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Le Fort fracture of skull
Le Fort fracture of skull
Le Fort fracture of skull
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A 3D CT reconstruction showing a Le Fort I fracture (arrow indicates fracture line)

The Le Fort (or LeFort) fractures are a pattern of midface fractures originally described by the French surgeon René Le Fort in the early 1900s.[1] He described three distinct fracture patterns. Although not always applicable to modern-day facial fractures, the Le Fort type fracture classification is still utilized today by medical providers to aid in describing facial trauma for communication, documentation, and surgical planning.[2] Several surgical techniques have been established for facial reconstruction following Le Fort fractures, including maxillomandibular fixation (MMF) and open reduction and internal fixation (ORIF). The main goal of any surgical intervention is to re-establish occlusion, or the alignment of upper and lower teeth, to ensure the patient is able to eat.[2] Complications following Le Fort fractures rely on the anatomical structures affected by the inciding injury.

Anatomy

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When discussing the anatomy of the face, it is often divided into thirds. The lower third extends from the chin to approximately the level of the upper teeth. The middle third continues from the teeth to just below the brow line. Finally, the upper third stretches from the brow to the hairline.[3]

The facial skeleton

The middle third of the face, or the midface, is the anatomical location in which Le Fort fractures occur. It comprises the maxillary bone, palatine bones, zygomas, zygomatic processes (of the temporal bone), ethmoid bone, vomer, nasal concha, nasal bones, and pterygoid processes (of the sphenoid bone).[2][3][4]

The maxillary bone contains important anatomical structures which are prone to injury during trauma. The maxillary sinuses are housed within the maxillary bone, and traumatic injury to these sinuses may cause sinus infections, and changes in eye placement and movement.[4] The infraorbital nerve (a terminal branch of CNV2) courses through the maxillary bone and provides sensation to the central face. Additionally, the maxillary bone contains the upper row of teeth (maxillary dentition). Occlusion, or the alignment of upper and lower teeth, is vital following midface trauma to ensure a patient is able to eat and speak.[2]

Facial biomechanics, or the study of forces on the facial bones, plays an important role in midface reconstruction following trauma. Although the biomechanics of the face are not fully understood due to their complex nature, several vertical and horizontal buttresses, or pillars, have been established. These buttresses dissipate the powerful forces the skull endures during biting and chewing.[2][5][6]

Classification

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History and Modern Day Use

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The Le Fort fractures are a pattern of midface fractures originally described by the French surgeon René Le Fort in the early 1900s.[1] Le Fort studied the effect of facial trauma by dropping cadavers from various heights and recording the different fracture patterns observed.[2] Today, with the evolution of high-speed motor vehicle accidents and advancements in medical imaging and surgical techniques, the low-speed fracture patterns originally described by Le Fort are not always applicable.[7] Modern midface fractures typically do not neatly fit into one of the Le Fort classifications and often occur in combination with other craniofacial trauma.[1] Nevertheless, the Le Fort type fracture classification is still used today as a starting point for describing midface fractures for communication, documentation, and treatment planning.[2]

Classification

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Le Fort I fracture

Traditionally, Le Fort described three types of fractures. All three fractures involve the nasal septum and the pterygoid plates.[2]

Le Fort II fracture
  • The Le Fort II fracture (pyramidal fracture) includes a fracture line from one of the lateral vertical buttresses across the maxillary bone, extending into the inferior orbital rim and crossing the midline (either through the nasal root or nasal bones).[5] The defining feature of this fracture pattern is involvement of the inferior orbital rim.[5] When viewed from the front, this fracture is classically shaped like a pyramid.
Le Fort III fracture

Patient Evaluation

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Initial Evaluation

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Every trauma patient presenting to the hospital should first be evaluated according to the Advanced Trauma Life Support (ATLS) protocol, which follows the ABC's (airway, breathing, circulation) of trauma. This includes ensuring the patient is able to breathe, confirming that the patient is actively breathing, and identifying and minimizing major bleeding.[1][2][6] Le Fort fractures have the potential to obstruct a patient's airway for a variety of reasons, preventing him or her from being able to breathe.[1][6] Medical providers should be prepared for emergency airway management should the patient develop an obstructed airway due to bleeding or swelling.[6] Other life-threatening injuries, including those to the brain, spine, or abdomen, should receive prompt evaluation by the appropriate medical specialist.[6]

Symptoms and Exam Findings

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After the initial evaluation is complete and the patient is stable, the patient should be evaluated by a surgeon that specializes in facial trauma, such as a plastic surgeon, an otolaryngologist (ear, nose, and throat surgeon), or an oral and maxillofacial surgeon (OMFS). The surgeon will perform a thorough facial exam, paying special attention to any new-onset facial asymmetry or distortion.[1] Facial swelling and bruising is very common in Le Fort fractures and can make evaluation of facial changes challenging.[6] It can be helpful to have a picture of the patient prior to his or her facial trauma as a comparison.

