LE FORT

FRACTURES
Dr. Amit T. Suryawanshi
Oral and Maxillofacial Surgeon
Pune, India
Contact details :
Email ID - amitsuryawanshi999@gmail.com
Mobile No - 9405622455
 CONTENTS
• Introduction
• History
• Surgical Anatomy of Maxilla
• Etiology of Lefort fractures
• Epidemiology
• Classification & LeFort fracture lines
• Clinical examination
• Clinical features
• Diagnostic radiography
• Management

- Emergency care

- Early care

- Definitive care

• Complications

• Controversies

• Conclusion.
 INTRODUCTION:

The maxilla represents the bridge between the cranial base

superiorly and the dentition inferiorly. Its intimate association
with the oral cavity, nasal cavity, and orbits and the important
structures adjacent to it make the maxilla a functionally and
cosmetically important structure.
Fracture of these bones is potentially life-threatening as
well as disfiguring. Hence we being maxillofacial
surgeons need to do systematic and timely repair of
these fractures to correct deformity and prevent
unfavorable sequalae.
 HISTORY

• The first clinical examination of a maxillary fracture was

recorded in 2500 BC.

• In 1822 Charles Fredrick William Reiche provided the

first detailed description of maxillary fractures.

• In 1823 Carl Ferdinand van Graefe described the use of a

head frame for treating a maxillary fracture.

 HISTORY

• In 1901 , Rene Le Fort published his landmark work, a

three-part experiment using 32 cadavers.

• The heads of the cadavers were subjected to low velocity

forces; the soft tissue were then removed and the bones

were examined.
 HISTORY

• Le Fort noted that generally face was fractured and the

skull was not. He then stated that fractures occurred
through three weak lines in the facial bony structure. From
these three lines the Le Fort classification system was
developed.
 External Fixation
Craniomaxillary fixation- Wassmund’s(1927) maxillary splint
with side bars attached to a head cap
 SURGICAL ANATOMY OF MIDFACE

• Lacrimal fossa is partially formed by maxilla .Hence

fracture can cause injury to nasolacrimal duct.
• Damage to infraorbital nerve can occur unilaterally or
bilaterally in fracture of maxilla.
• Fracture involving orbital walls may give rise the
change in the ocular level due to separation above the
attachment of suspensory ligament of lockwood.
(LeFort III)
• If orbital floor is fractured, there will be herniation of
orbital content into maxillary sinus.
 ETIOLOGY -

• Road traffic accidents (most common) -40%

• Industrial accidents- 10 %

• Assault -15%

• Sports.- 25 %

• Fall.- 10 %
• Most maxillary fractures occur in young men aged
between 16 to 40 years.

• Peak age- 21 - 25 years

• Male : Female - 4:1

 Lefort fracture classification

Rene LeFort (1901) discovered the complex

fracture patterns of Maxilla which is broadly
classified as

1. Lefort I
2. Lefort II
3. Lefort III
 IMPORTANT POINTS TO REMEMBER

(i) These fractures may occur unilaterally or may be

associated independently with a fracture of the zygomatic
complex.

(ii) There may be a midline separation of the maxillae or

extension of the fracture pattern into the frontal or
temporal bones.
 LIMITATIONS OF THE lefort CLASSIFICATION

• The LeFort classification has proven to be less satisfactory

to describe more complex fracture patterns, comminuted,
incomplete, combination maxillary fractures or to describe
fractures of the part bearing the occlusal segment.
• Need for newer system:

• Midface fracture patterns now are far more complex than those
produced in Le Fort's laboratory.

• Fractures involving the cranial base and other midface fracture

configurations, including severely comminuted segments of the
facial skeleton, are not accurately classifiable using the traditional
Le Fort scheme.

• A more precise system of describing fracture patterns is necessary

to establish an accurate diagnosis & determine potential surgical
approaches.
• MODIFIED LEFORT CLASSIFICATION:
Proposed by Marciani (1993)

• Le Fort I Low maxillary fracture

Ia Low maxillary fracture/multiple segments
• Le Fort II Pyramidal fracture
IIa Pyramidal and nasal fracture
IIb Pyramidal and NOE fracture
• Le Fort III Craniofacial disjunction
IIIa Craniofacial disjunction and nasal fracture
IIIb Craniofacial disjunction and NOE fracture.

