Le Fort Fractures

 Updated 3/2017 -- photos and all links removed as many no longer active and it was easier than checking each one.

The maxilla is the central keystone of the face. It links the cranial base superiorly with the occlusal plane of the lower jaw inferiorly. The maxilla has 4 processes: zygomatic, frontal, palatine, and alveolar. The maxillary sinus is housed within the maxilla and varies in size depending on the degree of pneumatization.

The fractures can be of significant functional and aesthetic importance. Functional problems can lead to disorders of occlusion, nasal obstruction, and trigeminal-nerve sensation. Aesthetic losses include decreased midface height, facial width, facial projection, and malar eminence. These losses can lead to a dish-face deformity.

Renee LeFort (1901) provided the earliest classification system of maxillary fractures. His model described "great lines of weakness in the face" using low-velocity impact forces directed against cadaver skulls. A discussion of fractures of the maxilla would not be complete without a description of LeFort's work.

LeFort Classification of Midfacial Fxs/Signs/Symptoms
Lefort I or transverse fracture of the maxilla (A in picture)

• The result is a "floating palate" with mobility of tooth bearing segment of upper jaw
• Disturbed occlusion
• Palpable crepitation in upper buccal sulcus
• ‘cracked pot’ percussion note from upper teeth

LeFort II or pyramidal fracture (B in picture)

• produces a separation and mobility of the midface
• Gagging on posterior teeth
• Anterior open bite
• Periorbital ecchymosis/hematoma
• There may be diplopia and /or subconjunctival hemorrhage
• There may be Infra-orbital nerve damage

LeFort III or craniofacial dysjunction (C in picture)

• Mobile middle third of face
• Similar symptoms as LeFort II
• There may be CSF Rhinorrhea (25-50% of II and III fractures)

Maxillary fractures today are often the result of motor vehicle accidents. These high-velocity injuries many times produce fracture patterns not classified by the standard LeFort system, but are described simply by the anatomic structure fractured and the degree of comminution present.

Ocular injury is also commonly associated with midfacial trauma. In a report by Al-Qurainy in 1991, 90.1% of their 363 patients with midfacial trauma had some form of ocular injury. Of those, 63% had transient or minor ocular injury, 16% moderately severe injury, 12% severe ocular injury (angle recession, retinal or vitreous injury, optic nerve damage). In those patients with ocular injury 2.5% lost vision in the affected eye. This data stresses the need for a high index of suspicion for ocular injuries in patients with midfacial trauma. So a thorough eye exam should be performed including visual acuity, inspection of the anterior chamber and the retina, pupillary reflexes, and extraoccular movements. An ophthalmologic consultation may be indicated.

IMAGING

Plain film x-rays have largely been replaced by CT scans. As with zygomatic fractures, a full facial analysis from the top of the head through the mandible with 1.5 mm axial cuts will allow coronal reformatting without additional scanning. Sagittal reformatting is useful in assessing the effect of a complex orbital fracture on the inferomedial bulge of the orbital floor. If the patient presents with neurologic compromise (head injury or intoxication) and cannot comply with a complete physical examination, it is prudent to obtain a complete scan at the time that the head CT scan is obtained.

MANAGEMENT OF THE AIRWAY

Surgical management of Le Fort fractures will require correction of the occlusion and intraoperative intermaxillary fixation. Nasal intubation and tracheotomy are often the preferred approaches, as they will not interfere with the maxillomandibular fixation. The following table was adapted from a flow sheet found in the Stewart text (5th reference):

	Dentition	Fracture Type
Nasal Airway		*Le Fort I Fx *Le Fort I Fx with Mandible Fx
Oral Airway through portal cut in Cunning splints or denture	Edentulous	Le Fort I / nasal Injury Le Fort II Fx Le Fort III Fx Panfacial Fx
Oral Airway with tube displace through space	Partially Dentate with Space	Le Fort I / nasal Injury Le Fort II Fx Le Fort III Fx Panfacial Fx
Guided Nasal Intubation *Fix Maxilla / Mandible *Switch to Oral Airway for Nasal/NOE reduction	Fully Dentate	Le Fort I/ nasal Injury Le Fort II Fx Le Fort III Fx Panfacial Fx
Surgical Airway		Le Fort I /nasal Injury Le Fort II Fx Le Fort III Fx Panfacial Fx

SURGICAL TREATMENT

The goals of surgical treatment 1)re-establish midfacial height and projection, 2) establish occlusal relationship, and 3) maintain integrity of nose and orbits. All patients with midface fractures are given antibiotics, because these fractures are considered open or compound. Violation of the paranasal sinus or alveolus and open soft-tissue wounds are inevitable sequelae of midface fractures. Antibiotics have been shown to decrease the incidence of infection after midface fractures.

