The Le Fort classification system describes 3 common fracture lines associated with maxillary trauma and craniofacial dysjunction. These patterns were observed initially in cadaveric experiments after slow-velocity blunt trauma. In modern practice, they are rare in isolation, but elements of these fractures are commonly seen after high-velocity, blunt facial trauma.
Figure 1. Le Fort's classification of midfacial fractures. Le Fort I, horizontal fracture of the maxilla, also known as Guerin fracture. Le Fort II, pyramidal fracture of the maxilla. Le Fort III, craniofacial dysjunction. Modified by Cyndie C. H. Wooley from Converse JM, ed. Reconstructive Plastic Surgery: Principles and Procedures in Correction, Reconstruction, and Transplantation. 2nd ed. Philadelphia: Saunders; 1977:2.
Figure 2. Le Fort fractures, lateral view. Note that all the fractures extend posteriorly through the pterygoid plates (arrow). Modified from Converse JM, ed. Reconstructive Plastic Surgery: Principles and Procedures in Correction, Reconstruction, and Transplantation. 2nd ed. Philadelphia: Saunders; 1977:2.
There have been varying trends, but motor-vehicle collisions and interpersonal violence are the 2 most common causes of maxillofacial fractures. Falls and sports injuries are less common causes.
It has been reported that about 25% of patients being treated in a hospital setting after a motor-vehicle collision will have sustained midfacial fractures. A large percentage of these will include elements of a Le Fort I, II, or III fracture.
Ocular injury has been reported in 24%–28% of facial fracture cases. Cervical spine injury is also found in 1.3% of patients with facial fractures and 4% of patients with facial injury from motor-vehicle collision.
The specific history of the trauma including the mechanism of injury, timing, and other interventions already undertaken should be elicited. Specific trauma circumstances can give insight into the type of injuries to be expected — e.g., panfacial fractures in unrestrained passenger in a high-speed motor-vehicle collision, zygomaticomaxillary complex (ZMC) fractures after assault with a metal object to the face, orbital fractures after assault with a closed fist — or necessitate further interventions, e.g., social services consultation after domestic abuse, investigation for "second jaw" lacerations in animal bites, searching for foreign bodies after windshield trauma.
In conscious patients, history should focus on the patient's breathing, vision, diplopia, occlusion, prior facial trauma, and ocular disease, and on review of prior photographs of the patient.
In addition to the facial fractures and ocular injury, a multidisciplinary team needs to be coordinated to manage the airway, cervical spine, and any intracranial concerns.
- The classic Le Fort midfacial fractures are common injury patterns involving a fracture to the maxilla that extends through the pterygoid plates. The 3 classic patterns are
- Le Fort I, AKA Geurin fracture: low transverse fracture through maxilla alveolus with no orbital involvement (Figure 4) creating a floating segment containing the palate and upper teeth and is often at the piriform aperture
- Le Fort II, AKA pyramidal fracture: fracture through the nasal bridge, lacrimal, and maxillary bones extending through the medial orbital floor and inferior orbital rim near the infraorbital foramen and then inferiorly along the lateral wall of the maxillary sinus (Figure 4), creating a floating segment including the lacrimal crests, the maxilla, the upper teeth, and the palate
- Le Fort III, AKA craniofacial dysjunction: Craniofacial dysjunction in which the fracture is through the nasal bridge, entire orbit, and laterally through the fronto-zygomatic suture completely detaching the lower facial skeleton from the skull base and suspended only by soft tissues (Figure 5)
- It is important to recognize that, even experimentally, multiple Le Fort fracture lines often occur and that clinically they are unlikely to be found "cleanly" (i.e., noncomminuted), symmetrically, or in isolation (Figures 3–5).
- As this system represents an escalating level of dysjunction of the midface from the cranial vault, Le Fort fractures should be described on each side corresponding to the most superior fracture line (Figure 6).
- A useful way to think about the orbital component of Le Fort II and III fractures is to consider the other complex fractures of the orbit: the naso-orbital ethmoidal (NOE) and ZMC fractures. That is, both the Le Fort II and III involve an NOE fracture and a fracture through the pterygoid plates. A Le Fort II fracture also involves a fracture through the orbital rim and floor, as seen at the medial extent of most ZMC fractures, whereas a Le Fort III involves a fracture of the zygomatic-frontal and zygomatic-sphenoid junctions, as seen at the lateral and posterior extent of most ZMC fractures.
Figure 3. Le Fort I fracture in sagittal plane.
Figure 4. Le Fort II fracture.
Figure 5. Le Fort III fracture.
Figure 6. Le Fort I and II fracture.
- Clinical ophthalmic and orbital exam:
- Visual acuity for signs of ocular injury such as traumatic optic neuropathy, hyphema, ruptured globe, retinal edema, or retinal tear
- Extraocular motility exam and the presence of pain or diplopia with movement
- Pupil exam for signs of an afferent pupillary defect, sphincter tear, ruptured globe, or traumatic mydriasis
- Facial sensation/infraorbital nerve evaluation
- Globe position with exophthalmometry and vertical position assessment
- Canthal assessment to evaluate for telecanthus
- Soft-tissue examination for lacerations and eyelid malposition
- Palpation of orbital rim for step deformities
- Additional facial exam:
- Airway compromise assessment
- Facial nerve function
- Soft tissue assessment for Battle's sign (bruising over mastoid)
- Midfacial retrusion assessment
- Intraoral exam to assess bite for dental occlusion abnormality (often anterior open bite) and intraoral bruising
- Intranasal exam for bleeding or cerebral spinal fluid (CSF) rhinorrhea
- Midface segment mobility exam: Stabilize forehead with one hand, grasp anterior alveolar arch/upper teeth with the other, and pull forward; can be immobile with severe impaction.
- Radiographic exam:
- Although plain films such as PA and Water's views can demonstrate sinus bleeding and fracture lines, modern assessment requires imaging with CT scan.
- Thin-slice noncontrast facial CT scan or spiral scan to allow for multiplanar reformatting to view images in the coronal, axial, and sagittal planes