(From: Marciani RD. Management of Midface Fractures: fifty years later. J Oral Maxillofac Surg 1993;51:962.)
• Le Fort IV LeFort II or III fracture and
cranial base fracture

IV a + Supraorbital rim fracture

IV b + Anterior cranial fossa and

supraorbital rim fracture

IV c + Anterior cranial fossa and

orbital wall fracture
• There is separation of complete
dentoalveolar part of maxilla
(Pterygomaxillary dysjunction) and
the fractured fragment is held only by
means of soft tissues.

• Cause -

A violent force applied over more

extensive area of maxilla above the
level of maxillary teeth results in
Lefort I fracture.
Fracture line –

The fracture line commences at

the point on the lateral margin
of the anterior nasal aperture,
passes above the nasal floor,
passes laterally above the canine
fossa and traverses the lateral
antral wall, dips down below the
zygomatic buttress and then
inclines upward and posteriorly
across the pterygomaxillary
fissure to fracture the pterygoid
laminae at the junction of their
lower third and upper 2/3 rd.
 LE FORT II

Cause –
Violent force, usually from an
anterior direction, sustained
by the central region of the
middle third of the facial
skeleton over an area
extending from glabella to
the alveolar margins results
in fracture of pyramidal
shape .
 Fracture line -
The fracture line runs below
frontonasal suture from the
thin middle area of nasal
bones down on either side
crossing the frontal process
of maxilla and passes
anteriorly across the lacrimal
bone, immediately anterior to
nasolacrimal canal. Then
fracture line passes
downward, forward and
laterally crossing the inferior
orbital margin in the region
of zygomaticomaxillary
suture
• . It may or may not involve
infraorbital foramen. Then
fracture line now extends
downward, forward and
laterally to traverse the
lateral wall of antrum, just
medial
zygomaticomaxillary
suture line.
As in Lefort I , this fracture line
passes beneath the Zygomatic
buttress, inclines abruptly traversing
the pterygomaxillary fissure at a
higher level and fracturing
the pterygoid laminae approximately
midway from its base. Seperation of
entire pyramidal block from the base
of the skull is completed via nasal
Septum.
 Le Fort III
Cause -
Due to force from the lateral direction with a severe impact.
Here , the initial impact is taken by Zygomatic bone
resulting in depressed fracture. Then entire middle third will
then hinge about the fragile ethmoid bone and the impact
will then be transmitted to the contralateral side resulting in
laterally displaced zygomatic fracture of opposite side.
(Craniofacial dysjunction)
 FRACTURE LINE -
• Line commences near the
frontonasal suture, causes
dislocation of the nasal
bones and disruption of
cribriform plate of the
ethmoid bone.Then line
crosses both the nasal bones
and frontal process of
maxilla, near the frontonasal
and frontomaxillary sutures
and then traverses the upper
limit of the lacrimal bones .
• continuing posteriorly, the
line crosses the thin orbital
plate of the ethmoid bone
constituting part of the
medial wall of the orbit. As
optic foramen is surrounded
by a dense ring of bone,
Then fracture line gets
deflected downward and
laterally to reach the medial
aspect of the posterior limit
of the inferior orbital fissure.
• From this point , fracture
descends across the upper
posterior aspect of maxillae in
the region of sphenopalatine
fossa and upper limit of
pterygomaxillary fissures and
fractures the roots of pterygoid
laminae at its base.
From anterior and lateral aspect of
inferior orbital fissure, line passes
across the lateral wall of orbit ,
adjacent to the junction of zygomatic
bone with greater wing of sphenoid
.The fracture line seperates
zygomatic bone from frontal bone
near suture and then inclines laterally
, running abruptly downwards across
the infratemporal surface, thus in
effect joins the previous line of
fracture seen on medial wall of orbit .
The entire middle third is thus
detached from the dense cranial
base.
 CLINICAL ASSESSMENT OF MIDFACE FRACTURES

• Extra-oral & Intra-oral examination.

 Inspection.

 Palpation.
 EXTRA-ORAL EXAMINATION

Inspection of midface-

• Swelling & Facial Asymmetry.

• Bruising of upper lip and lower half of mid-face.

• Bilateral Circum-orbital Ecchymosis ( Racoon’s eye).

• Periorbital Oedema.

