combined Le Fort I fracture on right and Le Fort II and III fractures on left. Look at four facial segments one side at a time. First, look at the right side: pterygoid process (fractured in this case: Le Fort fracture is most likely present), right anterolateral margin of nasal fossa above maxillary alveolar ridge (fractured: Le Fort I is likely present), inferior orbital rim on right (intact: Le Fort II is excluded), and zygomatic arch on right (intact: Le Fort III is excluded). Right-sided Le Fort I fracture is confirmed by noting other expected fractures in plane of Le Fort I fracture. Next, look at the left side: pterygoid process (fractured in this case: Le Fort fracture is most likely present), left anterolateral margin of nasal fossa above maxillary alveolar ridge (intact: Le Fort I is excluded), left inferior orbital rim (fractured: Le Fort II is likely present), and left zygomatic arch (fractured: Le Fort III is likely present). Left-sided Le Fort II and III fractures are confirmed by noting other expected fractures in planes of Le Fort II and III fractures. Coronal CT image shows inferior orbital rim on right (white arrows) is intact, so Le Fort II on right is excluded. Fracture of inferior orbital rim on left (black arrow) is seen; thus, Le Fort II is present on left.

View larger version (135K): [in a new window]   Fig. 7D. —Combined Le Fort I fracture on right and Le Fort II and III fractures on left. Look at four facial segments one side at a time. First, look at the right side: pterygoid process (fractured in this case: Le Fort fracture is most likely present), right anterolateral margin of nasal fossa above maxillary alveolar ridge (fractured: Le Fort I is likely present), inferior orbital rim on right (intact: Le Fort II is excluded), and zygomatic arch on right (intact: Le Fort III is excluded). Right-sided Le Fort I fracture is confirmed by noting other expected fractures in plane of Le Fort I fracture. Next, look at the left side: pterygoid process (fractured in this case: Le Fort fracture is most likely present), left anterolateral margin of nasal fossa above maxillary alveolar ridge (intact: Le Fort I is excluded), left inferior orbital rim (fractured: Le Fort II is likely present), and left zygomatic arch (fractured: Le Fort III is likely present). Left-sided Le Fort II and III fractures are confirmed by noting other expected fractures in planes of Le Fort II and III fractures. Coronal CT image shows fracture of lateral orbital rim (frontal process of zygoma) on left (solid arrow); Le Fort III fracture is present on left, because lateral rim is also a unique feature of Le Fort III fractures. Left orbital floor on left (open arrow) is fractured, as is expected in Le Fort II fractures. Right orbital floor is intact.

View larger version (105K): [in a new window]   Fig. 7E. —Combined Le Fort I fracture on right and Le Fort II and III fractures on left. Look at four facial segments one side at a time. First, look at the right side: pterygoid process (fractured in this case: Le Fort fracture is most likely present), right anterolateral margin of nasal fossa above maxillary alveolar ridge (fractured: Le Fort I is likely present), inferior orbital rim on right (intact: Le Fort II is excluded), and zygomatic arch on right (intact: Le Fort III is excluded). Right-sided Le Fort I fracture is confirmed by noting other expected fractures in plane of Le Fort I fracture. Next, look at the left side: pterygoid process (fractured in this case: Le Fort fracture is most likely present), left anterolateral margin of nasal fossa above maxillary alveolar ridge (intact: Le Fort I is excluded), left inferior orbital rim (fractured: Le Fort II is likely present), and left zygomatic arch (fractured: Le Fort III is likely present). Left-sided Le Fort II and III fractures are confirmed by noting other expected fractures in planes of Le Fort II and III fractures. Axial CT image shows only left zygomatic arch because of patient tilt in scanner. This arch (arrows) is intact, thus excluding Le Fort III on left.

View larger version (124K): [in a new window]   Fig. 7F. —Combined Le Fort I fracture on right and Le Fort II and III fractures on left. Look at four facial segments one side at a time. First, look at the right side: pterygoid process (fractured in this case: Le Fort fracture is most likely present), right anterolateral margin of nasal fossa above maxillary alveolar ridge (fractured: Le Fort I is likely present), inferior orbital rim on right (intact: Le Fort II is excluded), and zygomatic arch on right (intact: Le Fort III is excluded). Right-sided Le Fort I fracture is confirmed by noting other expected fractures in plane of Le Fort I fracture. Next, look at the left side: pterygoid process (fractured in this case: Le Fort fracture is most likely present), left anterolateral margin of nasal fossa above maxillary alveolar ridge (intact: Le Fort I is excluded), left inferior orbital rim (fractured: Le Fort II is likely present), and left zygomatic arch (fractured: Le Fort III is likely present). Left-sided Le Fort II and III fractures are confirmed by noting other expected fractures in planes of Le Fort II and III fractures. Axial CT image shows fracture of zygomatic arch on left (arrow) at zygomaticotemporal suture; Le Fort III is present on left.

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