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Facial Fractures: Beyond Le Fort
Facial Fractures: Beyond Le Fort
41 (2008) 51–76
0030-6665/08/$ - see front matter Ó 2008 Elsevier Inc. All rights reserved.
doi:10.1016/j.otc.2007.10.003 oto.theclinics.com
52 FRAIOLI et al
Structures involved
Each wall of the frontal sinus serves a dual function. The anterior wall of
the frontal sinus, formed by the frontal bone, is responsible for the aesthetic
contours of the forehead and the superior orbital rims. In addition, this
structure serves as the frontal bar, one of the key horizontal buttresses of
the facial skeleton (Fig. 1). The frontal bar helps to maintain the horizontal
dimension of the face and to provide a stable foundation for the vertically
oriented facial buttresses (see Fig. 1) that support the forces of mastication.
Fractures of the anterior table may be clinically important either by disrupt-
ing the aesthetic contour of the forehead or by destabilizing the frontal bar
from which the other facial bones are suspended [13]. The posterior wall of
the frontal sinus forms the anterior wall of the anterior cranial fossa, and
serves to separate the sinus contents from the cranial vault. Posterior table
fractures are therefore skull fractures, and must be recognized and managed
as such. The floor of the frontal sinus forms the medial orbital roof; it also
FACIAL FRACTURES 53
Fig. 1. The buttress system of the midface. The buttress system of the midface is formed by the
strong frontal, maxillary, zygomatic, and sphenoid bones and their attachments to one another.
The central midface consists of several fragile bones that easily ‘‘crumple’’ when subjected to
strong forces. These more fragile bones are surrounded by the thicker bones of the buttress
system, which provide structure and absorb the forces applied to the face. Most of the forces
absorbed by the face are masticatory, therefore the vertical buttresses are the most well devel-
oped. These include the medial nasomaxillary buttress and the lateral zygomaticomaxillary but-
tress. Three horizontal buttresses interconnect and provide support for the vertical buttresses:
the frontal bone and supraorbital rims (frontal bar), the nasal bones and inferior orbital
rims, and the maxillary alveolus. (From Linnau KF, Stanley RB Jr, Hallam DK, et al. Imaging
of high-energy midfacial trauma: what the surgeon needs to know. Eur J Radiol 2003;48:17–32;
with permission.)
houses the ostium to the nasofrontal duct in its posteromedial aspect [9].
The nasofrontal duct forms the drainage pathway of the frontal sinus into
the nose, so obstruction of this pathway can lead to mucocele, mucopyocele,
osteomyelitis, and epidural or subdural abscess [12].
Fig. 2. Frontal sinus obliteration. (A) Axial CT scan demonstrates fractures of both anterior
(arrowheads) and posterior (arrow) tables of the frontal sinuses. At exploration, the dura was
found to be intact and there was no evidence of CSF leak, therefore cranialization was not
performed. However, the presence of an associated severe NOE fracture suggested disruption
of the nasofrontal ducts bilaterally, and therefore the sinuses were obliterated bilaterally with
concominant plugging of the nasofrontal ducts with calvarial bone grafts (CBGs) and free peri-
cranium. (B) Postoperative axial CT scan showing reduction of the posterior table with fixation
of the anterior table fractures. (C) Coronal CT scan demonstrating the CBGs used to plug the
nasofrontal ducts (wide arrows). Additional CBGs were required in this patient to reconstruct
the floor, medial wall, and roof of the left orbit (thin black arrows).
Fig. 3. Frontal sinus cranialization. This patient was involved in a high-velocity motor vehicle
collision that resulted in combined anterior and posterior sinus fractures with displacement of
the posterior table, dura injury, and frontal contusion. Frontal sinus cranialization was per-
formed using an anteriorly based pericranial flap and CBGs to plug the nasofrontal ducts.
The anterior table fractures were managed with open reduction and fixation. (A) Preoperative
axial CT scan demonstrating anterior and posterior table fractures and associated pneumoce-
phalus (arrow). (B) Postoperative axial CT scan demonstrating cranialization (note the absence
of the posterior table). (C) Postoperative sagital CT scan demonstrating cranialization. The
arrow indicates the window made in the frontal bone to allow intracranial passage of the peri-
cranial flap. The pericranial flap was draped over the anterior skull base to reinforce the dura.
