LE-FORT FRACTURES

CASE REPORT:-

A 25 year old male patient reported with a complain of multiple facial injuries since 1 day.

History of Trauma:-

The patient reported with an alleged history of road traffic accident one day ago with
positive history of loss of consciousness of approx.10 mins. No history of vomiting, seizures
or ENT bleed was reported. Patient received first aid from a civil hospital. No medicolegal
case has been reported.

There was no past relevant medical or dental history associated before this episode of
trauma.

On examination, multiple abrasions on face were observed. Swelling of upper lip and
anterior open bite were present. Tenderness on palpation was associated bilaterally along
the buccal vestibule.

TMJ examination did not reveal any gross asymmetry or step deformity.

Intraoral examination revealed Ellis Class III fracture of teeth 11,21.

Palpation of the maxilla along with the teeth revealed tenderness of the overlying tissue as
well as characteristic “floating maxilla”.

Anterior open bite present due to premature contact of posteriors. Derranged occlusion was
present.

Further intra oral evaluation was avoided considering the nature of trauma to the patient.

A provisional diagnosis of Le Fort Fracture I/II/III was made.

RADIOLOGICAL EXAMINATION:-

A CT Face with reconstruction was advised to the patient.

CT Face revealed the following:-

 Bilateral Le Fort I facial fracture, with bilateral pterygoid plate fracture and
comminuted fractures through the maxillary sinuses. Neither orbital wall or
zygomatic arch were fractured.
 The temporomandibular joints were normally located.
 Hematoma within the maxillary sinuses, and extensive traumatic stranding in the
associated soft tissues was noted.

A Final Diagnosis Of Le Fort I Fracture was confirmed in confluent with the MDCT findings.
DISCUSSION:-

INTRODUCTION-

Rene Le Fort's seminal classification system for maxillary fractures has been the standard for
over 100 years. This system was developed through direct observation, and incorporates what
Le Fort described as “great weak lines” in the craniofacial skeleton.
Le Fort found three basic patterns of maxillary fracture lines: transverse, pyramidal and
craniofacial disjunction.

Classification (KEPT FOR DISCUSSION) (REPRESENTATIVE PICTURES AND CT SCANS WILL BE

ATTACHED)
The commonly used classification is as follows:
 Le Fort type I
o Horizontal fracture above the level of nasal floor, separating the teeth from
the upper face.
o fracture line passes through the alveolar ridge, lateral nose, inferior wall of
the maxillary sinus and lower third of the pterygoid laminae.
o Also known as a Guerin fracture or Low-level Fracture.
 Le Fort type II
o Fracture runs from thin middle area of the nasal bones crossing the frontal
process of maxilla into the medial wall of each orbit.
o pyramidal fracture, with the teeth at the pyramid base, and nasofrontal
suture at its apex
o Also known as Subzygomatic Fracture
 Le Fort type III
o craniofacial disjunction
o transverse fracture line passes through nasofrontal suture, maxillo-frontal
suture, orbital wall, and zygomatic arch/zygomaticofrontal suture
o because of the involvement of the zygomatic arch, there is a risk of
the temporalis muscle impingement
o unsurprisingly type III fractures have the highest rate of CSF leak
A memory aid is:
 Le Fort I is a floating palate (horizontal)
 Le Fort II is a floating maxilla (pyramidal)
 Le Fort III is a floating face (transverse)
Any combination is possible. For example, there may be type 2 on one side and contralateral
type 3, or there may be unilateral type 1 and 2 fractures. It should be noted that Le Fort
fractures are often associated with other facial fractures, neuromuscular injury and dental
avulsions.

The LeFort lines of fracture are most helpful in understanding the major fractures of the
central middle third of the facial skeleton but other fractures and fracture combinations
occur. The midface fractures can be easily classified for treatment and diagnosis planning as:
1. Dento-alveolar fractures
 2. Zygomatic complex fractures
3. Nasal complex fractures
4. Le Fort I, Guerin or low level fractures
5. Le Fort II, pyramidal or infrazygomatic fractures
6. Le Fort III or suprazygomatic fractures
7. Extended Le Fort fractures

