In a suspected Le Fort fracture, is a non‑contrast maxillofacial CT covering the paranasal sinuses (PNS) required, or can a PA (postero‑anterior) facial X‑ray be used instead?

Non-Contrast Maxillofacial CT is Required for Suspected Le Fort Fractures

For suspected Le Fort fractures, you must obtain a dedicated non-contrast maxillofacial CT covering the paranasal sinuses—plain radiographs (PNS or PA views) are inadequate and represent low-value care that should be avoided. 1

Why CT is Mandatory

Le Fort fractures are complex midface injuries involving multiple anatomical structures that plain films simply cannot adequately visualize:

• All Le Fort patterns involve the pterygoid plates, which are poorly visualized on plain radiographs 1
• Le Fort I: Transverse fracture through all maxillary sinus walls
• Le Fort II: Pyramidal pattern involving posterior alveolar ridge, nasal bones, inferior orbital rims, and lateral maxillary sinus walls
• Le Fort III: Complete craniofacial separation involving zygoma, medial/lateral orbital walls, nasal bridge, and potentially the orbital apex and carotid canal 1

Multidetector CT (MDCT) provides superior delineation of both osseous and soft-tissue structures with thin-section acquisitions that detect subtle nondisplaced fractures. The multiplanar and 3D reconstructions are critical for surgical planning, as surgeons rely heavily on these reformations for preoperative assessment 1

The Problem with Plain Radiographs

Recent evidence confirms that plain radiography in maxillofacial trauma is low-value care:

• A 2025 national database study found that 25.6% of patients still received inappropriate plain radiography despite clear guidelines favoring CT 2
• 5.5% of radiograph recipients required follow-up CT within 7 days, and 7.6% experienced diagnostic delays 2
• Plain films have limited diagnostic accuracy (53-82% for even simple nasal fractures) and do not alter management 1

Critical Associated Injuries You Cannot Miss

68% of patients with maxillofacial fractures have associated head injuries, making concurrent head CT often necessary 1. Specifically:

• Le Fort II and III injuries are frequently associated with naso-orbital-ethmoid fractures 1
• 7% have concomitant cervical spine injuries 1
• Le Fort III injuries can involve the orbital apex and carotid canal, requiring vascular imaging if clinically indicated 1

Common Pitfalls to Avoid

1. Don't rely on head CT alone: While head CT detects 95% of facial fractures, it often only partially images midface fractures. You need a dedicated maxillofacial CT 1

2. Don't order PNS views thinking they're "screening": This delays definitive diagnosis and adds unnecessary cost without clinical benefit 2

3. Don't forget the pterygoid plates: If you can't clearly see bilateral pterygoid plate involvement on imaging, you haven't adequately evaluated for Le Fort fractures 1

The Bottom Line

When clinical examination suggests Le Fort fracture (upper jaw mobility, malocclusion, facial elongation, periorbital ecchymosis, infraorbital nerve paresthesia), proceed directly to non-contrast maxillofacial CT with thin sections (typically 5mm or less) covering from the frontal sinus through the maxilla 1. This is the only imaging modality that provides the anatomical detail necessary for accurate diagnosis and surgical planning while avoiding the diagnostic delays and follow-up imaging associated with plain radiographs.