Biomedical & Pharmacology Journal

Vol. 7(1), 179-182 (2014)

Management of Lefort Fractures

VIJAY EBENEZER1, R. BALAKRISHNAN2 and ANATHA PADMANABHAN3

Department of Oral and Maxillofacial Surgery, Sree Balaji Dental College and Hospital,
Bharath University, Chennai - 600 100, India.

http://dx.doi.org/10.13005/bpj/470

(Received: January 03, 2014; Accepted: February 02, 2014)

ABSTRACT

Fractures of the maxillary facial bones, also described as LeFort fractures, are potentially
disfiguring and potentially lethal injuries that require careful examination and expectant management
skills. This review article provides an overview of fracture patterns, patient assessment, and the
specific management of patients with LeFort fractures.

Key words: Lefort fractures.

INTRODUCTION Much has changed in the 50 years since Dr

Parker described the development of rapid means
In everyday practice maxillofacial surgeons of transportation as a portent of an increase in
often encounter a wide range of midfacial fractures. maxillofacial trauma. Contemporary surgeons must
At the beginning of the 20th century, Ren Le Fort concern themselves with a host of nonsurgical care
mapped typical locations for facial fractures; these issues that are an integral part of oral and maxillofacial
are now known as Le Fort I, II, and III fractures. Le surgery practice. Standards of care are high and
Fort I fractures, also called Gurin or horizontal surgeon and patient needs are more complex.
maxillary fractures, involve the maxilla, separating Dramatically improved diagnostic capabilities, use
it from the palate.Le Fort II fractures, also called of open surgical techniques, improved rigid fixation
pyramidal fractures of the maxilla, cross the nasal devices, advances in techniques of resuscitation,
bones and the orbital rim. Le Fort III fractures, and more focused surgical training have markedly
also called craniofacial disjunction and transverse improved the care of the facial trauma patient.
facial fractures, cross the front of the maxilla and (Robert D marciani)
involve the lacrimal bone, the lamina papyracea,
and the orbital floor, and often involve the ethmoid Maxillo-facial injuries have increased
bone. are the most serious. Le Fort fractures, which in incidence due mainly to road traffic accidents.
account for 1020% of facial fractures, are often Approximately 4500 cases are seen annually in
associated with other serious injuries. Le Fort made the Singapore General Hospital. A review of 50
his classifications based on work with cadaver skulls, consecutive cases of severe maxillo-facial injuries
and the classification system has been criticized seen in the Department of maxillofacial Surgery
as imprecise and simplistic since most midface showed that the majority were Lefort II type fractures
fractures involve a combination of Le Fort fractures. (64%) followed by Lefort I fractures (14%) and Lefort
Although most facial fractures do not follow the III fractures (8%). There were seven cases which
patterns described by Le Fort precisely, the system had a combination of multiple facial fractures. The
is still used to categorize injuries. significant associated injuries occurred in the limbs
(32%), the head (30%) and in the chest (8%)(Ann
180 EBENEZER et al., Biomed. & Pharmacol. J., Vol. 7(1), 179-182 (2014)

Acad Med Singapore.)The emergency management Lefort III

of maxillo-facial trauma is discussed in some detail *Mobile middle third of face
and some of the problems in the treatment of severe *Gagging on posterior teeth
or multiple facial fractures are also highlighted in this *Anterior open bite
article. *Periorbital ecchymosis/haematoma
*Nose included or separate
Reconstruction of multiple area injuries is *Eyes diplopia, subconjunctival haemorrhage
simplified by a highly organized treatment sequence *Steps zygomatic buttress, infraorbital margin
that conceptualizes the face in two groups of two *Infraorbital nerve damage
units. Each unit is divided into sections, and each *Separation at F-Z suture
section is assembled in three dimensions. Sections *CSF Rhinorrhea
are integrated into units and units into a single
reconstruction. Conceptually, in each unit, facial Diagnosis
width must first be controlled by orientation from Radiological diagnosis of Lefort fractures
cranial base landmarks. Projection is then (and often are made using plain film techniques or computer
reciprocally with width) established. Finally, facial tomography.(Sylvia Aparicio,Gillian Lieberman)
length is set both in individual units and in the upper plain film technique includes waters view, Caldwell
and lower face. view,submentovertex view and lateral view. An
orthopantomogram is usually employed in the
soft tissue is considered the four th process of diagnosis.computer tomography is
dimension of facial reconstr uction. Bone more favourable due to its precision and accuracy.
reconstruction should be completed as early as fractures existing beneat intact mucosa can escape
possible to minimize soft tissue shrinkage, stiffness diagnosis and result in occlusal abnormalities during
and scarring of soft tissues in nonanatomic positions. treatment.Manson, Paul N. M.D.; Shack, R. Bruce
Soft tissue that heals from a single insult over M.D.; Leonard, Larry G. M.D.; Su, C. T. M.D.; Hoopes,
anatomically constructed bone support provides John E. M.D)
the most natural facial appearance.( 1990 Mutaz B.
Habal, MD) Modes of management
Address emergencies related to maxillofacial
Signs and symptoms trauma prior to definitive treatment. These include
Lefort 1 airway compromise and excessive bleeding. If the
*Mobility of whole of tooth bearing segment of airway is compromised and orotracheal intubation
upper jaw cannot be established, the midface complex may
*Disturbed occlusion be impacted posteroinferiorly, causing obstruction.
*Palpable crepitation in upper buccal sulcus Disimpaction may be attempted manually or with
*Cracked pot percussion note from upper teeth large disimpaction forceps around the alveolar
*Haematoma intra-orally over root of zygoma arch and premaxilla. If the segments do not move
*Haematoma in palate readily and the airway is obstructed, an emergent
*Fractured cusps of cheek teeth tracheotomy or cricothyrotomy may be necessary.
*Bruising of upper lip and lower half of mid-face Severe bleeding may occur from soft tissue
lacerations or intranasal structures. A combination of
Lefort II pressure, packing, cauterization, and suturing may
*Mobile maxilla be useful in such situations. Stabilize the patient
*Gagging on posterior teeth and treat serious insults to the airway, neurologic
*Anterior open bite system, cervical spine, chest, and abdomen prior to
*Periorbital echymosis/haematoma definitive treatment of the maxillofacial bones.( Kris
*Nose included or separate S Moe, MD, FACS) Maxillary fractures are treated
*Eyes diplopia, subconjunctival haemorrhage by reduction and immobilization. Establishment
*Steps zygomatic buttress, infraorbital margin of preinjury occlusion and midface buttress
*Infra-orbital nerve damage alignment provides the foundation for this treatment
 EBENEZER et al., Biomed. & Pharmacol. J., Vol. 7(1), 179-182 (2014) 181