DIAGNOSTIC SIGNS OF LE FORT FRACTURES (Practical points) [DISCUSSION]

 fracture of the pterygoid plates is mandatory to diagnose Le Fort fractures
 anterolateral margin of the nasal fossa involvement
o if fractured, it is a type I fracture
o if intact, it excludes a type I fracture
 inferior orbital rim involvement
o if fractured, it is a type II fracture
o if intact, it excludes a type II fracture
 zygomatic arch involvement
o if fractured, it is a type III fracture
o if intact, it excludes a type III fracture
 nasofrontal suture involvement indicates either a type II or III fracture
 a combination of fractures may occur on the same side
 bilateral fractures may be asymmetric
 may occur with other non-Le Fort fractures of the face and skull

Classical Identifying Clinical Features of Le Fort fracture

Increased vertical dimension/open bite/ occlusion gagging

Guerin sign

Cracked pot sound

Moon face

Bilateral circumorbital ecchymosis

Subconjunctival ecchymosis / haemorrhage

Diplopia

Telecanthus

CSF rhinorrhoea

Le Fort-I Le Fort- II Le Fort-III

Fracture palpation
To detect
•bony irregularities,
•step-offs, crepitus
•sensory disturbances.

One hand stabilizes the skull so that the examiner’s contralateral hand can provide
movements
STRUCTURES INVOLVED LE FORT I-

Bones fractured in a Le Fort I fracture include the lower nasal septum, the inferior portion of
the pyriform apertures, the canine fossae, both zygomaticomaxillary buttresses, the
posterior maxillary walls, and the pterygoid plates.
Among Le Fort fractures, only the Le Fort I fracture involves the lateral aspect of the
pyriform aperture. Therefore, the absence of a lateral pyriform fracture rules out a Le Fort I
fracture.

SIGNS AND SYMPTOMS OF LE FORT I FRACTURES:

 Commonly swelling of the upper lip and cheeks is seen.

 Ecchymosis present in maxillary buccal sulcus from periosteal tear.
 Nasal block- mucosal tear in maxillary/ ethmoid sinus may induce bleeding causing a
nasal block forcing the patient to undergo oral breathing.
 Eye or ocular signs are usually absent.
 Guerin sign- ecchymosis in the palate in the area of greater palatine foramen
bilaterally (not seen in all cases).
 Occlusion may be disturbed. Pain while speaking and moving the jaw.
 Sometimes there may be upward displacement of the entire fragment, locking it
against the superior intact structures, such a fracture is called as impacted or
telescopic fracture . A classical open bite may be seen in this case.
 Palatal fracture- midpalatal split evident as linear mucosal tear in midpalate.
 One classic feature is that percussion of maxillary teeth results in distinctive ‘cracked
pot sound’
 Mobility of dentulous segment of maxilla is also called as floating maxilla.
 Palpation reveals tenderness and step deformity along the piriform aperture, buccal
sulcus and tuberosity regions.
TREATMENT & MANAGEMENT PROTOCOLS:-

GOALS & PROTOCOL:-

 Restore anatomy in all 3 dimensions: Plating all maxillary buttresses (if possible)
 Restore vertical dimensions and horizontal projection
 Restoration of premorbid occlusion

Tracheostomy is an effective and safe way of securing airway management in the setting of
severe facial trauma.

SURGICAL MANAGEMENT:-

Reconstruction Sequence begins with establishing the most reliable reference structures as
the first step.
•Occlusion
•Outside-to-inside
•Up-to-down
•Down-to-up

Surgical repair traditionally follows the sequence of arch bar placement, fracture exposure,
fracture reduction, malocclusion repair, plate fixation, and soft tissue repair.
Le Fort I fractures may be accessed by a gingivobuccal sulcus incision, and fixed by re-
establishing the midfacial buttresses using 1.5 to 2.0 mm L and J plates. To prevent the
forces of mastication from disrupting the repair, emphasis must be put on placing the plates
in the same direction as the forces of mastication. The most common disturbance in a
treated Le Fort injury is reduced midfacial height and projection rather than the facial
elongation and retrusion seen in an untreated Le Fort fracture. It becomes important,
therefore, to restore the facial height and projection by anatomic reconstruction of the
buttresses of the maxilla. Anteriorly, nasomaxillary and zygomaticomaxillary buttresses are
reconstructed after alignment, providing bone grafts and rigid fixation for stability. The
fracture is usually worse on one side. The more intact side is often the best key to the
correct facial height. Correction of the posterior facial height does not require accurate
reconstruction of the pterygoid buttresses, but is achieved by IMF. ( Surgical Management
of Le Fort I, add an animation if possible when u read this surgical procedure)
CONCLUSION-