• Subconjunctival Hemorrhage.
• Cerebrospinal fluid rhinorrhoea

• Lengthening of Midface

• Depressed midface (dish face)

• Saddle shaped depression of nose

• Enophthalmos

• Proptosis

• Diplopia
• Subconjunctival hemorrhage-

• Localized (black eye) confined to preseptal soft tissues

(Also seen in anterior cranial fossa, orbital & zmc

fractures.)
• Cerebrospinal Fluid Rhinorrhoea

-Watery nasal or postnasal salty discharge

(Ring Test- but it lacks sensitivity & specificity)

 EXTRA-ORAL EXAMINATION
• Enophthalmus (Le Fort III)

Increase in orbital volume by displacement of Lateral orbital wall

Suspensory ligament of Lockwood displaced

Eyelid follows the globe in downward direction

Hooding of eyes
EXTRA-ORAL EXAMINATION
Retro bulbar haemorrhage

Tension builds up
within the muscle cone

Proptosis
(Anterior displacement of eyeball)
Palpation -

1. Subcutaneous Emphysema – Crepitus

2. Tenderness

3. Step Deformity

4. Abnormal Mobility of bone

5. Impairment of sensation
 INTRA-ORAL EXAMINATION

INSPECTION -

1. Disturbed occlusion (posterior occlusal gagging , open bite)

2. Haematoma intraorally over root of zygoma

3. Haematoma in palate (Guiren’s sign)

4. Fractured cusps of teeth

5. Midline diastema
 Palpation -

• Mobility of whole of tooth bearing segment of upper jaw elicited at

fronto-nasal suture in Le Fort II & III fracture.

• Mobility of whole of the upper jaw (free-floating) elicited at
infraorbital margin in Le Fort II fracture.
• Mobility of whole of the upper jaw (free-floating) elicited at
fronto-zygomatic suture in Le Fort III fracture.
• Palpable crepitation in upper buccal sulcus in Le Fort I & II
fracture.
Clinical features -

• Slight swelling of the upper lip is seen.

• Ecchymosis present in the buccal sulcus beneath each zygomatic

arch.

• Disturbance in occlusion with variable amount of mobility in the

tooth bearing segment of the maxilla.
• The patient may develop open bite if the fractured segment is

mobile , due to posterior gagging of occlusion.

• Sometimes fracture of the palate can also be associated with

Le Fort I fracture.
• In Le Fort I, the teeth and maxilla are mobile, but the nose and
upper face is fixed.

• Percussion of the maxillary teeth results in distinctive 'cracked-pot

sound',

• No tenderness and mobility of the zygomatic arch and bones.

 Clinical features -

• The resulting gross edema of the middle third gives an appearance of

"moon face" to the patient.

• On intraoral examination, retropositioning of the whole maxilla and

gagging of the occlusion are seen.

• When maxillary teeth are grasped, the mid-facial skeleton moves as a

pyramid and the movement can be detected at the infraorbital margin and
the nasal bridge.
• Hematoma formation is seen in the buccal sulcus opposite to the
maxillary first and second molar teeth as a result of fracture of the
zygomatic buttress.

• Step deformity at the infraorbital rims or frontonasal junction is

noticed.

• Orbital wall fractures can cause entrapment with limitation of ocular

movement.
• CSF rhinorrhoea is possible and should be looked for.

• Bilateral circumorbital ecchymosis giving an appearance of

'raccoon eyes' is invariably seen in the fractures of both Le Fort II

and Le Fort III.

• Subconjunctival hemorrhage develops rapidly in the area adjacent to

the site of injury.(mostly in medial half )

• Diplopia may be seen in cases of orbital floor injury.

• Pupils are at level unless there is gross unilateral enophthalmos.

• Anaesthesia or paraesthesia of the cheek as a result of injury to the

infraorbital nerve due to the fracture of the inferior orbital rim.

• Obvious deformity of nose with epistaxis.

 LE FORT III FRACTURE
Clinical features -
• Gross oedema of the face.

• Bilateral circumorbital ecchymosis with subconjunctival

hemorrhage.

• Characteristic 'dish face' appearance with lengthening of the face.

• Mobility of the whole of facial skeleton as a single unit.

• When lateral displacement has taken place tilting of the

occlusal plane and gagging of one side is seen.

• Tenderness and often separation of the bones at the

frontozygomatic suture.

• 'Hooding of eyes' may be seen due to separation of the

frontozygomatic suture.

• Deformity of the zygomatic arches.

• CSF rhinorrhoea.

• Depression of ocular levels.

