LE FORT FRACTURES

AND ITS
MANAGEMENT
DR KASSIM A.J
DEPARTMENT OF NEUROSURGERY
UBTH.

03-06-2022
OUTLINE
• 1. INTRODUCTION
• 2. KEY WORDS
• 3. THE CRANIOFACIAL ANATOMY
• 4. MID FACE FRACTURES
• 5. LE FORT FRACTURES
• 6. MANAGEMENT OF LE FORT FRACTURES
• 7. COMPLICATIONS
• 8. CONCLUSION
• 9. REFERENCES
INTRODUCTION
• Le fort fractures are classic transfacial fractures of the middle face
involving the maxillary bone and surrounding structures in either a
horizontal, pyramidal or transverse direction.(Bradley et al 2017)
• They are
• 1.Le fort 1-Guerin fracture
• 2.Lefort 2-Pyramidal or Subzygomatic fracture
• 3.Le fort 3-High transverse or Suprazygomatic fracture
INTRODUCTION
• Understanding le fort fractures and its management will require
• 1. Embryology of the craniofacial complex
• 2. The Anatomy of the facial bone
• 3. General principles of Fracture management
KEY WORDS
• 1. FRACTURE
• This is a complete or incomplete break in the continuity of a bone.
• 2. CRANIOMAXILLOFACIAL TRAUMA:
• These are any injury involving the cranium, facial bones and soft tissues. Including
the orbit and the anterior cranial fossa
• 3. OSTEOSYNTHESIS
• This is a surgical procedure that joins and stabilizes the ends of fractured bones
by mechanical devices such as plates, pins, rods, wires and screw.
• 4. ASSESSMENT / EVALUATION:
• Evaluation / appraisal of a patient using selected skills (history-taking,
physical examination, laboratory work-up & interpretation of results,
imaging, and social evaluation) aimed to achieve specific goal(s)
ANATOMY OF THE CRANOFACIAL
SKELECTON
The Anatomic complexity of the facial skeleton that challenges the
practice of craniofacial surgery is derived from its embryologic origins.
The external human face develops between the 4th and 6th week of
embryonic development. The face is derived from structures that lie
around the stomatodaeum during the 4th week of embyogenesis.
(Langman’s Medical Embryology, 11th Edition.)
• These structures include:
• 1. Frontonasal process
• 2. 1st Pharyngeal
• (I) Two Maxillary mandibular Processes of each side
• (II) Two Mandibular processes of each sides
CRANIOFACIAL FEATURES OF THE 4TH WEEK
INTRAUTERINE LIFE
ANATOMY OF THE CRANOFACIAL SKELECTON

• These embryonic structures forms the anterior cranium and the

facial bones
The cranium – encases the brain and is formed by 8 bones
2 paired bones; Parietal & temporal bones

4 unpaired bones; Frontal, sphenoid, ethmoidal &

occipital bones
The cranial base -The brain rests on cranial base, with various
vessels and nerves going through various foramina (neurocranium).
The facial skeleton comprises of 14 bones.

• 6 paired bones; Nasal, lacrimal, maxilla, zygoma, inferior nasal concha

and palatal bones

• 2 unpaired bones; mandible and vomer

THE FACIAL SKELECTON
• The face is demarcated into three thirds by two imaginary horizontal lines(the upper,
middle & lower thirds).
• 1.Upper Third- Frontal bone
•
• 2.Middle Third- Between frontal bone and mandible
• comprising of central midfacial bone(the maxilla, the nasoethmoid) and
• lateral midfacial bone (zygoma)

• 3.Lower Third- Mandible

• the lower third comprising the mandible, with the condyles articulating with the base
of the skull
THE MIDDLE FACE
• The middle face is the area bounded
• 1.Superiorly:
• by a line drawn from the zygomaticofrontal suture across the frontonasal
and frontomaxillary suture to the zygomaticofrontal suture of the opposite
side
• 2.Inferiorly:
• by the occlusal plan in a dentate case or the alveolar ridge in an edentulous
case
• 3. Posteriorly
• As far as the fontal bone above and the spenoid bone below
Anatomic peculiarities of the middle face
• The middle facial skeleton is the most delicate part of the face, with
relatively thin & fragile bones that articulates in a very complex
fashion.