If the surgeon suspects a Le Fort fracture, they may test for abnormal movement of the maxillary bone by planting one hand on the patient's forehead and using the other hand to press on the roof of the patient's mouth.[1] Movement in the maxillary bone either in isolation or with the nose is suggestive of a Le Fort I or II fracture, respectively.[1]

The cranial nerves (CNs) should be examined if the patient is awake and able to participate in the exam process.[2] The CN exam evaluates facial movement and sensation. Special attention should be made to the fifth CN (CNV) as one of its branches (the infraorbital nerve) courses through the maxillary bone.[2] If this nerve is injured during trauma, it can result in numbness or tingling around the nose or within the mouth.[2]

The surgeon will also examine the patient's mouth for bleeding, swelling, cuts, foreign objects, changes in bite, and newly lost teeth. Additionally, an eye exam assessing vision and pupillary response may be warranted, especially in Le Fort II and III fractures due to the involvement of the orbit.[2] If there is suspicion that the skull base has been injured, such as during a Le Fort III fracture, the patient should be examined for clear drainage from the ear or nose which may be caused by a cerebrospinal fluid (CSF) leak.[2][6] Abnormal findings during these mouth, eye, ear, or nose exams may require further evaluation.

Signs Indicating Further Evaluation

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If it was determined that the patient lost a tooth during the inciting trauma, the tooth's location should be identified as it could have become lodged in the airway, aspirated into the lungs, or swallowed.[1] If there is concern for an aspirated tooth, an x-ray can confirm the tooth's location.[1][6] If the eye exam reveals abnormalities in either vision or the pupillary response, prompt evaluation by a neurosurgeon and an ophthalmologist should occur.[2] Skull base injuries can result in a cerebrospinal fluid (CSF) leak, which can present as a clear, metallic-tasting liquid draining from the nose or the ear.[2] If a CSF leak is suspected, the patient should be evaluated by a neurosurgeon.[6]

Diagnosis

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Although diagnosis can be suspected by history and physical exam, imaging is required for an accurate diagnosis. A computed tomography (CT) of the face and skull is the imaging of choice for diagnosing Le Fort fractures.[5][7] CT imaging has greatly replaced the use of plain x-ray as CTs are significantly more likely to show when a fracture is present compared to an x-ray.[7] Additionally, CT imaging is far more useful in visualizing the skeletal injuries in Le Fort fractures than magnetic resonance imaging (MRI).[7] However, MRIs may be useful if there is extensive soft tissue injuries.[6]

Treatment

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Surgical treatment of Le Fort fractures is almost always necessary, especially if the fractures are displaced or impact facial functions like eating and speaking.[6] Fractures can be repaired through maxillomandibular fixation (MMF) and/or open reduction and internal fixation (ORIF) after life-threatening injuries have been addressed.

Goals of Intervention

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The primary goal of any intervention is to ensure that a patient is able to eat and speak. This is done by re-establishing occlusion (alignment of upper and lower teeth) and stabilizing facial biomechanics (via the vertical and horizontal facial buttresses discussed previously) to support chewing.[1] Other goals of intervention include restoring cosmetic deformities from the trauma, but this should never be prioritized over re-establishing occlusion.[1]

Maxillomandibular Fixation

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Maxillomandibular fixation (MMF), also known as intermaxiallary fixation (IMF), is a surgical procedure to re-establish occlusion by fixating the upper and lower teeth in their correct position. It can be used in isolation or in combination with open reduction and internal fixation (ORIF) in treating Le Fort fractures.[6] Several surgical techniques exist for establishing MMF, with selection relying on the individual patient injury and surgeon preference.[1][2] MMF involves fixation of the upper and lower teeth for 6–8 weeks, which limits a patient's ability to speak, eat, breathe through their mouth, and maintain adequate oral hygiene.[1] MMF patients should be provided with wire cutters or scissors for emergency situations.[1] A patient in MMF will be placed on a liquid-only diet during the entirety of their treatment, which may result in weight changes.[1][8] MMF has some effect on a patient's ability to breathe through their mouth while in place, so patients with a history of pulmonary disease who rely on mouth breathing may not qualify for MMF.[8] Additionally, patients with psychological or seizure disorders may not be good MMF candidates.[1]

Open Reduction and Internal Fixation

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Open reduction and internal fixation (ORIF) is a surgical term that refers to open surgical repair of broken bones. It is required for correction of complex Le Fort fractures affecting facial function or involving neurological complications (visual changes, CSF leak).[6] ORIF is especially important for repairing unstable facial buttresses in order to allow the patient to tolerate chewing. Plates and screws are often permanently fixated to facial bones to stabilize the lateral and medial vertical buttresses bilaterally.[2] Bone grafts may also be required to stabilize the buttresses.[2] ORIF can be used in isolation or in combination with maxillomandibular fixation (MMF) in treating Le Fort fractures.[6] Following surgery, patients may require up to six weeks of rest before they are able to return to the demands of their daily life.[6] As all patients heal slightly differently, ORIF may result in a less-than-ideal correction of facial bones, resulting in poor occlusion or facial asymmetries. Furthermore, as with any surgery, ORIF comes with risk of scarring, nerve injury, and infection.[2]

