Rhea and Novelline Simplifying the CT Diagnosis of Le Fort Fractures

Pictorial Essay
James T. Rhea1,2 Robert A. Novelline1
Rhea JT, Novelline RA

How to Simplify the CT Diagnosis of Le Fort Fractures

OBJECTIVE. The numerous components seen in the Le Fort fractures make classification difficult. Our objective is to simplify the task of classifying Le Fort fractures. CONCLUSION. Each of the Le Fort fractures has at least one unique component that is easily recognizable: I, the anterolateral margin of the nasal fossa; II, the inferior orbital rim; and III, the zygomatic arch. Classification of the Le Fort fractures is simplified by using these unique components to establish a tentative classification that is then confirmed. ene Le Fort [1] described the planes of injury that result from significant force to the midface. The classification of these fractures includes Le Fort I, II, and III types of fractures [2]. Le Fort and maxillary fractures accounted for 25.5% of 663 facial fractures recently reported from a level 1 trauma center [3]. Although visualization of injury to the struts and buttresses of the face is required for repair of these fractures with restoration of the 3D stability and symmetry of the face [4], the Le Fort classification appears to be a succinct way of summarizing and communicating the major planes of certain fractures. Common to all Le Fort fractures is fracture of the pterygoid processes. It is rare for the pterygoid processes to be fractured in the absence of a Le Fort fracture. In addition, each of the Le Fort fractures has a unique component. The purpose of this pictorial essay is to illustrate the use of these unique components to easily and quickly identify which type of Le Fort fracture is present. The Le Fort I fracture is the only one that involves the anterolateral margin of the nasal fossa just above the maxillary alveolar process. This fracture of the anterolateral margin of the nasal fossa is easily seen on coronal or 3D CT images of the face (Fig. 5). If the pterygoid processes are broken and this portion of the maxilla is broken, a Le Fort I fracture most likely is present. If the anterolateral margin of the nasal fossa is intact, a Le Fort I fracture is excluded. The Le Fort II fracture is the only one that involves the inferior orbital rim. The inferior orbital rim is also easily seen on coronal or 3D CT images of the face (Fig. 6). If the pterygoid processes are broken and the inferior orbital rim is broken, probably a Le Fort II fracture is present. If the inferior orbital rim is intact, a Le Fort II fracture is excluded. The Le Fort III fracture is the only one that involves the zygomatic arch. The zygomatic arch is easily seen on axial or 3D CT images of the face (Fig. 7). If the pterygoid processes are broken and the zygomatic arch is broken, probably a Le Fort III fracture is present. If the zygomatic arch is intact, a Le Fort III fracture is excluded. Three Steps in Diagnosing a Le Fort Fracture First, always look at the pterygoid processes, especially on coronal images. A fracture of the

Received June 2, 2004; accepted after revision November 2, 2004.

1Department

of Radiology, Harvard Medical School, Massachusetts General Hospital, Fruit St., FH 210, Boston, MA 02114.

2Present address: Department

of Radiology, University of California San Francisco and San Francisco General Hospital, 1001 Potrero Ave., Rm. 1x55, San Francisco, CA 94110. Address correspondence to J. T. Rhea (jrhea@sfghrad.ucsf.edu).

AJR 2005;184:17001705 0361803X/05/18451700 American Roentgen Ray Society

Unique Component of Each Type of Le Fort Fracture Figures 1, 2, and 3 illustrate the planes of the Le Fort I, II, and III fractures, respectively. The pterygoid processes are broken in all types of Le Fort fracture. Figure 4 highlights a unique and easily recognizable component of each of the types of fracture.

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Simplifying the CT Diagnosis of Le Fort Fractures

Fig. 1.Le Fort I fracture. (Reprinted with permission from [2]) A and B, 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.

Fig. 2.Le Fort II fracture. (Reprinted with permission from [2]) A and B, 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.

Fig. 3.Le Fort III fracture. (Reprinted with permission from [2]) A and B, 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.

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Fig. 4.Drawings show unique components of each type of Le Fort fracture. (Reprinted with permission from [2]) A, 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. B, In Le Fort II fracture, inferior orbital rim (arrow) is broken. This structure is intact in both Le Fort I and III fractures. C, In Le Fort III fracture, zygomatic arch (arrow) is broken. This structure is intact in both Le Fort I and II fractures. Fig. 5.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. A, Coronal CT image shows bilateral fractures of pterygoid processes (arrows). B, Sagittal CT image shows fractures (arrows) in horizontal plane of walls of maxillary sinus. C, 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. D, Coronal CT image shows fractures of lateral margins of nasal fossa (solid arrows) and lateral wall of maxillary sinuses (open arrows). E, 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.