• Bones of the middle facial skeleton rarely fracture in isolation and are
mostly involved in comminuted fractures

• The maxilla form a great proportion of the middle facial skeleton and
it absorbs external forces which it transmits to the adjacent
articulating bones
MIDDLE FACE FRACTURES
• Middle third fractures can be classified
• 1.Based on the level of fracture line:
• Low level fracture
• Mid level fracture
• High level fracture
2.Based on the direction of the fracture line(by Erich 1942)
Horizontal
Pyramidal
Transverse
However the Universally accepted classification of the midface is the Le fort
classification
 LE FORT
FRACTURES
LE FORTE FRACTURES
• Originally described by Rene Le Fort in 1901, Le Fort fractures are
specific facial bone fracture patterns that occur in the setting of blunt
facial trauma most commonly involving motor vehicle collision,
assault, or falls. (Noffze et al 2011)
• All Le Fort fracture types involve the pterygoid processes of the
sphenoid bones and therefore, disrupt the intrinsic buttress system
to the midface.(Kunz et al 2014) Though mortality rates are low,
these fractures seldom occur in isolation and are often associated
with serious injuries of the head and neck.
CLASSIFICATION OF MIDFACE
FRACTURES BY RENE LE FORT 1901
• A. LE FORT 1: Guerin fracture
• B. LE FORT 2: Pyramidal or subzygomatic fracture
• c. LE FORT 3: High transverse or suprazygomatic or craniofacial
dysjunction