Role of Antibiotics

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The role of antibiotics in midface trauma is a complex and highly patient-dependent topic. Facial trauma patients with lacerations (or wounds) to the inner lining (mucosa) of the mouth or the nose traditionally have been started on antibiotics as soon as they enter the hospital and have remained on antibiotics for a minimum of 24 hours after surgery.[2] However, some preliminary studies on preoperative antibiotic use suggest that they may not be necessary to prevent bacterial infections, though these are based on small patient populations and are not strong enough studies to set specific recommendations regarding preoperative antibiotic use.[9] Therefore, patients are still often placed on antibiotics before surgery, especially if they are at an increased risk of developing infection (including, but not limited to, patients that are elderly, tobacco users, diabetic, and/or immunocompromised).[9][10] If a patient is begun on antibiotics, it is difficult to determine how long they should remain on antibiotics postoperatively.[10] Although multiple studies have been performed examining postoperative antibiotic use, they have come to contradicting conclusions.[11] The more recent studies have suggested that antibiotics may not have any advantage in preventing postoperative bacterial infections.[10][11] However, these studies acknowledge that their results are based predominantly on the young, healthy, male patients with non-specific facial trauma that make up the majority of the studies' participants and may not be applicable to the everyone experiencing midface trauma.[10] With limited studies specifically on midface trauma, no standards for postoperative antibiotic use has been determined. The use of postoperative antibiotics relies on the surgeon's clinical recommendations and individual patient risk factors.[10]

Prognosis

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Longterm outcomes of Le Fort fractures depend on the severity and location of the fracture. The most common complication of Le Fort fractures include imperfect fracture reduction resulting in poor dental occlusion.[2] Other longterm effects of Le Fort fractures include various nerve injuries, either from the inciting injury or from surgical correction, resulting in facial movement and sensory deficits.[2] If one or both of the maxillary sinuses are injured during the trauma, it can result in chronic sinus infections or injuries to the eye which may require further surgical correction.[2] Le Fort III fractures that injure the optic nerve or the extraocular muscles that move the eye may result in visual defects.[2]

See also

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References

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Revisions and contributorsEdit on WikipediaRead on Wikipedia

Le Fort fracture of skull

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Le Fort fractures are a system of classifying midfacial fractures of the skull, characterized by disruptions to the pterygoid plates and facial buttresses resulting from high-energy blunt trauma. These fractures, first systematically described by French surgeon René Le Fort in 1901 through experiments on cadavers subjected to simulated blunt force, divide into three main types based on the anatomical planes of separation: horizontal (type I), pyramidal (type II), and craniofacial dysjunction (type III). They represent 8.67% to 24.84% of all facial fractures, with a male-to-female ratio ranging from 3:1 to 12:1 and a peak incidence in individuals aged 20 to 30 years. Le Fort type I fractures involve a horizontal separation of the tooth-bearing portion of the from the upper , extending from the lateral nasal walls through the maxillary sinuses and posterolaterally to the pterygoid plates; they account for approximately 2.15% to 6% of facial fractures. Le Fort type II fractures form a pyramidal pattern, traversing the , inferior orbital rims, and zygomaticomaxillary sutures before reaching the pterygoid plates, comprising about 4.64% to 5% of cases and often associated with orbital involvement. Le Fort type III fractures result in complete detachment of the midface from the cranium, involving the naso-orbito-ethmoidal complex, zygomatic arches, and orbital walls, with an incidence of 1.88% to 3%; these are the most severe and frequently bilateral. Only about 24% of midfacial fractures follow these classic Le Fort patterns exactly, with many presenting as combinations or variations. The primary etiology of Le Fort fractures is high-velocity trauma, such as motor vehicle collisions (accounting for around 50% of cases), assaults, falls, or , where the force vector determines the fracture level—lower forces typically produce type I, while higher energies lead to types II or III. Clinically, patients present with facial swelling, ecchymosis (e.g., periorbital or sublingual), , and midfacial mobility upon palpation; associated risks include leakage, airway compromise, and concomitant intracranial or cervical spine injuries, particularly with types II and III. Diagnosis relies on (ATLS) protocols followed by thin-slice (≤3 mm) computed tomography (CT) imaging to delineate fracture extent and involvement of critical structures like the orbits or base, as plain radiographs are insufficient. Treatment is predominantly surgical, involving open reduction and internal fixation with titanium plates to restore facial projection, occlusion, and buttress integrity, ideally within one week of injury; conservative management with closed reduction or observation is reserved for stable, nondisplaced fractures. Complications such as infection, malunion, , or persistent underscore the need for multidisciplinary care involving maxillofacial surgeons, neurosurgeons, and ophthalmologists.