Fig. 4. Traditional ZMC fracture. (A) Three-dimensional (3D) surface rendering demonstrates
disruption of the three suture lines surrounding the malar eminence: the zygomaticofrontal
suture (white arrow), the zygomaticomaxiallry suture (black arrow), and the zygomaticotempo-
ral suture (arrowhead). These three sutural disruptions lend the ZMC fracture its nickname,
‘‘tripod fracture.’’ Note the associated NOE fracture (*). (B) Coronal CT scan showing
fractures of the lateral orbital wall (straight arrow), orbital floor (curved arrow), and zygomati-
comaxiallary suture (arrowhead). (C) Axial CT demonstrating medial displacement of a bone
fragment (arrow) from the lateral orbital wall toward the globe. (D) Postoperative CT scan
following removal of the bone fragment and reconstruction of the lateral orbital wall with
a relatively radiolucent Lactosorb bioabsorbable plate (arrows). The NOE fracture (arrowhead)
has been incompletely reduced.
maxillary wall, lateral maxillary wall, and zygomatic arch). Thus, the name
‘‘tripod fracture’’ is technically inaccurate. A more compelling reason to avoid
the term ‘‘tripod fracture’’ is because it fails to recognize that this fracture
complex is intermediate on a spectrum of injuries that range from an isolated,
nondisplaced fracture limited to the zygomatic arch to severe displacement
and comminution of the zygoma and surrounding bones. This spectrum of
fractures all have similar mechanisms of injury, but differ in the amount of
58 FRAIOLI et al
force applied and therefore in the degree of bone loss and displacement [20].
For this reason, it is preferable to classify this entire spectrum of fractures
together as zygomaticomaxillary complex (ZMC) fractures.
Structures involved
The zygoma is an approximately quadrilateral-shaped bone. The body of
the zygoma forms the malar prominence, which is an important aesthetic
feature of the face. A prominent malar eminence has been described as ‘‘a
sign of youth and beauty’’ [21]. Through its attachments to the surrounding
facial bones, the zygoma also helps to determine midfacial height and width
[22]. From the laterally oriented malar prominence, the zygoma sends four
projections that articulate with the surrounding facial bones. Superiorly, the
zygoma articulates with the frontal bone at the narrow frontozygomatic
suture; medially, it has a wider articulation with the maxilla, involving
both the anterior and lateral walls of the antrum. The curved bony strut
of the zygoma lying between these superior and medial projections forms
the lateral orbital wall and the lateral aspect of the infraorbital rim and
orbital floor. Posteriorly, the zygoma articulates with the sphenoid bone,
and laterally it extends as the zygomatic arch to attach to the temporal
bone at the zygomaticotemporal suture.
The presence of the thick bone of the zygoma at the lateral corner of the
midface allows it to act as a cornerstone to provide support to the other
facial bones [23]. The maxilla directly contacts the frontal bone at the fron-
tomaxillary suture line and the sphenoid bone posteriorly above the maxil-
lary tuberosity and anterior to the sphenopalatine foramen. The zygoma
then overlies and reinforces this area through its attachments to the under-
lying frontal, maxillary, sphenoid, and temporal bones.
Fig. 5. ZMC variants. (A) Axial CT shows posterior displacement of the ZMC (double arrow).
This displacement would be masked clinically by soft tissue swelling (note symmetry of facial
soft tissues). (B) Internal rotation (arrow) of a ZMC fracture. Note the increased interzygomatic
distance. (C) External rotation (arrow) of a ZMC fracture. Note the decreased interzygomatic
distance. (D) Zygomatic arch angulation. Although no discrete fracture line is seen through the
arch, it is abnormally angulated (arrow), which is sufficient for the diagnosis of ZMC fracture.
60 FRAIOLI et al
from the ethmoid and palatine bones and the body of the sphenoid bone.
Fractures in these areas should also alert the radiologist to possible orbital
apex involvement.
