Facial fractures classification
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facial fractures classification Le Fort
This diagnostic image displays 3D-CT reconstructions of two different patients (labeled a and b) highlighting various patterns of Le Fort facial fractures.
This Comparison Chart consists of three anatomical diagrams (a, b, and c) of the human skull, viewed from an anterior perspective. It illustrates the René Le Fort classification of midfacial fractures through shaded red regions. Diagram (a) represents a Le Fort I fracture, showing a transverse fracture line through the maxilla, isolating the alveolar process and palate. Diagram (b) represents a Le Fort II fracture (pyramidal fracture), with the shaded area extending superiorly through the nasal bones and infraorbital rims, involving the maxillary body. Diagram (c) represents a Le Fort III fracture (craniofacial dysjunction), where the shaded region encompasses the entire midface, including the zygomatic bones, orbital floors, and nasal bones, effectively separating the facial skeleton from the skull base. This visual educational resource is designed for maxillofacial surgery and emergency medicine training to differentiate the varying degrees of midfacial skeletal instability and anatomical involvement across these three fracture types.
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mandible fracture classification zones
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nasoorbital ethmoid NOE fracture orbital blowout
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Facial Fractures - Classification
Facial fractures are organized by the region of the facial skeleton they involve. The face is divided into three anatomical thirds - upper, middle, and lower - each with distinct fracture patterns and clinical significance.
Anatomical Framework
The facial skeleton rests on a system of vertical and horizontal buttresses - thickened bony struts that disperse traumatic forces away from the brain and cervical spine. Fractures tend to follow these buttress lines. The vertical buttresses include the nasomaxillary (medial), zygomaticomaxillary (lateral), pterygomaxillary, and posterior mandibular. The horizontal buttresses include the frontal, zygomatic, maxillary, and mandibular.
I. UPPER FACIAL FRACTURES
Frontal Bone / Frontal Sinus Fractures
The frontal bone is the most prominent structure of the upper face and contains the air-filled frontal sinus (pneumatization begins at age 7 - hence different fracture patterns in children vs. adults).
Classification by sinus wall involvement:
- Anterior table fractures - involve only the anterior wall of the frontal sinus. Isolated, nondisplaced fractures can be observed. Displaced fractures causing nasofrontal outflow tract obstruction require ORIF.
- Posterior table fractures - involve the wall adjacent to the anterior cranial fossa. These are complex, often associated with dural injury and CSF rhinorrhea. May require cranialization of the sinus or obliteration.
- Combined anterior + posterior table fractures - both walls involved; significant risk of intracranial complications.
Key clinical signs: forehead lacerations, isolated upper lid ecchymosis (orbital roof involvement), salty nasal drainage/CSF rhinorrhea (posterior table + dural breach), pneumocephalus on CT.
II. MIDFACE FRACTURES
1. Nasal Fractures
The most common facial fracture. Can be displaced or non-displaced. The critical concern is a septal hematoma - if untreated, it causes avascular necrosis of the cartilage leading to saddle nose deformity. Loss of support of upper lateral cartilages can cause internal valve stenosis and nasal obstruction.
2. Naso-Orbito-Ethmoid (NOE) Fractures
Caused by significant force to the nasal bridge, fracturing the deep central ethmoid complex without necessarily creating a full Le Fort pattern. NOE fractures are classified by the Markowitz system:
- Type I - single large central fragment bearing the medial canthal tendon; treated with ORIF
- Type II - central fragment comminuted but medial canthal tendon attached to one fragment
- Type III - severe comminution of the central fragment; medial canthal tendon insertion disrupted (transnasal canthopexy required)
Key associations: CSF rhinorrhea (cribriform plate involvement), anosmia, telecanthus.
3. Orbital Fractures (Blowout Fractures)
The orbital walls fracture in order of frequency: floor > medial wall > lateral wall > roof.
- Pure blowout: only the internal orbital wall, not the rim
- Impure blowout: orbital wall + rim
- Orbital floor fracture - entrapment of the inferior rectus causes diplopia and limited upgaze
- Medial wall fracture - easily missed; orbital emphysema common
- Orbital roof fracture - rare in adults (3-9.3% of facial fractures), more common in children (18-35% of pediatric facial fractures); divided into "pure" (roof only) and "impure" (roof + rim)
- Complications: enophthalmos, hypophthalmos, retro-orbital hematoma (compartment syndrome), superior orbital fissure syndrome (CN III, IV, V1, VI), orbital apex syndrome (adds optic nerve compression - surgical emergency)
4. Zygomatic (Tripod / Trimalar) Fractures
The zygoma has 4 articulations - with the frontal, temporal, maxillary, and sphenoid bones. A tripod fracture involves three bones: lateral orbit, zygoma, and maxilla. The zygoma can be pushed in, rotated laterally/medially, or inferiorly. If displaced, it can impinge the coronoid process (trismus) or compress orbital structures (proptosis).