Introduction and Epidemiology

Definition

Le Fort fractures represent specific patterns of midface fractures characterized by the separation of the and adjacent facial bones from the base. These injuries disrupt the structural integrity of the midfacial , often resulting from high-impact trauma to the face. Originally identified through experiments, Le Fort fractures provide a foundational framework for understanding transverse disruptions in the craniofacial complex. A defining characteristic across all Le Fort fractures is the bilateral fracture of the pterygoid plates of the , which serves as the posterior attachment point connecting the midface to the cranial base. This involvement ensures the dissociation of the midfacial unit from the , distinguishing Le Fort patterns from other facial fractures. The pterygoid plate fractures are essential for the mobility observed in the affected midface segments. In clinical practice, Le Fort fractures are classified into types I, II, and III based on the extent and plane of injury, facilitating accurate and guiding surgical intervention in management. This classification system emphasizes the need for multidisciplinary assessment to address associated complications such as airway compromise or leakage.

Incidence and Risk Factors

Le Fort fractures represent 10-20% of all facial fractures, with midface fractures comprising 50-71% of injuries overall. In specific studies, the incidence varies by type and population: Le Fort I accounts for approximately 2.1-2.9% of facial fractures, Le Fort II for 2.2-3.0%, and Le Fort III for 1.5-2.7%. These fractures are more prevalent in high-impact trauma settings, where they constitute up to 24.84% of facial injuries in some series, though rates can be lower in others, such as 8.67% in certain regional cohorts. Demographically, Le Fort fractures predominantly affect males, with a male-to-female ratio ranging from 3:1 to 12:1, and peak incidence occurs in young adults aged 20-30 years. In pediatric populations, the incidence increases with age, affecting about 4% of all facial fractures and 9.6% of midface fractures, with 81.1% of cases in adolescents aged 12-19 years and a 69% male predominance. Concomitant injuries are common, including fractures in 40.7% of cases, which underscores the association with severe multisystem trauma. The primary risk factors for Le Fort fractures involve high-energy blunt force trauma, with motor vehicle accidents accounting for 50% of cases and correlating with higher fracture severity, such as Type III patterns at increased speeds. Other etiological factors include falls (27.9% in developed countries) and assaults (39.7%), which more frequently cause lower-energy Type I or II fractures. Intoxication significantly elevates risk, present in 13.6% of Type I, 18.1% of Type II, and 52.1% of Type III cases, while absence of safety devices like seat belts or helmets further heightens vulnerability in vehicular and sports-related incidents. Urban living and lower have also been linked to increased occurrence.

Historical Background and Classification

Development by René Le Fort

René Le Fort, a French military surgeon, conducted a series of experiments in 1901 using 35 cadavers to determine the most common patterns of midfacial skeletal injuries from . He inflicted varying degrees of force on the cadavers through methods such as striking with a wooden club or metal rod, dropping cannonballs, stomping, applying vise pressure, or hurling heads against a table, simulating real-world impacts while avoiding penetrating injuries like gunshots. To examine the results, Le Fort boiled the skulls to strip away soft tissues, revealing consistent fracture lines along the midface's paths of least resistance, which he documented as predictable patterns separating portions of the from the cranium. These studies formed the foundation of the Le Fort classification, identifying three idealized transverse fracture types that involve the pterygoid plates and disrupt midfacial support. However, the original experiments suffered from significant limitations, including inconsistent force application, non-standardized trauma orientations, and variable mechanisms, which produced theoretical patterns rarely observed exactly due to the complexities of living tissue and real trauma dynamics. Clinical data indicate that only about 24% of midface fractures align with classic Le Fort patterns, with 56% showing partial resemblance alongside additional injuries and 20% featuring that deviates entirely from the defined lines. In contemporary practice, the Le Fort system endures as a vital tool for standardizing communication among clinicians and guiding treatment planning, despite the prevalence of asymmetric, mixed, or incomplete fractures highlighted by advanced imaging. To accommodate these variations, modifications such as the Wassmund extension have been integrated, adding categories like type IV for supraorbital involvement and type V for forehead fractures, thereby broadening applicability without supplanting the core framework.