the goals of treatment of lefort fractures are to The timing and treatment indications
reestablish preinjury occlusion with normal face for orbital facial fractures are evolving. For orbital
height and projection of face. The proper occlusal floor fractures, nonresolving oculocardiac reflex,
relationship between dental arches is established the white-eyed blowout fracture, and early
with intermaxillary fixation. Recent advances in enophthalmos or hypoglobus are indications for
the treatment of maxillary fractures have been use immediate surgical repair. Surgery within 2 weeks
of extended open reduction techniques with rigid is recommended in cases of symptomatic diplopia
plate and screw fixation of the facial buttresses. with positive forced ductions and evidence of orbital
Bone grafts have been used to replace missing soft tissue entrapment on computed tomography
or comminuted bone with early treatment of these examination or large orbital floor fractures, which
injuries. This more aggressive surgical approach may cause latent enophthalmos or hypo-ophthalmos.
has dramatically improved the aesthetic results For midfacial, lateral, supraorbital, medial wall, and
now obtainable with fewer secondary deformities. nasoethmoidal fractures, repair within 2 weeks is
(Erl anger health systems: Tennessee Craniofacial indicated to avoid difficult repair from immediate
Center) posttraumatic wound healing.(MA Burnstine)

Orthognathic surgery involving osteotomy A comparison between two samples of

and repositioning of the mandible, maxilla or both patients with facial fractures is reported: the first
is performed to treat skeletal disproportion of the treated non-surgically and the second with open
lower face.(James I beck MBBS FRCS, Kevin D reduction and rigid internal fixation. The functional
johnstonMBcHB ) results for both groups were similar. However, open
reduction gave better occlusal results, anatomic
Most alveolar fractures occur in the restoration and faster recovery rates than non-
premolar and incisor regions. The treatment of surgical techniques(Giacomo De Riu, Ugo Gamba,
these fractures involves proper reduction and rapid Marilena Anghinoni, Enrico Sesenna)
stabilization. Manipulation by pressure and rigid
stabilization of the fragments are accepted closed- The incidence of severe hemorrhage
reduction techniques.( Sertac Aktop, Onur Gonul, secondary to facial fractures is rare; however, it can
Tulin Satilmis,Hasan Garip and Kamil Goker) be life threatening. The incidence of life threatening
hemorrhage from facial fracture was 1.2%.( Bynoe,
Major displacement or difficulty with close Raymond P. MD; Kerwin, Andrew J. MD; Parker,
reduction may necessitate open reduction. Alignment Harris H. III MD; Nottingham, James M. MD; Bell,
of the involved teeth, edema of the segments, Richard M. MD; Yost, Michael J. PhD; Close, Timothy
restoration of proper occlusion, and edema of the C. MD; Hudson, Edwin R. MD; Sheridan, David J. MD;
teeth in the fractured segment are important. The Wade, Michael D. MD) When common modalities of
removal of teeth with no bony support may be treatment such as pressure, packing, and correction
considered, but should not be performed before the of coagulopathy fail to control the hemorrhage,
fractured bony segments have healed,even if the transcatheter arterial embolization offers a safe
teeth are considered to be unsalvageable. Segment alternative to surgical control
edema can be performed with acrylic or metal
cap splints, orthodontic bands, fibreglass splints,
transosseous wires, small or mini cortical plates, or
transgingival lag screws.

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1. Robert D marciani 4. Kris S Moe MD, FACS

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3. Mutaz B. Habal, MD Craniofacial Center
182 EBENEZER et al., Biomed. & Pharmacol. J., Vol. 7(1), 179-182 (2014)

6. James I beck MBBS FRCS, Kevin D Johnston Hudson, Edwin R. MD; Sheridan, David J. MD;
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8. MA Burnstine Leonard, Larry G.MD: hoopes, John, E.MD
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