• LIMITATIONS OF THIS CLASSIFICATION

• 1. Inability to accurately predict reduction techniques
• 2. Cannot account for asymmetric fracture pattern
Le fort I fracture:
• The le fort 1 fracture line commence at the point on the lateral
margin of the anterior nasal aperture. it passess above the nasal floor
and it passess laterally above the canine fossa and transverse the
lateral antral wall. it then dips below the zygomatic buttress and
incline upward and posteriorly across the pterygomaxillary fissure to
fracture the pterygoid laminae at the junction of the lower 1/3 and
upper 2/3.
• At the same time, from the same starting point, the fracture also
passess along the the lateral wall of the nose to join the lateral line of
fracture behind the tuberosity.
• Characteristic of le fort 1 fracture
• 1.Usually caused by a violent force applied over a more extensive
area, above the level of the teeth.
• 2. It can be unilateral or bilateral depending on the direction and
severity of the force
• 3. It may occur as a single entity or in association with Lefort II and III
SIGN AND SYMPTOMS OF LE FORT I
FRACTURE
• These can be
• 1.Extra oral signs
• 2.Intraoral signs.
• NB: All the signs and symptoms listed below may not always be
present in a classic le fort I fracture but most of these can be seen
depending on the level of injury and the direction of the force
• EXTRA ORAL SIGNS
• 1.Swelling and oedema of the lower midface and upper lip
• 2. Bilateral epistalsis
• 3.Pain around the alar nasa and collumelar
• 4. Immobility of the jaw
• 5. Air emphysema
• INTRAORAL SIGNS AND SYMPTOMS
• 1.Floating maxilla
• 2.Guerin sign
• 3.Traumatic Anterior Open Bite
• 4.Gross inflamation of the upper lip
• 5.Echymosis of the buccal vestibule
• 6.”Cracked cup” sound on percussion of the upper anterior teeth
• 7.Mid palatal split
• 8. Malocclusion
• 9.Laceration or Devolving injury of the buccal vestibule
• 10. Mobility of the dentoalveolar segment of the maxilla
• 11. inflammation of the upper lip, collumela and alar nasal
Lefort II fracture
• The fracture line runs below the frontonasal suture from the thin
middle area of the nasal bone down on either side. it crosses the
frontal process of the maxillary bone and passess anteriorly to the
lacrimal bone anterior to the lacrimal canal. From this point, it
passess downward foward and laterally crossing the inferior orbital
margin in the region of the zygomaticomaxillary sutures. it may or
may not involve the infraorbital foramen. The fracture line then
extend downward and forward and laterally to transverse the lateral
wall of the antrum just medial to the zygomaticomaxillary suture line.
It transverses beneath the zygomatic butress. it then transverses the
pterygomaxillary fissure bidway from the base.
SIGN AND SYMPTOMS OF LEFORT II
FRACTURE
These are extraoral and intraoral.
EXTRA ORAL SIGNS
1. Gross oedema of the face
2. Bilateral circumorbital edema and echymosis
3. Subconjuctival haemorrhage confined to the medial half of the eye.
4. Liquorrhea and rhinorrhea
5. Mobility of the mid facial segment
6. Diplopia
• 7. Anaesthesia or parasthesia of the cheek
• 8. Step deformity in the bone of the infraorbital margin(most important in
differentiating Le fort II from Le fort III
• 9. Meningitis
10. No tenderness or disorganization and mobility of the zygomatic bone and
arch
11. Nasal disfigurement
12. Enophthalmos if there is concommitant fracture of the floor of the orbit
13. Surgical emphysema
14. Malocclusion
• INTRAORAL FEATURES
• 1.Deranged occlusion
• 2.Posterior gagging of occlusion with retro positioning of the maxilla
• 3.Airway obstruction
Le fort III fractures
• It is usually caused by a force applied from the lateral direction.
• The line of fracture commences near the frontonasal suture, causes
dislocation of the nasal bone and fracture of the cribiform plate of
ethmoid. with tearing of the dura mater and consequent CSF
rhinorrhoea. it crosses both the nasal bone and the frontal process of
the maxilla, near the frontonasal and maxillary sutures and then
transverses the upper limit of the lacrimal bone.it continued
postireiorly and crosses the thin orbital plate of ethmoid bone which
forms part of the medial wall of the orbit
• Because the optic foramen is surrounded by a dense ring of bone, the
fracture line gets deflected downward and laterally to reach the medial
aspect of the posterior limit of the inferior orbital fissure.
• The inferior orbital fissure constitute a natural line of weakness and
from its anterior and lateral end, the fracture passes across the lateral
wall of the orbit, adjacent to the junction of the zygomatic bone with
the greater wing of spenoid. It seperate the zygomatic bone from the
frontal bone near the frontozygomatic suture and then inclined laterally
and downward across the infratemporal surface, thus in effect joining
the previous line of fractrure seen on the medial wall of the orbit.
SIGN AND SYMPTOMS OF LE FORT III
FRACTURE
• A.Extra oral features
• B.Intra oral features
• EXTRAORAL FEATURES
• 1.Tenderness and separation at the Frontozygomatic suture
• 2.Lengthening of the face
• 3.Unilateral or bilateral zygomatic complex fracture
• 4. A characteristic DISH Face deformity
• 5. Movement of the entire facial skeleton as a single block
• 6. Enopthalmos, diplopia or impairment of vision
• 7. Hooding of the eye
• 8. Cerebrospinal fluid rhinorrhea, liquorrhea and otorrhoea
• 9. Bilateral periorbital ecchymosis (a sign of basal skull fracture or
subgaleal hematoma)
• 10.BATTLE sign
• 11.Haematotympanum
• 12. Orbital dystopia with associated antimogoloid slant
• 13.Flattening,Widening and deviation of nasal bridge
• 14. Traumatic neuropathy
• INTRAORAL FEATURES
• 1.Deranged occlusion
• 2.Posterior gagging with retrocclusion
• 3.Anterior open bite
• 4.Airway obstruction
• 5.Mid palatal split
MODIFIED LE FORT FRACTURE by
marciani 1993
• Le Fort I (low-maxillary fracture):
• This is a horizontal fracture in the body of maxilla that results in
detachment of a tooth bearing segment from the rest of maxillary
body.
• Le Fort I a: Low maxillary fracture multiple segments.
• Le Fort II (pyramidal fracture):
• In this fracture the maxilla will be separated from the base of the skull
by fractures of the nasal bone and the frontal processes of the
maxillae.
• Le Fort II a: Pyramidal and nasal fracture.
• Le Fort II b: Pyramidal and naso-orbioethmoidal (NOE) fracture
• Le Fort III (Cranio facial disjunction):
• It separates the middle third of the face from the cranium.
• Le Fort III a: craniofacial disjunction and nasal fracture.
• Le Fort III b: craniofacial disjunction and NOE.
• Le Fort IV:
• Le Fort II or III and cranial base fracture.
• Le Fort IV a: Supraorbital rim fracture.
• Le Fort IV b: Anterior fossa and supraorbital rim fracture.
• Le Fort IV c: Anterior cranial fossa and orbital wall fracture.
Mechanism of Lefort Fractures
• Understanding the biomechanics of craniomaxillofacial trauma gives
an insight in understanding the pattern of injury.
• The precise nature of Le fort injury to the Craniomaxillofacial region is
determined by:
• 1. the amount of force exerted
• 2. the resistance to the force offered by the craniofacial bones.
• 3. the direction and the point of application of the force.
• 4. In addition, the pattern of injury will be determined by the cross-
sectional area of the agent or object that struck
 Biomechanical forces (Nm) necessary to cause fractures of
the facial skeleton at different locations.
(Nahum et al 1975)
800- 1600