Types of Le Fort Fractures

Le Fort fractures are classified into three primary types based on the anatomical planes of injury through the midfacial skeleton, all of which characteristically involve fractures of the pterygoid plates of the . These classifications, originally described by Le Fort, delineate the extent of midfacial detachment from the cranium and help guide clinical assessment. Type I (Guérin or low transverse fracture) involves a horizontal fracture line through the lower , separating the and from the upper . This fracture typically propagates through the lateral nasal wall, the walls of the , and the inferior aspects of the ipsilateral or bilateral pterygoid plates, often extending to the in bilateral cases. It results in mobility of the lower while preserving the integrity of the upper midface structures. Type II (pyramidal fracture) is characterized by a pyramidal-shaped fracture that ascends through the central midface, involving the , medial walls of the and lacrimal bones, the orbital floor, and the inferior orbital rims bilaterally, with extension to the pterygoid plates posteriorly. Unlike Type III, it spares the and lateral orbital walls, leading to disarticulation of the central midface pyramid from the surrounding bones. Type III (transverse or craniofacial dysjunction fracture) represents a high transverse that completely detaches the entire midface from the cranium, traversing the frontozygomatic suture, medial and lateral orbital walls, , and pterygoid plates, often incorporating the naso-orbito-ethmoid complex. This pattern causes craniofacial separation, with the facial skeleton suspended only by soft tissue attachments. Variants of Le Fort fractures include asymmetric presentations, where different types occur on opposite sides (e.g., Type I on one side and Type II on the other), and combined types involving multiple fracture levels simultaneously. A rare Type IV variant extends superiorly into the supraorbital region and , resulting in further cranial involvement beyond the standard Type III pattern.

Anatomy and Pathophysiology

Facial Skeleton Involved

The midface, or maxillofacial skeleton, forms a complex architectural framework that supports the upper airway, orbits, and , and is particularly susceptible to Le Fort fractures due to its relative weakness compared to the . Key bones involved include the , which comprises the central body and housing the upper teeth, providing foundational support for the midfacial structure. The zygomatic bones contribute lateral stability, articulating with the and temporal bones to form the zygomatic arches. and the , including its orbital plates, form the medial and superior boundaries of the and orbits, while the sphenoid bone's pterygoid plates serve as critical posterior attachments linking the midface to the skull base. Orbital floors and walls, composed of contributions from the , zygoma, and ethmoid, enclose the ocular contents and are prone to involvement in these injuries. Biomechanically, the facial skeleton relies on a series of vertical and horizontal buttresses to withstand masticatory and traumatic forces. The vertical buttresses—nasomaxillary (along the medial maxillary wall from the to the medial orbital rim), zygomaticomaxillary (lateral maxillary wall to the zygomaticofrontal suture), and frontomaxillary (frontal process of the )—provide primary vertical support, transmitting forces from the teeth to the cranium. The pterygomaxillary junction, a weak point between the and sphenoid pterygoid plates, often serves as a propagation site for fractures due to its thin bony interface and lack of robust muscular attachments. Horizontal buttresses, such as the infraorbital rims and zygomatic arches, offer supplementary resistance but are more vulnerable to shearing under transverse loads. These structures maintain close anatomical proximity to vital neurovascular elements, heightening the risk of associated complications in Le Fort fractures. The , a branch of the maxillary division of the (CN V2), traverses the orbital floor and exits via the on the maxillary body, potentially leading to sensory deficits in the midface upon disruption. The , supplying the midfacial soft tissues and , courses through the near the pterygoid plates, where injury may cause significant hemorrhage. In fractures extending superiorly, the at the orbital apex and branches of the are at risk due to involvement of the ethmoid and sphenoid attachments to the base.

Mechanism of Injury

Le Fort fractures arise from to the midface, where the direction, magnitude, and velocity of the applied dictate the resulting pattern by exploiting lines of least resistance in the , such as the pterygomaxillary buttress and maxillary sinuses. These injuries are biomechanically propagated through the disruption of facial buttresses, with attachments guiding the fracture lines and often contributing to associated damage in adjacent structures. High-energy mechanisms, such as accidents, predominate in more severe cases, while lower-energy impacts suffice for isolated patterns. Type I fractures typically result from low-energy, downward-directed forces applied to the lower , such as those from falls from standing height or blunt assaults like punches, causing a horizontal detachment of the from the upper face. In these scenarios, approximately 56% of cases involve such low-velocity trauma, leading to propagation through the lateral nasal walls, , and pterygoid plates. Higher-velocity equivalents of this mechanism, however, elevate the fracture line higher along the lateral , as demonstrated in comparative analyses of trauma impacts. Type II fractures stem from higher-energy, inferomedial or straight-on forces to the mid-maxilla or nasal bridge, often in assaults or falls from greater heights, producing a pyramidal fracture that extends from the through the infraorbital rims and into the pterygoid plates. These forces disrupt the nasomaxillary and zygomaticomaxillary buttresses, with the oblique propagation influenced by the relative rigidity of surrounding soft tissues and bone. Type III fractures, representing craniofacial dissociation, occur with the highest energy levels from lateral or glancing blows to the upper and zygoma, or severe downward impacts to the , as seen in high-speed collisions or multi-story falls, separating the entire midface from the cranial base along a transverse path. This pattern follows the skull base parallels, involving the frontozygomatic suture, orbital walls, and , and is frequently compounded by concurrent cranial or cervical injuries due to the force dissipation.