Structures involved
The nasal bones articulate superiorly with the nasal process of the frontal
bone, laterally with the frontal process of the maxilla, and medially with one
another. Just deep to the nasal bones lie the thin bones and air spaces of the
ethmoid sinuses. The lateral boundary of the ethmoid sinuses is the medial
orbital wall, which is formed by contributions from the frontal process of
the maxilla as well as the lacrimal, frontal, ethmoid, sphenoid, and palatal
bones [31]. As discussed in the preceding paragraph, high-velocity trauma
to this area is generally transmitted to involve all of these bones to varying
degrees. Evolutionarily, there is great advantage to the design of these thin
bones and air-filled spaces: they form a low-resistance ‘‘crumple zone’’ that
62 FRAIOLI et al
Fig. 6. NOE fractures: Markowitz classification. (A) Type I fracture. The central fragment is
large enough to allow direct plating of the fragment with attached bone. (B) Type II fracture.
The central fragment is more comminuted that in Type I, but the MCT remains attached to the
central fragment. (C) Type III fractures involve severe comminution of the central fragment
with avulsion of the MCT. (From Markowitz BL, Manson PN, Sargent L, et al. Management
of the medial canthal tendon in nasoethmoid orbital fractures: the importance of the central
fragment in classification and treatment. Plast Reconstr Surg 1991;87(5):843–53; with
permission.)
Fig. 7. Markowitz Type I NOE fracture. (A) A 3D surface-rendered CT scan showing large non-
comminuted central fragment (arrow). (B) Postoperative sagital CT scan showing cantilevered
bone graft (arrow) in place to restore nasal projection. (C) Postoperative 3D surface rendering
demonstrates plating of the central fragment (thin arrow) and cantilevered bone graft (thick arrow).
Associated injuries
The cribiform plate forms the roof of the nasal cavity; as such, it is at risk for
involvement in cases of NOE fracture. The nasofrontal duct may also be in-
jured at the site of its outflow in the anterior ethmoid sinuses. Finally, NOE
fractures are associated with high-force trauma involving the medial orbital
wall and have been associated with several ocular injuries, including hyphema,
vitreous hemorrhage, lens dislocation, and globe rupture [30]. These associ-
ated injuries should be sought and commented upon in the radiology report.
Fig. 8. NOE fracture and repair. (A) Axial CT through the NOE shows a left Type II (small
fracture fragment, but still attached to the canthal ligament) fracture (arrow). (B) Postoperative
frontal radiograph shows a cerclage wire (arrows) attached to both NOE fragments to hold
them into position.
Structures involved
The orbit is shaped like a cone, with the apex posteriorly. The greatest
diameter is not at the inferior orbital rim, however, but approximately 15
mm posterior to it, at a point where the medial wall, roof, and floor of
the orbit are all concave relative to each other [39]. Posterior and postero-
medially to this, the orbital floor becomes convex. This configuration has
important implications for reconstruction of orbital fractures, as failure to
reconstruct the convex portion (including the medial orbital wall) is one
of the common causes of postoperative enophthalmos [40].
Fig. 9. Orbital blowout fractures. Although orbital floor fractures (arrow, A and B) are the
most common type of blowout fracture, medial wall fractures (arrowheads, A) and superior
wall fractures (arrow, B) may also be seen.
FACIAL FRACTURES 67
There are three main indications to treat isolated orbital wall fractures.
The first is entrapment of any of the extraocular muscles. Entrapment of
the muscle can cause ischemic damage, and permanent dysfunction can
occur if the fracture is not reduced and the muscle released expeditiously
[41,42]. Entrapment is diagnosed on clinical exam and cannot be directly
assessed on CT. However, herniation of the extraocular muscles beyond
the bony margins of the orbit is suggestive of entrapment and should be
sought on CT. The radiologic diagnosis of herniation may be especially dif-
ficult in children, as the more pliable bone may result in ‘‘trapdoor’’ frac-
tures (Fig. 10). These fractures result when the bone of the inferior orbit
is displaced inferiorly and forms a greenstick fracture. The pliable bones
Fig. 10. Orbital ‘‘trapdoor’’ fracture. (A) The small mass of soft tissue at the maxillary sinus
roof could be confused with blood, but it actually represents a herniated and incarcerated right
inferior rectus muscle. Note the loss of the inferior rectus muscle shadow (compare with right
eye, arrowhead). (B) The fracture is subtle on bone windows because the displaced bone has
snapped back into place. (C) Postoperative coronal CT scan showing reduction of the fracture
with reappearance of the inferior rectus muscle shadow within the orbit.