200-400

200-650
150- 300

300-750
550- 900

1N = 0.10197 kg
• Regardless of these figures, underlying conditions such as
osteoporosis, bone neoplasm, hyperparathyroidism and prolonged
steroid therapy may weaken the facial bones and predispose to
fracture below the documented force level
 Epidermiological facts about Lefort
fracture
• 1. Though these fractures are defined by the collection of bones
involved, only 24% of Le Fort fractures followed the classically described
fracture patterns (Patil et al. 2014)
• 2. Patients mainly affected were in the third decade of life.
• 3. The male–female ratio was 4.4:1. Men accounted for 81.5% of the
total number of patients (Zaleckas et al 2015).
• 4. Le Fort fractures, have a mortality rate of 11.6% (Bellamy et al 2013)
• 5. Isolated Le Fort I, II, and III fractures are very rare (Corneliue et al
2013)
• 6. 5.4% of le fort fractures are associated with spinal cord injuries (Chen
et al 2006)
 MANAGEMENT OF LE FORT
FRACTURE
MANAGEMENT OF LE FORT FRACTURE
• Management is usually Multidisciplinarity.
• The Team includes a Traumatologist, Neurosurgeon, Maxillofacial
surgeon, Radiologist, Ophthalmologist and Nurses
• Some basic management principles for patients with traumatic brain
injury (TBI) and Vision threatening injuries apply equally to those who
happen to sustain a craniofacial injury of which le fort fractures are a
common type.
• Successful treatment of patients with Le fort injuries is heavily
dependent on.
• 1. The surgeon's appreciation of the associated nonfacial injuries e.g.
The Brain, spine and ocular injuries
• 2. Precise clinical and diagnostic imaging examination to establish a
three-dimensional configuration of the fractured segments
• 3. The application of well-established principles of facial fracture
repair.
PRINCIPLE OF MANAGEMENT OF
MIDFACIAL FRACTURE.
• 1.Evaluation / Assessment
• 2. Accurate diagnosis
• 3. Hospitalization And Early care
• 4. Determination of priority of treatment
• 4. Early reconstruction
• 5. Post operative mangement
• 6. Follow up
Evaluation / Assessment
Evaluation / Assessment
• Entails a primary trauma survey and secondary assessment for
concomitant injuries and specific factors that guide management.
• Obtain the chief complaint
• Investigate the chief complaint.
• Obtain a brief history alongside assessment.
• Institute monitoring of vital signs
Accurate Diagnosis
• This can be gotten from thorough history, examination,and
radiographic evaluation.
• Radiographs include
• 1. Trauma series
• 2. Craniofacial CT Scan
• 3. For patient who cannot afford CT Scan, Occipitomental (Walters
view) will be valuable for initial diagnosis of midface fractures
Radiographic Evaluation
• Craniofacial CT with axial, coronal, and sagittal cuts is Gold standard.
There are four key areas to evaluate.
• 1. Pterygoid plates, strong indication of LeFort fracture.

• 2. Lateral margin of nasal fossa, suggestive of LeFort I fracture.

• 3. Inferior orbital rim, suggestive of LeFort II.

• 4. Zygomatic arch, suggestive of LeFort III.

