Le Fort Fractures

Dara Liotta, MD
Article by
New York Facial Plastic Surgeon

Synonyms
LeFort fractures, maxillary fractures, Guerin fracture (Le Fort I), horizontal fracture (Le Fort I), pyramidal fracture (Le Fort II), craniofacial dysjunction (Le Fort III)

Definition

In 1901, Rene Le Fort categorized fracture patterns of the Maxilla resulting from a single blow to cadaveric skulls. The fracture lines, or “linea minoros resistentiae”, described by Le Fort in 1901 are the basis for the modern Le Fort classification.  A Le Fort I fracture (also known as a Guerin fracture, or horizontal fracture) is a single horizontal fracture through the maxilla that passes through the septum medially, extending laterally through the pyriform rims, passing below the zygomatico-maxillary suture line, and transecting the pterygomaxillary junction to interrupt the pterygoid plates. Le Fort I fractures result in a mobile hard palate. A Le Fort II fracture (pyramidal fracture) passes through the nasal bridge medially (at or around the nasofrontal suture), extending laterally through the frontal process of the maxilla, lacrimal bones, orbital floor, inferior orbital rim, anterior wall of the maxillary sinus, passing below the zygoma, and transecting the pterygomaxillary junction to interrupt the pterygoid plates.  Le fort II fractures result in a pyramid-shaped mobile bone fragment that includes the nasal complex and entire maxilla, including the hard palate.  A Le Fort III fracture (craniofacial dysjunction) passes through the nasal bridge medially (at or around the nasofrontal suture), extending laterally through the medial orbital rim, medial orbital wall, nasolacrimal groove, eithmoid bones, floor of the orbit, inferior orbital fissure, lateral orbital wall, zygomaticofrontal suture and zygomatic arch.  Internally, the fracture extends though the perpendicular plate of the ethmoid, vomer, and pterygoid plate interface, to the base of the sphenoid posteriorly.  A Le Fort III fracture separates the entire midface from the cranium.  The resultant mobile bone fragment includes the nasal complex, inferior half of the orbit, zygoma, and entire maxilla, including the hard palate.  It is important to realize that pure Le Fort fractures are uncommon in clinical practice, and most midfacial fractures are an amalgam of various types of Le Fort fractures.  Pure Le Fort fractures occur in less than 50% of midfacial fractures.

Figure 1 (Le Fort_fig1.tif): Le Fort I fracture (Guerin fracture, or horizontal fracture). The shaded area represents the resultant mobile bone fragment.
Figure 2 (Le Fort_fig2.tif): Le Fort II fracture (pyramidal fracture). The shaded area represents the resultant mobile bone fragment.
Figure 3 (Le Fort_fig3.tif): Le Fort III fracture (craniofacial dysjunction). The shaded area represents the resultant mobile bone fragment.


Etiology
Le Fort fractures are generally the result of blunt-force trauma to the midface.  Common causes include motor vehicle accidents, interpersonal altercations, assaults, falls, and sports-related injuries.


Clinical PresentationMaxillary fractures often occur as the result of significant trauma and evaluation should begin with airway control and hemodynamic stabilization.  Serious intracranial injury may be seen in up to 38% of patients with midfacial fractures; serious ophthalmologic injury may be seen in up to 28% of patients.  Spinal cord injury should be ruled out, and any overt globe injury should be evaluated. A thorough history and physical, including a complete head and neck exam, may then be performed.

The midface is attached to the cranium by three vertical buttresses that help distribute masticatory forces and stabilize the midface: the medial buttress (frontomaxillary buttress) and lateral buttress (zygomatico-maxillary buttress) anteriorly, and the pterygomaxillary buttress posteriorly.  Le Fort fractures disrupt these buttresses, resulting in altered vertical height of the midface, malocclusion with open bite, and mobile bone fragments that may cause airway compromise.  Mobile bone fragments that result from Le Fort fractures tend to be driven posteroinferiorly along the slope of the skull base, producing a flattened facial appearance.  Palatal fractures may occur along with Le Fort fractures and intraoral ecchymosis, lacerations or palpable step-offs may be appreciated.   As Le Fort II and III fractures necessarily disrupt the nasal bridge, naso-orbital-ethmoid complex and orbital rims, these types of fractures result in more obvious external findings such as nasal deformity, subconjunctival and periorbital ecchymosis and edema, infraorbital anesthesia from injury to the infraorbital nerve, possible gaze restriction or diplopia from soft tissue entrapment, or CSF rhinorrhea from disruption of the cribiform plate.  Le Fort III fractures may result in bleeding from basilar skull fractures near the stylomastoid foramen.  This bleeding may track superficially, resulting in ecchymosis overlying the mastoid process and occiput (Battle’s sign).  Significant facial edema is common with Le Fort fractures, and it is important to keep in mind that presence of a Le Fort fracture does not rule out presence of additional maxillofacial injuries.
Figure 4 (Le Fort_fig4.tif): Anteroposterior view of the vertical buttresses of the facial skeleton
Figure 5 (Le Fort_fig5.tif): Lateral view of the vertical buttresses of the facial skeleton

Diagnostics

Le Fort II and III fractures involve orbital wall fractures, and the eye must be completely evaluated. Intracranial injury must also be ruled out, and suspicion for CSF rhinorrhea should be high.  Maxillofacial CT scan is considered the modality of choice for diagnosis of Le Fort fractures.

Treatment
Treatment of ocular and CNS injuries should precede treatment of Le Fort fracture in the presence of a stable airway.  Proper repair of complex midfacial fractures may require a surgical airway.  Treatment greatly depends on the extent of the injuries and often requires a multi-specialty approach. 

Reconstruction of the zygomatico-maxillary buttress (lateral buttress) and fronto-zygomatic buttress (medial buttress) is an important part of restoring normal occlusion and vertical height of the midface and stabilizing the midfacial skeleton against masticatory forces. Palatal fractures may accompany Le Fort fractures, and it is important to recognize when palatal fractures are present, as palatal splints will be required during repair.


References

1. Cummings, C (2005) Otolaryngology, Head & Neck Surgery, 4th edn. Mosby, Pennsylvania, pp 602-636.
2. Papel, ID (2002) Facial Plastic and Reconstructive Surgery, 2nd edn.  Thieme, New York, pp759-767.
3. Stewart, M (2005) Head, Face and Neck Trauma, Comprehensive Management.  Thieme, New York, pp39-5177-85.