68 FRAIOLI et al
then snap rapidly back into to a near-normal position, but the inferior rectus
muscle can become trapped in the fracture line in the process. This may
occur without any evidence of bone loss in the orbital floor or blood or
soft tissue in the maxillary sinus. CT findings in trapdoor-type fractures
can be quite subtle, and may be overlooked if they are not actively sought
[41]. One characteristic finding in such fractures is the loss of the inferior rec-
tus muscle in the orbit (see Fig. 10). Coronal reformats are critical in the
evaluation of the orbital floor.
The second indication for treatment is to prevent postoperative globe
malposition and its resulting complications of diplopia or enophthalmos.
Because of the diffuse soft tissue edema associated with facial fractures, it
can be difficult to assess in the acute setting whether or not a patient’s frac-
tures will result in globe malposition after the swelling has resolved.
Although there is no set rule, many surgeons believe that orbital reconstruc-
tion is necessary in the following situations: (1) early clinical enophthalmos,
before the soft tissue edema has dissipated, (2) displacement of greater than
50% of the orbital floor (Fig. 11), (3) orbital volume change greater than 1.5
mL (5% of normal orbital volume), and (4) significant fat or soft tissue dis-
placement [39–43].
The third indication for surgery of the orbit is when the force of the
impact is so severe that the lateral orbital wall (orbital plate of the sphenoid
bone) impacts into the orbital apex or middle cranial fossa (Fig. 12). In such
cases, surgery may be indicated for decompression of neural structures [39].
The surgeon should be cautioned, however, that surgical intervention may
worsen a tenuous situation, (ie, secondary to intraoperative compression/
Fig. 11. Large orbital floor fracture. Coronal reformatted CT shows a fracture encompassing
almost the entire orbital floor (arrowheads). Fractures of greater than 50% of the orbital floor
are usually repaired surgically.
FACIAL FRACTURES 69
Fig. 12. High-impact orbital fracture. The orbital floor fracture on this axial CT extends from
the inferior orbital rim (arrow) all the way to the apex (arrowhead), where it involves the lateral
wall of the optic canal. Extension to the rim or apex indicates high traumatic force, and is an
important factor in surgical repair.
Le Fort fractures
More than 100 years ago, Rene Le Fort devised a classification system for
midface fractures. This classification scheme is based on his finding that
blunt trauma tends to cause fractures along three particular lines of weak-
ness inherent in the design of the facial skeleton [38]. Le Fort based his sys-
tem on his observation of experimental fractures made in cadavers.
Fractures occurring in 21st-century, real-life situations (in particular,
high-velocity motor vehicle accidents) often deviate from this classification
system, and ‘‘pure’’ Le Fort fractures are rare. Nevertheless, the Le Fort
70 FRAIOLI et al
Structures involved
There are three types of Le Fort fractures (Fig. 13). Each Le Fort level
describes not an isolated fracture, but rather a pattern of fractures involving
multiple facial bones. The most consistent and uniting feature of the Le Fort
fractures is the presence of bilateral pterygoid fractures. Pterygoid fractures
are found in all three classes of Le Fort fractures, and are the key to estab-
lishing the diagnosis [44]. If a CT reveals bilateral pterygoid fractures, a Le
Fort fracture should be suspected. Conversely, if the CT scan does not
reveal pterygoid fractures, the Le Fort fractures can be excluded [44].