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Simplifying the CT Diagnosis of Le Fort Fractures pterygoid processes almost always indicates that fractures in at least one of the Le Fort planes are present. Second, to classify the type of Le Fort fracture, look at the three bony structures that are unique to a given type of Le Fort fracture: the anterolateral margin of the nasal fossa, the inferior orbital rim, and the zygomatic arch. If one of these structures is intact, the corresponding type of Le Fort fracture is excluded. If one of these structures is broken, the corresponding type of Le Fort fracture is most likely present (Appendix 1). Third, if one of the Le Fort fractures is suspected because of a break in its unique component, the fracture should be confirmed by identifying the other fractures that would be expected in the plane of that type of Le Fort fracture. Avoiding Pitfalls One pitfall is to rely on the clinical history that resulted in a diagnosis based on physical examination. The physical findings of a Le Fort fracture may not always be present [5, 6]. Another pitfall is to terminate a search of the images after identifying one Le Fort fracture. Fractures may occur in more than one Le Fort fracture plane on the same side [7]. For example, there may simultaneously

Fig. 6.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. A, Coronal CT image shows bilateral fractures of pterygoid processes (arrows). B, 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. C, 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. D, Axial CT image shows fractures of orbital floors (arrows), as is expected in Le Fort II fracture. E, Axial CT image shows fractures of anterior portion of medial orbital walls (arrows), as is expected in Le Fort II fracture. F, Sagittal CT image shows fracture across nasal bone (arrow) that might be seen in either Le Fort II or III fracture.

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Fig. 7.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. A, Coronal CT image shows bilateral fractures of pterygoid processes (arrows). B, 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. C, 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. D, 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. E, 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. F, Axial CT image shows fracture of zygomatic arch on left (arrow) at zygomaticotemporal suture; Le Fort III is present on left.

be Le Fort II and III fractures on the same side (Fig. 7). To avoid this pitfall, look at all three unique components of the Le Fort fractures even after one component is seen to be fractured. A third pitfall is to expect that Le Fort fractures are bilaterally symmetric. Fractures can occur in different Le Fort planes on each side.

For example, a Le Fort I fracture may occur on one side and another type of Le Fort fracture on the contralateral side (Fig. 7). To avoid this pitfall, look at the pterygoid processes and each of the three unique components first on one side and then on the other side. A fourth pitfall is the occurrence of a Le Fort fracture simultaneously with other fa-

cial fractures. Having postulated that a Le Fort fracture is present because of a fracture of the pterygoid processes and a unique Le Fort component, it is necessary to confirm the type of Le Fort fracture that you think is present and look for fractures that do not fit the plane of the Le Fort fracture you have diagnosed. Confirming the type of Le Fort

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Simplifying the CT Diagnosis of Le Fort Fractures fracture involves ensuring that fractures are seen throughout the plane of the expected Le Fort fracture type. Summary The use of the Le Fort classification, although an oversimplification and inadequate for surgical planning in an individual case, is a succinct way of communicating and summarizing the major fracture planes that exist. It is possible to quickly and accurately diagnosis the presence and type of Le Fort fracture by evaluating the pterygoid processes and the unique components of each type of Le Fort fracture. It is then necessary to confirm that fractures are present throughout the expected Le Fort plane.
3. Turner BG, Rhea JT, Thrall JH, Small AB, Novelline RA. Trends in the use of CT and radiography in the evaluation of facial trauma, 19922002: implications for current costs. AJR 2004;183:751754 4. Donat TL, Endress C, Mathog RH. Facial fracture classification according to skeletal support mechanisms. Arch Otolaryngol Head Neck Surg 1998;124:13061314 5. Manson PN, Markowitz B, Mirvis S, Dunham M, Yaremchuk M. Toward CT-based facial fracture treatment. Plast Reconstr Surg 1990;85:202212 6. Romano JJ, Manson PN, Mirvis SE, Dunham M, Crawley W. Le Fort fractures without mobility. Plast Reconstr Surg 1990;85:355362 7. Levine RS, Grossman RI. Head and facial trauma. Emerg Med Clin North Am 1985;3:447473

References
1. Le Fort R. Etude experimentale sur les fractures de la machoire superieure. Rev Chir 1901;23:208227, 360379, 479507 2. Rhea JT, Mullins ME, Novelline RA. The face. In: Rogers LF. Radiology of skeletal trauma, 3rd ed., vol. 1. Philadelphia, PA: Churchill Livingstone, 2002:315375

APPENDIX 1. Diagnosing Le Fort Fractures First, evaluate the following four structures for fracture: 1. Pterygoid process 2. Lateral margin of nasal fossa 3. Inferior orbital rim 4. Zygomatic arch Le Fort fracture almost always present Unique to Le Fort I Unique to Le Fort II Unique to Le Fort III

Second, confirm presence of other fractures in the suspected Le Fort plane.

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