5. Le Fort Fractures
The most widely used classification of midfacial fractures, originally described by René Le Fort. A key rule: all Le Fort fractures involve the pterygoid plates. Fractures can be unilateral, bilateral, or a combination of different Le Fort levels on each side.
| Level | Name | Fracture Line | Mobility on Exam |
|---|---|---|---|
| Le Fort I | Transverse / Guérin's fracture | Horizontal fracture through the maxilla above the tooth roots; extends from pterygoid plates through lateral wall of maxillary sinus and piriform aperture of nose. Separates the alveolar process and palate from the rest of the midface. | Mobile alveolar ridge only |
| Le Fort II | Pyramidal fracture | Extends from pterygoid plates superiorly across the nasal bones, lacrimal bones, orbital floor, and inferior orbital rim, creating a pyramid-shaped fragment (maxilla + nasal complex). | Nasal complex + maxilla moves as a unit |
| Le Fort III | Craniofacial dysjunction | Complete separation of the entire midface from the skull base. Fracture extends from nasal bridge posteriorly along medial orbital wall (ethmoids), along orbital floor, through lateral orbital wall, and through the zygomatic arch. Associated with CSF leak. | Entire face (including zygomas) moves |
Clinical note: Pure Le Fort III is rare. Real-world fractures are often asymmetric, mixed-level (e.g., Le Fort II on one side, Le Fort III on the other), or comminuted - particularly in high-energy trauma. A CT scan is essential to define the true extent.
III. LOWER FACIAL FRACTURES
Mandible Fractures
The mandible is the most commonly fractured facial bone after the nasal bones. Classified by anatomical region:
| Region | Description |
|---|---|
| Symphysis | At the midline between the two mental foramina (some define symphysis as the exact midline and parasymphysis as off-midline to the foramen) |
| Parasymphysis | Between the midline and the mental foramen |
| Body | Between the mental foramen and the angle of the mandible |
| Angle | At/posterior to the region of the third molar, behind the tooth-bearing segment (dentoalveolar buttress unavailable) |
| Ramus | Posterior to the angle, in the vertical portion of the mandible |
| Subcondylar | Traverses the sigmoid notch and exits behind the angle; most common site due to the thin bone here |
| Condyle | Fracture of the condylar head itself |
| Coronoid | Fracture of the coronoid process (rare; extends anteriorly from sigmoid notch) |
Common fracture patterns:
- Fist/blunt trauma or fall: symphysis, parasymphysis, body
- A symphysis fracture often produces a contralateral condylar fracture (indirect force)
- Angle fractures have reduced dentition support and often require ORIF
- Subcondylar fractures may be managed conservatively (closed) or operatively depending on displacement and occlusion
IV. PANFACIAL FRACTURES
When injuries span all three facial thirds simultaneously (upper, mid, lower face), the injury is termed a panfacial fracture. These are high-energy injuries requiring complex multidisciplinary reconstruction, typically with restoration of the facial buttresses using rigid internal fixation.
Summary Table
| Region | Fracture Type | Key Classification |
|---|---|---|
| Upper face | Frontal sinus | Anterior table / Posterior table / Combined |
| Midface (central) | Nasal | Displaced / Non-displaced |
| Midface (central) | NOE | Markowitz Types I / II / III |
| Midface (orbital) | Blowout | Pure / Impure; Floor / Medial / Lateral / Roof |
| Midface (lateral) | Zygomatic | Tripod / Isolated arch |
| Midface (maxilla) | Le Fort | I (transverse), II (pyramidal), III (craniofacial dysjunction) |
| Lower face | Mandible | Symphysis / Parasymphysis / Body / Angle / Ramus / Subcondylar / Condyle / Coronoid |
| All three thirds | Panfacial | No sub-classification; described by component fractures |
Sources:
- Current Surgical Therapy, 14e - "Evaluation and Management of the Patient with Craniomaxillofacial Trauma"
- Bailey and Love's Short Practice of Surgery, 28e - Chapter 31: Maxillary, Zygomatic, and Orbital Fractures
- Rosen's Emergency Medicine, 9e - Chapter 34: Facial Trauma
- K.J. Lee's Essential Otolaryngology - Facial Fracture Classification
- Cummings Otolaryngology Head and Neck Surgery - Midface and Mandible Fractures
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