The Le Fort I fracture is a horizontal fracture through the maxilla,
cephalic to the maxillary dentition. Bones fractured in a Le Fort I pattern
include the lower nasal septum, the inferior portion of the piriform aper-
tures, the canine fossae, both zygomaticomaxillary buttresses, the posterior
maxillary walls, and the pterygoid plates. The Le Fort II fracture is often
described as being pyramidal in shape [44]. It traverses the nasofrontal junc-
tion and extends laterally across the medial orbital wall, orbital floor,
infraorbital rim, and then through the zygomaticomaxillary suture line. It
also proceeds posteriorly through the nasal septum and pterygoid plates.
The Le Fort III fracture is a complete craniofacial separation, resulting in
separation of the facial bones from the cranium along the line of the naso-
frontal and zygomaticofrontal suture lines. As in Le Fort II fractures, the
fracture transverses the nasofrontal junction and extends laterally through
the orbit; however, Le Fort III fractures involve not only the medial and
inferior orbital walls but also the lateral orbital wall, zygomaticofrontal
suture line, and zygomatic arch. As with the other Le Fort fractures, the
fracture line also extends posteriorly through the nasal septum and ptery-
goid plates.
Each Le Fort fracture pattern has at least one unique component fracture
that is easily recognizable and separates it from the other Le Fort fractures
[44]. Rhea and Novelline recently used these unique identifying fractures to
design a simple method for identifying and classifying facial fractures [44].
Only the Le Fort I fracture involves the lateral aspect of the piriform aper-
ature. Only the Le Fort II fracture involves the inferior orbital rim and
zygomaticomaxillary suture line. Finally, only the Le Fort III fracture
involves the zygomatic arch and the lateral orbital wall. When midfacial
fractures are present and a Le Fort fracture pattern is suspected, the authors
recommend first looking at the pterygoid plates. If there is a bilateral pter-
ygoid fracture, a Le Fort fracture is likely present. The next step is to inspect
the three defining fractures discussed above: the lateral piriform aperatures,
the inferior orbital rim, and the zygomatic arch. The presence or absence of
each of these fractures determines whether a fracture of that type is present
FACIAL FRACTURES 71
or absent [44]. For example, the absence of a lateral piriform fracture rules
out a Le Fort I; the presence of a zygomatic arch fracture makes is likely
that a Le Fort III fracture is present.
The final step is then to look systematically for fractures of the other
bones that are involved in the Le Fort levels. This is important because it
is possible to have a Le Fort fracture on one side and an isolated ZMC
or NOE fracture on the other side. The presence of the key indicator frac-
tures does not definitively diagnose the Le Fort level; instead, it serves to
alert the radiologist to the high likelihood of a particular Le Fort fracture.
The other associated fractures must still be identified. Finally, it is possible
to have more than one Le Fort level on a single side of the facial skeleton
[44]. For this reason, all three key indicator fractures must be examined,
allowing each Le Fort level to be ruled in or ruled out, regardless of whether
there is a coexisting Le Fort fracture of a different level [44].
Fig. 14. Axial CT scan demonstrating oblique palatal fracture (arrows) in a patient with bilat-
eral Le Fort fractures. The presence of associated palatal fracture adds to the difficulty of estab-
lishing dental occlusion before fracture reduction.
Fig. 13. Le Fort fractures. (A) Schematic of the Le Fort fracture patterns. (From Linnau KF,
Stanley RB Jr, Hallam DK, et al. Imaging of high-energy midfacial trauma: what the surgeon
needs to know. Eur J Radiol 2003;48:17–32; with permission.) (B) Axial CT scan demonstrating
fractures of the bilateral pterygoid plates (arrows). Presence of bilateral pterygoid plate frac-
tures is strongly suggestive of the presence of Le Fort fractures. (C) Coronal reformat of
a Le Fort I fracture shows fracture lines extending though the walls of the maxillary antrum
(arrows) and across the nasal septum, without orbital involvement. (D) Coronal reformat of
a LeFort II fracture shows fracture lines through the maxillary antrum (arrow), and through
the inferior and medial walls of the orbital (arrowheads), as well as the nasal bridge. (E) Coronal
reformat of a Le Fort III fracture shows fractures though the zygomatic arch and lateral orbital
walls (arrow), as well as the orbital roofs (arrowhead).
74 FRAIOLI et al
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