Clinical Presentation

Symptoms

Patients with Le Fort fractures commonly report severe facial pain, particularly around the midface and upper jaw, due to the involvement of the maxillary bone and surrounding soft tissues. Swelling is frequently described as significant and diffuse, contributing to a sensation of facial fullness and discomfort. Numbness or in the cheek, upper lip, and teeth often occurs secondary to involvement, affecting sensation in the midface region. Malocclusion, manifesting as misalignment of the teeth or an open bite, leads to difficulty in chewing and biting, with patients noting instability in their bite. Type-specific symptoms vary based on the fracture level. In Le Fort I fractures, patients may experience an anterior open bite and ecchymosis within the mouth, exacerbating pain during oral movements. For Le Fort II and III fractures, epistaxis (nasal bleeding) is prominent, often bilateral and profuse, alongside (CSF) rhinorrhea presenting as a clear, watery nasal discharge. These higher-level fractures also commonly involve orbital structures, leading to reported vision changes such as (double vision) or , particularly with upward gaze. Systemic symptoms associated with Le Fort fractures include , which may arise from concurrent intracranial injuries or tension in the structures, and , potentially linked to elevated or the overall trauma response. These symptoms underscore the need for prompt evaluation to address both and potential neurological involvement.

Physical Examination Findings

Physical examination for Le Fort fractures focuses on identifying signs of midfacial instability and through systematic and observation. Facial is a hallmark finding, often diffuse and progressive, obscuring underlying bony contours shortly after injury. Ecchymosis commonly appears in the periorbital regions, presenting as "" in Types II and III fractures due to involvement of the orbital rims and surrounding tissues. Subconjunctival hemorrhage may also be evident, particularly in higher-level fractures, extending across the without posterior limits. Palpation techniques are essential for detecting bony disruptions. Crepitus on gentle palpation of the midface indicates from communication with , a frequent sign across all types. To evaluate mobility, the examiner stabilizes the patient's forehead with one hand while grasping the maxillary alveolus or upper teeth with the other, then rocks the segment anteriorly and posteriorly; abnormal movement confirms midfacial dissociation. An anterior open bite may be observed on inspection of occlusion, resulting from posterior displacement of the . Loose or avulsed teeth, along with intraoral ecchymosis in the buccal vestibule or , further support the diagnosis. Type-specific findings aid in during examination. In Type I fractures, mobility is limited to the lower and , with localized swelling of the upper lip and vestibular ecchymosis. Type II fractures demonstrate pyramidal mobility involving the and , accompanied by bilateral periorbital , epistaxis, and potential infraorbital nerve hypesthesia. Type III fractures exhibit craniofacial dysjunction, with the entire midface movable relative to the cranium; additional signs include facial elongation (dish-face deformity), traumatic from naso-orbito-ethmoidal involvement, and due to orbital volume expansion. may occur acutely in Types II or III from retrobulbar . Airway evaluation is a critical component of the physical exam, as posterior displacement of segments, combined with hemorrhage and , can lead to obstruction, especially in Types II and III. Inspection for , use of accessory muscles, or bloody secretions from the nares or mouth guides immediate intervention priorities.

Diagnosis

Initial Assessment

The initial assessment of a with suspected Le Fort begins with adherence to the (ATLS) protocol, employing the ABCDE approach to systematically address life-threatening conditions in the acute setting. This structured evaluation ensures prioritization of immediate threats, particularly in maxillofacial trauma where airway compromise is a primary concern. Airway management takes precedence, as Le Fort fractures—especially types II and III—can lead to obstruction from hemorrhage, , or posterior displacement of midfacial structures, necessitating prompt securing via orotracheal with fiberoptic or video guidance; nasotracheal is contraindicated due to risk of penetration, and surgical airways like cricothyroidotomy may be required if conventional methods fail. is then evaluated for adequate ventilation, with bag-mask support provided if needed, while monitoring for complications such as aspiration or associated with facial fractures. Circulation assessment focuses on controlling profuse hemorrhage, which is more common in Le Fort II and III fractures due to vascular injury in the and , through direct pressure, nasal packing, or fluid resuscitation to address potential . Disability involves a rapid using the to detect associated intracranial injuries, which occur in up to 5.4% of cases, alongside evaluation for cervical spine instability, reported in 5.4% of patients with Le Fort fractures. Exposure follows, with full undressing to inspect for hidden injuries while preventing , leading into a comprehensive head-to-toe secondary survey that includes monitoring for shock indicators like and , and screening for concomitant trauma such as ocular injuries or base fractures. History gathering, obtained from the patient or witnesses once stabilized, elicits details on the mechanism of injury (e.g., high-impact blunt force), duration of loss of consciousness indicating possible , and intoxication status, which heightens risks of airway compromise and alters clinical presentation. Facial signs such as or ecchymosis may be noted briefly during this survey.