INJURY SCORING
• For lefort fractures, two important injury scoring systems are valuable
for appropriate diagnosis and management. they are.
• 1. Glasgow coma scale (GCS)
• Mild TBI (13-15), Moderate TBI (9-12) Severe TBI (3-8)
• 2. Facial Injury severity score (FISS)
• Mild (FISS score 1-3) , Moderate (FISS score 4-7) Severe (FISS score 8-
15)
Purpose of injury scoring systems
• 1. Appropriate triage and classification of trauma patients
• 2. Predict outcomes for patient and family counseling
• 3. Quality assurance
• 4. Research
• 5. Extremely useful for the study of outcomes
• 6. Reimbursement purposes etc
EARLY CARE
• After Emergency care has stabilized the patient the early care of the
patient depends on the risk level, the age of the patient and level of
consciousness
• Early care includes
• 1-pain control
• 2-Antitetanus prophylaxis
• 3-Initial stabilization of the fracture
• 4-Debridement and dressing of wounds
• 5-Elective tracheostomy for airway compromise
•
• 6-History
• 7-Complete head and neck examination
• 8-Radiographic investigation
• 9-Diagnosis
• Diagnosis is base on history examination
• and radiographic evaluation.
FRACTURES MANAGEMENT
The basic principles for fracture
management
• 1. Incision and access
• 2. Debridement
• 3. Reduction
• 4. Fixation
• 5. Immobilization
• 6. Functional Rehabilitation
• 7. Review and Follow up
INCISION AND ACCESS
• Most Le Fort I fractures are accessed surgically through a gingivo-buccal
sulcus approach
• Le Fort II and III fractures often required additional subciliary or
transconjunctival or bicoronal approaches.
• A coronal approach offers wide exposure of the zygomatic arch in Le Fort II
and III fractures, but can result in complications secondary to the dissection
of neurovascular structures.
• Minimally invasive surgical approaches provide an alternate method for
surgical management of Le Fort fracture types II and III as they can be
accessed via lateral eyebrow, intraoral vestibular, and subciliary
approaches.
DEBRIDEMENT
• 1.Soft tissue cleaning:
done with normal saline,antiseptic solution(Hibitane in water)
• 2.Exploration for devitalized tissues
e.g broken teeth,detached bone fragments
• 3.Exploration for impacted foreign body
e.g prosthetics,clothing materials,sand
• 4.Soft tissue closure within 24 hours to prevent infection to aid better
wound healing and protection of underlying tissue
• 5.Antiseptic dressing with appropriate material
• 6.Appropriate medication
REDUCTION
• This is restoring the fractured fragments to their normal anatomical
position. As a general principle, all fractures should be exposed and
reduced before plating.
• It can be:
• 1.Open reduction
• 2.Close reduction
• 3.Elastic traction
• Open reduction allows visual identification of the fracture fragments why
close reduction allows alignment without visualization of the fracture .
• Reduction instruments - Rowe disimpaction forceps is the choice
instrument
• The Rowe disimpaction forces are side specific. They allow precise 3-D
movement of fracture fragments of the centrally impacted midface or
maxilla.
• Note: Special attention has to be given to the patient’s individual
fracture pattern so that the use of these instruments does not result in
significant shearing at the skull base or orbit. Otherwise, severe
complications such as blindness can occur.
• Other instrument: Stromeyer hook, poswillos hook, carrol girard screw
The AO-CMF has provided detailed guidelines
regarding the management of facial fractures
• 1. In general, closed procedures, if internal fixation is not required for stability
of the reduction, are favored.
• 2. Consider preoperative chlorhexidine gluconate or povidone-iodine swish
and spit.
• 3. Scalpel over monopolar cautery for mucosal incisions
• 4. Bipolar cautery for hemostasis on lowest power setting
• 5.Self-drilling screws for monocortical screw fixation
• 6. If drilling is required, use absolute minimal irrigation
• 7. If drilling is required, consider a battery-powered low-speed drill
• 8. If osteotomy is required, consider osteotome instead of power saw
• 9. Avoid repeated suctioning/irrigation
• 10. Avoid long-term MMF if possible as protection for providers is
limited in the clinic for in-office adjustments and removal
FIXATION OF LEFORT FRACTURES
• Internal fixation with plating system is the Gold standard for fixation
of le fort fractures. Depending on the fracture pattern an L-, T-, Y-plate
or a straight plate may be used. these plates can be metal (Titanium
plates) or resorbable plates (polylactic acid)
• but other systems can be used. e.g
• Transosseous wiring
• Bone lamps
• Antral packs
• For Le fort I
• plate stabilization at piriform rims and zygomaticomaxillary
buttresses.
• For Le fort II
• Reduce fractures and plate stabilization at the
• piriform rim, zygomaticomaxillary buttresses, orbital rim, and
management of NOE component if necessary.

