Rhea and Novelline

Simplifying the CT Diagnosis of Le Fort

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Fractures

Pictorial Essay
James T. Rhea1,2
Robert A. Novelline1
How to Simplify the CT Diagnosis of
Rhea JT, Novelline RA

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 The Le Fort I fracture is the only one that

R of injury that result from significant

force to the midface. The classifica-
tion 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 visualiza-
tion 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 commu-
nicating 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 ab-
sence of a Le Fort fracture. In addition, each
of the Le Fort fractures has a unique compo-
nent. The purpose of this pictorial essay is to
Received June 2, 2004; accepted after revision
November 2, 2004. illustrate the use of these unique components
to easily and quickly identify which type of
1Department
of Radiology, Harvard Medical School, Le Fort fracture is present.
Massachusetts General Hospital, Fruit St., FH 210, Boston,
MA 02114.
2Present address: Department of Radiology, University of
Unique Component of Each Type of
California San Francisco and San Francisco General Le Fort Fracture
Hospital, 1001 Potrero Ave., Rm. 1x55, San Francisco, CA Figures 1, 2, and 3 illustrate the planes of
94110. Address correspondence to J. T. Rhea
(jrhea@sfghrad.ucsf.edu). the Le Fort I, II, and III fractures, respec-
tively. The pterygoid processes are broken in
AJR 2005;184:1700–1705
all types of Le Fort fracture. Figure 4 high-
0361–803X/05/1845–1700 lights a unique and easily recognizable com-
© American Roentgen Ray Society ponent of each of the types of fracture.
involves the anterolateral margin of the nasal
fossa just above the maxillary alveolar pro-
cess. 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 por-
tion of the maxilla is broken, a Le Fort I frac-
ture 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 ptery-
goid processes are broken and the inferior or-
bital 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 frac-
ture 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

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 Simplifying the CT Diagnosis of Le Fort Fractures
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Fig. 1.—Le Fort I fracture. (Reprinted with permission

from [2])
A and B, Drawings in lateral (A) and frontal (B) projec-
tions show Le Fort I fracture runs horizontally above
maxillary alveolar process. Pterygoid plates are bro-
ken, 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 rela-
tive to remainder of face.

A B

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 bro-
ken 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.

A B

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 frac-
ture separates bones of face from rest of skull. Ptery-
goid 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 poste-
rior 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.
A B

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A B C

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 ptery-
goid processes (arrows).
B, Sagittal CT image shows fractures (arrows) in horizon-
tal plane of walls of maxillary sinus.
C, Three-dimensional image in lateral projection shows frac-
ture 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 frac-
ture.
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.
A B

C D E

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 Simplifying the CT Diagnosis of Le Fort Fractures
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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 na-
sal fossa, the inferior orbital rim, and the zy-
gomatic arch. If one of these structures is
intact, the corresponding type of Le Fort
fracture is excluded. If one of these struc-
tures is broken, the corresponding type of
Le Fort fracture is most likely present (Ap-
pendix 1).
Third, if one of the Le Fort fractures is
suspected because of a break in its unique
component, the fracture should be con-
firmed 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

A B C

D E F

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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 Rhea and Novelline
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A B C

D E F

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 (frac-
tured: 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 sep-
aration 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 frac-
tures 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 pit-
fall, 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 di-
agnosed. Confirming the type of Le Fort

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 Simplifying the CT Diagnosis of Le Fort Fractures
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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, al-
though an oversimplification and inadequate
for surgical planning in an individual case, is
a succinct way of communicating and sum-
marizing the major fracture planes that exist.
It is possible to quickly and accurately diag-
nosis 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.
References
1. Le Fort R. Etude experimentale sur les fractures de
la machoire superieure. Rev Chir 1901;23:208–227,
360–379, 479–507
2. Rhea JT, Mullins ME, Novelline RA. The face.
In: Rogers LF. Radiology of skeletal trauma, 3rd
ed., vol. 1. Philadelphia, PA: Churchill Living-
stone, 2002:315–375
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, 1992–2002: implications
for current costs. AJR 2004;183:751–754
4. Donat TL, Endress C, Mathog RH. Facial fracture
classification according to skeletal support mech-
anisms. Arch Otolaryngol Head Neck Surg
1998;124:1306–1314
5. Manson PN, Markowitz B, Mirvis S, Dunham M,
Yaremchuk M. Toward CT-based facial fracture
treatment. Plast Reconstr Surg 1990;85:202–212
6. Romano JJ, Manson PN, Mirvis SE, Dunham M,
Crawley W. Le Fort fractures without mobility.
Plast Reconstr Surg 1990;85:355–362
7. Levine RS, Grossman RI. Head and facial trauma.
Emerg Med Clin North Am 1985;3:447–473

APPENDIX 1. Diagnosing Le Fort Fractures

First, evaluate the following four structures for fracture:

1. Pterygoid process Le Fort fracture almost always present

2. Lateral margin of nasal fossa Unique to Le Fort I
3. Inferior orbital rim Unique to Le Fort II
4. Zygomatic arch Unique to Le Fort III

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

AJR:184, May 2005 1705