Imaging Studies

Computed tomography (CT) scanning serves as the gold standard for diagnosing and characterizing Le Fort fractures, providing detailed visualization of fracture lines, pterygoid plate involvement, and associated soft tissue or orbital injuries. High-resolution multidetector CT with multiplanar reformations is recommended, utilizing fine-cut axial slices of 1-3 mm thickness to ensure precise assessment of bony disruptions and midface detachment from the skull base. Three-dimensional (3D) reconstructions from these CT datasets further enhance evaluation by offering a comprehensive view of complex fracture patterns, which is particularly valuable for preoperative planning and confirming the extent of pterygoid process fractures essential to all Le Fort types. Panoramic radiographs may supplement CT imaging when evaluating dental or occlusal involvement, especially in Le Fort I fractures affecting the alveolar process and maxillary teeth, though they are not sufficient for primary diagnosis. Magnetic resonance imaging (MRI) is occasionally employed for detailed assessment of soft tissue injuries or nerve damage, such as optic nerve edema or facial nerve involvement not fully elucidated by CT, but it is not routine due to CT's superior bony resolution. Diagnostic confirmation of Le Fort fractures on CT requires evidence of pterygoid plate fractures (unilateral or bilateral) coupled with separation of the midface along the characteristic anatomical planes, distinguishing these injuries from isolated maxillary disruptions. CT demonstrates markedly higher sensitivity for detecting these features compared to outdated plain radiographs, which often miss subtle pterygoid involvement and associated injuries.

Management

Initial Stabilization

Initial stabilization of patients with Le Fort fractures adheres to Advanced Trauma Life Support (ATLS) principles, focusing on securing the airway, controlling hemorrhage, and ensuring hemodynamic stability prior to definitive management. Airway management takes precedence due to the high risk of compromise from midfacial instability, posterior displacement of fracture segments, oronasal bleeding, or edema, which can lead to obstruction or aspiration. Orotracheal intubation using rapid sequence induction is the preferred initial technique when visualization allows, as it provides a secure airway while minimizing cervical spine manipulation. In cases of severe midface distortion where orotracheal intubation is challenging or impossible, alternative methods such as submental intubation or a surgical airway via cricothyrotomy or tracheostomy are indicated to establish ventilation. Concurrently, epistaxis must be addressed promptly with anterior and posterior nasal packing to prevent airway soiling and maintain patency. Hemorrhage control is vital, as these fractures often involve vascular structures like the maxillary artery, leading to potentially life-threatening blood loss from the pterygopalatine fossa or nasal cavity. Initial steps include direct external pressure on bleeding sites and placement of nasal or pharyngeal packs to achieve local hemostasis, alongside fluid resuscitation to maintain circulating volume. If bleeding persists despite packing, angiography-guided embolization or surgical ligation of the internal maxillary artery may be required for definitive control. Pain control is achieved through intravenous administration of analgesics, such as or , titrated to patient response while avoiding oversedation that could exacerbate respiratory compromise. Close monitoring is essential for complications including (CSF) leak, manifested as clear from a dural tear, and rising , particularly in Le Fort III fractures with associated cranial base involvement; serial neurologic assessments and imaging guide further intervention if deterioration occurs.

Surgical Interventions

Surgical intervention for Le Fort fractures is typically performed 5 to 14 days after injury to allow resolution of facial edema while preventing , with open reduction and (ORIF) serving as the gold standard approach to restore midfacial projection, height, and occlusion. This timing balances the need for stabilization with the risks of delayed , such as fibrous union, particularly in stable patients without immediate threats like airway compromise. ORIF involves precise reduction of segments followed by rigid fixation using 1.5- to 2.0-mm miniplates and screws applied to the buttresses, including the nasomaxillary, zygomaticomaxillary, and frontomaxillary pillars, to ensure stable reconstruction. Maxillomandibular fixation (MMF) is routinely employed intraoperatively and often postoperatively for 4 to 6 weeks using arch bars, wires, or screws to reestablish proper dental occlusion and support reduction, especially in cases involving palatal splits or associated mandibular injuries. Surgical access varies by fracture level: intraoral or gingivobuccal sulcus incisions for Le Fort I, subciliary or transconjunctival approaches for Le Fort II to expose the infraorbital rim, and coronal incisions for Le Fort III to access the craniofacial junction, with midfacial techniques sometimes used for broader exposure in complex pyramidal or transverse patterns. with autologous material, such as iliac crest or calvarial bone, is indicated for defects exceeding 5 mm to maintain vertical height and prevent . Type-specific considerations guide plate selection and additional repairs. For Le Fort I fractures, 2 to 4 miniplates are typically placed along the lateral pyriform rim and zygomaticomaxillary to secure the horizontal maxillary segment, often sufficient without load-bearing hardware due to the lower transverse level. Le Fort II fractures require at the infraorbital rim, nasofrontal suture, and zygomaticomaxillary , with attention to orbital reconstruction if is present. In Le Fort III fractures, load-bearing plates (often 2.0 mm or larger) are essential at the zygomaticofrontal sutures and frontozygomatic regions to counter the higher forces across the transverse craniofacial separation, alongside repair of associated naso-orbito-ethmoidal (NOE) complex injuries using transnasal wiring or cantilever for medial canthal support. All types necessitate evaluation and simultaneous fixation of concomitant fractures, such as orbital walls or the , to achieve functional and aesthetic outcomes.