• Difficulty in opening the mouth, inability to move lower

jaw.
RADIOGRAPHIC PRESENTATION OF LE
FORT FRACTURES
MANAGEMENT
LE FORT FRACTURES - TREATMENT STAGES

1. Emergency care & Stabilization -

( First aid and resuscitation )

2. Initial Assessment and Early care-

3. Definitive Treatment-

4. Rehabilitation -
STAGE I - Emergency care & Stabilization

1. Maintenance of airway.
2. Control of hemorrhage.
3. Prevent or control shock.
4. C-Spine stabilization.
5. Control of life-threatening injuries.
6. Head injuries, chest injuries, compound limb
fractures, intra abdominal bleeding.
 EMERGENCY CARE

• Evaluate the airway -

• Existence & identification of obstruction.
• Manually clear fractured teeth, blood clots,
dentures.
• Endotracheal intubation if needed.

NOTE:
• Altered level of consciousness is the most
common cause of upper airway obstruction.
 TREATMENT OF BLOOD LOSS &
SHOCK

• Hemorrhage is most common cause of

shock after injury.
• Multiple injury patients have
hypovolemia.
 Monitor vital signs closely.
• Goal is to restore organ perfusion.
 TREATMENT OF BLOOD LOSS &
SHOCK

• External bleeding controlled by direct pressure

over bleeding site.
• Gain prompt access to vascular system with IV
catheters.
• Fluid replacement:
• Ringer’s Lactate
• Normal saline
• Transfusion.
 STABILIZATION OF ASSOCIATED INJURIES

• C-spine injury is primary concern with all

maxillofacial trauma victims.
• Signs/symptoms of C-Spine injury
• Neurologic deficit.

• Neck pain.
 STABILIZATION OF ASSOCIATED INJURIES

• C-spine injury suspected:

• Avoid any movement of
neck
• Establish & maintain
proper immobilization
until vertebral fractures
or spinal cord injuries
ruled out
• Lateral C-spine
radiographs
• CT of C-spine
• Neurologic exam
 STAGE II. Initial Assessment and Early care

• Emergency care has stabilized patient.

• Initial stabilization of fractures.
• Debridement & dressing of soft tissues.
• Physical exam & history.
• Laboratory tests.
• Clinical & Radiographic Assessment of Patient.
Diagnosis of maxillofacial injuries.
• Pre-operative planning.
 STAGE II. Initial Assessment
 Pre-operative planning
1. Need for Tracheostomy
2. Surgical Approaches to Midface
3. Whether ‘Open’ or ‘Closed’ methods of reduction are to
be employed.
4. Necessity for & type of Maxillary fracture Fixation.
 STAGE II. Initial Assessment
 Pre-operative planning

• Surgical Approaches to Midface

 Incisions for exposure of LeFort fractures
1. Supraorbital eyebrow incision (Lefort III)
2. Subciliary incision (LeFort II & III)
3. Median lower lid (LeFort II & III)
4. Infraorbital incision (LeFort II & III)
5. Transconjunctival (LeFort II )
6. Zygomatic arch
7. Transverse nasal (LeFort II & III)
8. Vertical nasal incision (LeFort II & III)
9. Medial orbital incision.
10. Intra-oral vestibular incision. (LeFort I)
CLASSIFICATION OF METHODS OF MAXILLARY
FRACTURE FIXATION

A ) Internal Fixation-
1. Suspension Wires
2. Direct Osteosynthesis

B) External Fixation-
1. Craniomandibular
2. Craniomaxillary
 Internal Fixation

Suspension Wires – non-rigid osteosynthesis -

i. Frontal-central or laterally placed

ii. Circumzygomatic
iii. Zygomatic
iv. Circumpalatal/palatal screw
v. Infraorbital
vi. Piriform Aperture
vii. Peralveolar
DIFFERENT TYPES OF INTERNAL FIXATION BY SUSPENSION
WIRE
 Internal Fixation

Suspension Wires- Circumzygomatic wiring by Obwegeser.