Exposure is crucial in repair of the midface fracture. Generally speaking, a Le Fort I fracture is approached from a sublabial exposure, a Le Fort II fracture is approached with a combination of sublabial and periorbital exposure, and a Le Fort III fracture requires a combination of sublabial and bicoronal fracture for adequate exposure.

The surgical approaches to fractures of the midface have changed radically in the past 20 years. The technology has now evolved to allow for miniplate fixation to the midface instead of bulky external hardware. Complex internal wiring used to be the standard of care 10 years ago, but due to poor cosmetic results and extended periods of IMF, newer technologies (mini-plate technology) have replaced it. If large bone deficiencies are present, bone grafting may be necessary.

The following general guidelines are meant for edentulous patients, but are good start for planning for all. Those with teeth can also be treated with arch bars, etc while their general health improves. Remember most of these patients with have serious (head, neck, chest, etc) injuries also.

No Displacement

• Soft Diet for 2-3 weeks
• Incorporation of dentures

Displacement, Patient Stable, Good General Condition

• Open reduction
• Reconstruction of midfacial buttresses
• Miniplate osteosynthesis with simultaneous preprosthetic surgery if necessary

Displacement, Patient in poor general condition
Le Fort I Level--

• No active therapy
• Le Fort I osteotomy later

Le Fort II or III Level--

• Minimal therapy, repositioning of nose and orbital rim
• Le Fort I osteotomy later

COMPLICATIONS
Early

• Extensive hemorrhage
• Airway obstruction
• Infection--When given appropriate antibiotics, the risk of meningitis is small (less than 1%). Sinusitis occurs in 1-2%.
• CSF leak
• Ocular Problems -- Approximately 17-25% of patients with severe fractures will suffer some type of ocular problem--blindness (1-2%), diplopia, enophthalmos, epiphora, blurred vision, lacrimal drainage problems.

Late

• Palpable or exposed hardware
• Non-union/ Malunion
• CN V2 Anesthesia -- The incidence of an immediate postoperative infraorbital nerve deficit from Le Fort I and II fractures has been reported at 65%. It is directly related to fracture displacement of 1 mm or more. Patients with less than 1 mm displacement regain normal sensation after 3 months. 30% of those with displacement of greater than 1 mm have a persistent sensory deficit at 1 year.
• Disturbances of Smell and Taste may occur in 23-38% of patients with up to 80% of Le Fort III patients reporting disturbance of smell.
• Extra-Occular Muscle Imbalance
• Malocclusion may result from fixation of improperly reduced fractures or insufficient fixation.
• Secondary Facial Deformities result from inadequate reduction and stabilization of the nasal bones. Nasal deformities are reported in 12-33% of upper midface fractures.

REFERENCES
Le Fort Fractures by Anil R Shah, MD and Galdino Valvassori, MD --eMedicine Article, Oct 27, 2006
Facial Trauma, Maxillary and Le Fort Fractures by David W Kim, MD and Kristin K Egan, MD --eMedicine Article, June 8, 2006
Maxillary and Periorbital Fractures by Gordon Shields MD and Francis B Quinn MD; Grand Rounds Presentation, UTMB; January 7, 2004
Atlas of Emergency Medicine; Kevin J. Knoop, Lawrence B. Stack, Alan B. Storrow; Google Books
Head, Face, and Neck Trauma: Comprehensive Management; Michael G. Stewart, MD; Google Books
Facial Fractures; Core Curriculum Syllabus: Emergencies in Otolaryngology-Head and Neck Surgery; Baylor College of Medicine
Facial Fractures: The Upper Face by Dough Humphreys, MD; Dalhousie University (PDF file)
Maxillo-facial Injuries; PatientPlus