Adjunctive Measures

In the management of Le Fort fractures, antibiotic prophylaxis is a key adjunctive measure to prevent infection, particularly given the frequent involvement of , which classifies these injuries as contaminated. Prophylactic antibiotics are indicated for open or contaminated fractures (including Le Fort fractures involving or teeth). Per the Facial Trauma Practice Management Guidelines (2024), administer ampicillin-sulbactam for 24 hours; no prophylaxis is recommended for closed fractures. This aligns with Surgical Infection Society guidelines recommending a short course (≤24 hours) using ampicillin-sulbactam or equivalent to cover oral and anaerobes, minimizing postoperative infection risk. Ampicillin-sulbactam remains a first-line choice due to its broad coverage against oral and anaerobes commonly implicated in maxillofacial trauma. Postoperative nutrition and monitoring protocols are essential to support healing and detect early complications in patients with Le Fort fractures, who often require maxillomandibular fixation (MMF) that impairs oral intake. Patients are typically kept nil per os (NPO) immediately postoperatively to protect the airway and surgical sites, with enteral nutrition initiated via nasogastric tube within 24-48 hours if MMF is in place. Progression to a or soft diet occurs once MMF is released or as tolerated, usually after 4-6 weeks, to avoid disrupting fracture reduction. Serial clinical examinations are performed daily in the acute phase and weekly thereafter to monitor for signs of (e.g., fever, purulent drainage) or , with adjustments to fixation or antibiotics as needed. A multidisciplinary approach enhances outcomes by addressing associated injuries common in Le Fort fractures. Ophthalmology consultation is routinely sought for orbital involvement, such as enophthalmos or extraocular muscle entrapment in Le Fort II or III patterns, to evaluate and manage visual or ocular motility deficits. Similarly, neurosurgical input is critical for cases with cerebrospinal fluid (CSF) leaks, which occur in up to 20% of severe midface fractures; this may involve dural repair or lumbar drainage to prevent meningitis. Coordination among trauma, maxillofacial, and specialty teams ensures comprehensive care tailored to the fracture's extent.

Complications and Prognosis

Potential Complications

Le Fort fractures carry several immediate risks, including , which occurs in approximately 4% of cases following open reduction and internal fixation (ORIF). Airway obstruction is another acute concern, necessitating tracheostomy in up to 22.4% of patients overall and 43.5% of those with Le Fort III fractures due to midface and displacement. Recurrence of epistaxis can arise from damage to the medial maxillary buttress, particularly in Le Fort II fractures, potentially requiring additional intervention to control bleeding. Cerebrospinal fluid (CSF) leak is a significant immediate complication in Le Fort II and III fractures, resulting from skull base involvement, with reported incidences ranging from 8.9% across Le Fort types to 25-50% specifically in types II and III. In intermediate phases, or may develop if fixation is inadequate, affecting up to 8% of cases and leading to persistent dental misalignment. Ocular complications are prominent, especially with orbital involvement in Le Fort II and III fractures. occurs in 21% of patients, often due to extra-ocular muscle or . may result from orbital volume changes, while injury leads to in a notable proportion of cases. damage and are rarer but severe risks in high-energy trauma, with ocular injuries reported in 8.3% of Le Fort II and 6.7% of Le Fort III fractures, sometimes progressing to blindness in 0.84% despite intervention. Surgical fixation with plates can contribute to these intermediate issues if hardware migration occurs.

Long-term Outcomes

The prognosis of Le Fort fractures is influenced by several key factors, including the severity of the fracture, with higher-grade injuries such as Type III associated with worse outcomes due to greater involvement of craniofacial structures. Timely surgical intervention, particularly open reduction and (ORIF), significantly improves recovery, while the presence of concomitant injuries like or exacerbates morbidity and delays functional restoration. Patients may experience various chronic issues following Le Fort fractures, including facial asymmetry resulting from persistent in approximately 10.9% of cases, which can affect aesthetic appearance and self-perception. Chronic sinusitis is a recognized long-term complication, often arising from sinus involvement in midface fractures and leading to recurrent infections or obstruction. Temporomandibular joint (TMJ) dysfunction manifests as mastication difficulties in up to 40% of patients, potentially causing ongoing or limited mobility. Additionally, psychological impacts are common, with maxillofacial trauma contributing to (PTSD), anxiety, and depression in a substantial proportion of cases, particularly those involving orbital complex fractures like Le Fort II and III. Success metrics for Le Fort fractures emphasize return to function and aesthetic restoration, with ORIF achieving satisfactory functional and aesthetic outcomes in about 89% of patients. Return to work rates vary by severity, reaching 70% for less complex Le Fort I and II fractures but dropping to 58% for Type III or comminuted cases. While mortality remains low overall (0-8.7% depending on type), untreated fractures result in high morbidity, including chronic and functional impairment.

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