 Internal Fixation
Suspension Wires-
Circumzygomatic wiring by Obwegeser
 Internal Fixation

Suspension Wires- Orbital rim wiring

Suspension Wires-
Piriform aperture wiring
 Summary of Suspension wiring according to fracture site

Type of Suspension Wire Type of Le Fort Fracture

1. Frontal

a. Central Le Fort III & II

b. Lateral Le Fort III & II

2. Le Fort I & II
Circumzygomatic

3. Zygomatic Le Fort I

4. Infraorbital Le Fort I

5. Piriform Aperture Le Fort I

 DISADVANTAGES OF SUSPENSION WIRING

• Incomplete fixation of fractured fragments

• Insufficient visualization of fractures by closed
reduction
• Compression against the cranial base
• No 3-dimensional stability
• Patients dislike intra-oral splints as it hinders
oral hygiene maintainence.
 Internal Fixation

Direct Osteosynthesis -

1. Interosseous Wires.

2. Plates and Screws.

 Direct osteosynthesis
Intraosseous Wires-

1. Maxillary (Lefort –I )
2. Zygomaticomaxillary (Lefort –II)
3. Frontonasal (LeFort –II &III)
4. Zygomaticofrontal (Lefort III)
5. Zygomatic bone (comminuted)
Disadvantages -
 Non rigid type of osteosynthesis
 No 3 dimensional stability, it provides only
monoplane traction.
 IMF is always needed
 Interfragmentary pressure can not be controlled.
 Under functional stress, wire loses rigidity, direction
control and surface contact.
 Delayed healing because of micromovement at
fracture site.
 Direct osteosynthesis-

2. Plates & Screws for midface fractures -

 Stainless steel mini-plating system

 Titanium mini-plating system

 Vitallium, Cobalt chromium, molybdenum alloy plates

 Bioresorbable plating system.

 BONE PLATE OSTEOSYNTHESIS

Advantages –
1. Simple & less intraoperative time
2. Intraoral approach is sufficient
3. Postoperative IMF is not needed or period of
IMF is reduced.
4. Three dimensional stability and early return of
function.
• STAGE III. DEFINITIVE TREATMENT

 LEFORT I FRACTURE
 LEFORT II FRACTURE
 LEFORT III FRACTURE
• STAGE III. DEFINITIVE TREATMENT
LEFORT I FRACTURE

 SURGICAL APPROACH- MAXILLARY VESTIBULAR

REDUCTION- ROWE OR HAYTON WILLIAMS FORCEP
FIXATION- 4-point fixation with MINIPLATE.
IMMOBILISATION- MAXILLOMANDIBULAR FIXATION(MMF)
 LEFORT II FRACTURE
 SURGICAL APPROACH-
A – Subciliary incision
B – Sub tarsal incision
C - Infraorbital incision
D - Extension of Subciliary
incision
Existing Laceration

Maxillary vestibular approach

can also be taken for LeFort II
fracture
 GLABELLA
CORONAL APPROACH APPROACH
REDUCTION- ROWE OR HAYTON WILLIAMS FORCEP
 FIXATION- 3-POINT fixation
• IMMOBILISATION- MAXILLOMANDIBULAR FIXATION
• STAGE III. DEFINITIVE TREATMENT
LEFORT III FRACTURE-
 SURGICAL APPROACH-

Existing Laceration
A . LATERAL EYEBROW APPROACH GLABELLA
B. UPPER-EYELID APPROACH APPROACH
CORONAL APPROACH - PREAURICULAR APPROACH
REDUCTION- ROWE OR HAYTON WILLIAMS FORCEP
ZYGOMA HOOK
 FIXATION- 3-point fixation
• IMMOBILISATION- MAXILLOMANDIBULAR FIXATION if
required
 PRINCIPLES OF MAXILLARY
RECONSTRUCTION
• Miniplates can bridge gaps of up to approximately 0.5cms
• Gaps >0.5cms – bone grafts
• Bone grafts bridging the gap should be wedged
underneath the plate & held in place with screws fixed
from plate directly into the graft.
 IMMEDIATE BONE GRAFTING

Buttress reinforcement retained by plates or screws can

assist in restoring maxillary height & preventing
Contour deficiencies.
• Rib graft
• Iliac crest
• Calvaria
• Mandibular bone graft
• Alloplastic bone graft
 CONCLUSION:

Le fort fractures are common in the trauma patient. They

require accurate radiologic diagnosis and surgical
management to prevent severe functional debilities and
cosmetic deformity.
A thorough understanding of the anatomy, craniofacial
buttresses and treatment options will give the maxillofacial
surgeon the optimal tools for achieving a successful result.
 REFERENCES:

1. Rowe NL, Williams JL. Maxillofacial Injuries.

Edinburgh, Churchill Livingstone,1985.
2. Oral and maxillofacial trauma : Fonseca vol. 2.
3. Marciani RD. Management of Midface
Fractures: fifty years later. J Oral Maxillofac
Surg 1993;51:962
4. www2.aofoundation.org
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