• The orbital floor should be treated last after ensuring that the zygoma
and the maxilla are in the proper position to prevent increased orbital
volume.
• For Le fort III
• Fixate using plates starting at the
• frontozygomatic suture
• nasal region
• zygomaticomaxillary buttresses
• piriform rims, and zygomatic arch as needed
IMMOBILIZATION
This is the period of stable fixation required to ensure full restoration of function and
occlusal alignent.. Immobilization is usually accomplished with Intermaxillary fixation
using Arch bars and Islet wires.
Other methods of immobilization include
• Bonded bracket
• Gunning splint
• cap splint
Arch bar and Islet wires
IMMOBILIZATION OF FRACTURE IN
TOOTH BEARING AREA
• A simple guide to time of immobilization for fracture of the tooth
bearing area is as follows
• 1.For young adults receiving early treatment in which tooth has been
• removed from the fracture line, Immobilize for 3weeks
• 2.If tooth is retained in the line of fracture add 1 week
• 3. For age 40 years and above,add 1 week
• 5.For children and adolescents Subtract 1 week
•
Postoperative Care
• 1. Keeping the patient’s head in a 30 degree upright position both
preoperatively and postoperatively may significantly improve periorbital
edema and pain.
• 2. Analgesic
• 3. Antibiotics
• 5. Diet: soft diet
• 4. Nasal decongesant
• 5. Opthalmic ointment
• 6. Postoperative imaging has to be performed within the first days after
surgery. 3-D imaging (CT, cone beam) is recommended
FOLLOW UP
• Clinical follow-up depends on the complexity of the surgery, and
whether the patient has any postoperative problems.
• With patients having fracture patterns including periorbital trauma,
issues to consider are the following:
• 1. Diplopia (for Lefort II & III)
• 2. Infraorbital nerve paraesthesia
• 3. Malunion
• 4. Tempromandibular joint dysfunction
Follow up schedule
• one week after discharge from hospital
• one month after discharge
• 3rd month after discharge
• 6th month after discharge.
REHABILITATION
• This is the functional restoration of patient to the premorbid state.this
can be achieved through
• 1.diet modification(high protein diets)
• 2.Jaw excercise to restore facial muscle bulk and tone
• 3. Other dental and ophthalmological needs
(Tpye I and IV non surgical periodontal therapy ,ocular and Dental
prosthetics to restore lost eye or broken tooth )
• 4.Regular follow up
REFERENCES
• Cornelius CP, Gellrich N, Hillerup S, Kusumoto K, Schubert W,Fusetti S.
AO Surgery Reference. 2013. Available
fromhttps://www2.aofoundation.org/wps/portal/surgery
• Chen WJ, Yang YJ, Fang YM, Xu FH, Zhang L, Cao GQ. Identification and
classification in le fort type fractures by using 2D and 3D computed
tomography. Chin J Traumatol. 2006;9(1):59–64.
• Fraioli RE, Branstetter BF, Deleyiannis FW. Facial fractures: Beyond le
fort. Otolaryngol Clin North Am. 2008;41(1):51–76. [PubMed] [Google
Scholar]
• Kaul RP, Sagar S, Singhal M, Kumar A, Jaipuria J, Misra M. Burden of
maxillofacial trauma at level 1 trauma center. Craniomaxillofac Trauma
Reconstr. 2014;7(2):126–30. [PMC free article] [PubMed] [Google
Scholar]
• Kunz C, Audige L, Cornelius CP, Buitrago-Tellez CH, Frodel J, Rudderman R, et
al. The comprehensive AOCMF classification system: Midface fractures -
level tutorial. Craniomaxillofac Trauma Reconstr. 2014;7(Suppl 1):S059–67.
[PMC free article] [PubMed] [Google Scholar]
• Langman’s Medical Embryology, 11th Edition.
• Noffze MJ, Tubbs RS. Rene le fort 1869-1951. Clin Anat. 2011;24(3):278–81.
• Patel R, Reid RR, Poon CS. Multidetector computed tomography of
maxillofacial fractures: The key to high-impact radiological reporting. Semin
Ultrasound CT MR. 2012;33(5):410–17. [PubMed] [Google Scholar]
THANK YOU