Le Fort fractures are specific patterns of facial bone fractures that develop secondary to
blunt facial trauma. While mortality rates due to Le Fort fractures themselves are low, these
injuries rarely occur in isolation and are frequently associated with other severe injuries to
the head and neck. The ability to quickly and accurately diagnose Le Fort fractures is crucial
to the successful management of blunt facial trauma patients.
Among the several kinds of classifications of maxillary fractures, the Le Fort classification
system is widely known, and provides a method for concise communication of fracture
patterns between clinicians and radiologists. A thorough understanding of the facial
skeleton is essential for proper diagnosis and treatment of Le Fort fractures, to prevent
cosmetic and functional deformities.

TIP DUMP
Le Fort I:
Occlusal sagging
Cracked-pot sound on upper teeth percussion
Ecchymosis in upper buccal vestibule

Le Fort II:
Step deformity at infraorbital margins
Presence/absence of paraesthesia of cheek
Diplopia/ Enopthalmos
Mobility of midface detected at the infraorbital margins and nasal bridge.

Le Fort III:
Tenderness and separation at FZ suture and zygomatic arches
Lengthening of face
Depression of ocular levels
Enophthalmos
‘Hooding’ of eyes
CSF Rhinorrhoea
Lateral displacement of midline of upper jaw
Mobility of whole of facial skeleton as a single block

For precise anatomical reduction

•Reconstruction should be started in the area that gives maximum information.
•Fixation of fractures with different plates and screws for three-dimensional stability.
•Wide exposure and using the buttresses.
•Immediate use of bone grafts when necessary.
•Careful management of lacerations and incisions.
•Immediate definitive repair within 48–72 hours to prevent scarring.
Classical LE Fort Fracture Patterns.
Patient CT scan (CORONAL SECTION) showing le fort I fracture.
Patient CT scans (AXIAL)
Patient CT scan AXIAL (Non-contrast) showing blood filled sinus.
NOTE:- I COULD NOT ATTACH CLINICAL PICTURES DUE TO UNAVAILABILITY OF PATIENT
DATA. YOU CAN MANIPULATE IT BY USING VISUAL ANIMATIONS AND CT PICTURES IN THE
ATTACHMENT.

NOTE: The CT scan axial sections and coronal sections are difficult to explain on a video and
beyond syllabus for the target audience. I would advice to delete the slides. Use #D
reconstructed images only for the explanation.
REFERENCES:-

 Gaillard, F., Ibrahim, D. Le Fort fracture classification. Reference article,

Radiopaedia.org. https://doi.org/10.53347/rID-1317
  Pascoe, H. Le Fort 1 fractures. Case study, Radiopaedia.org. (accessed on 19 Jan
2022) https://doi.org/10.53347/rID-37489
 Phillips BJ, Turco LM. Le Fort Fractures: A Collective Review. Bull Emerg Trauma.
2017;5(4):221-230. doi:10.18869/acadpub.beat.5.4.499.
 Kim HS, Kim SE, Lee HT. Management of Le Fort I fracture. Arch Craniofac Surg.
2017;18(1):5-8. doi:10.7181/acfs.2017.18.1.5
 Contemporary Oral & Maxillofacial surgery by by James Hupp & Myron
Tucker & Edward Ellis.

MCQs:

1. Panda facies is commonly seen after

a) Le fort I fractures
b) Le fort II fracture
c) Mandible Fracture
d) None of the above

2. Floating maxilla is typically seen found in

a) Le fort I fractures
b) Le fort II fracture
c) Craniomandibular dysjunction
d) All of the above

3. The highest rate of CSF leak occurs in:

a) Le Fort I is a floating palate (horizontal)
b)Le Fort II is a floating maxilla (pyramidal)
c)Le Fort III is a floating face (transverse)
d) zygomatic maxillary fracture

4. The 1st step in management of head injury is

a) Secure airway
b) I V mannitol
c) I.V dexamethasone
d) Blood transfusion

5. Guerin’s sign is
a) Ecchymosis at greater palatine foramens
b) Ecchymosis at mastoid foramen
c) Ecchymosis at condylar region
d) Ecchymosis at infraorbital foramen