The Le Fort (or LeFort) fractures are a pattern of midface fractures originally described by the French surgeon René Le Fort in the early 1900s. He described three distinct fracture patterns. Although not always applicable to modern-day facial fractures, the Le Fort type fracture classification is still utilized today by medical providers to aid in describing facial trauma for communication, documentation, and surgical planning. Several surgical techniques have been established for facial reconstruction following Le Fort fractures, including maxillomandibular fixation (MMF) and open reduction and internal fixation (ORIF). The main goal of any surgical intervention is to re-establish occlusion, or the alignment of upper and lower teeth, to ensure the patient is able to eat. Complications following Le Fort fractures rely on the anatomical structures affected by the inciding injury.
Anatomy When discussing the anatomy of the face, it is often divided into thirds. The lower third extends from the chin to approximately the level of the upper teeth. The middle third continues from the teeth to just below the brow line. Finally, the upper third stretches from the brow to the hairline.
The middle third of the face, or the midface, is the anatomical location in which Le Fort fractures occur. It comprises the maxillary bone, palatine bones, zygomas, zygomatic processes (of the temporal bone), ethmoid bone, vomer, nasal concha, nasal bones, and pterygoid processes (of the sphenoid bone). The maxillary bone contains important anatomical structures which are prone to injury during trauma. The maxillary sinuses are housed within the maxillary bone, and traumatic injury to these sinuses may cause sinus infections, and changes in eye placement and movement. The infraorbital nerve (a terminal branch of CNV2) courses through the maxillary bone and provides sensation to the central face. Additionally, the maxillary bone contains the upper row of teeth (maxillary dentition). Occlusion, or the alignment of upper and lower teeth, is vital following midface trauma to ensure a patient is able to eat and speak. Facial biomechanics, or the study of forces on the facial bones, plays an important role in midface reconstruction following trauma. Although the biomechanics of the face are not fully understood due to their complex nature, several vertical and horizontal buttresses, or pillars, have been established. These buttresses dissipate the powerful forces the skull endures during biting and chewing.
Classification
History and Modern Day Use The Le Fort fractures are a pattern of midface fractures originally described by the French surgeon René Le Fort in the early 1900s. Le Fort studied the effect of facial trauma by dropping cadavers from various heights and recording the different fracture patterns observed. Today, with the evolution of high-speed motor vehicle accidents and advancements in medical imaging and surgical techniques, the low-speed fracture patterns originally described by Le Fort are not always applicable. Modern midface fractures typically do not neatly fit into one of the Le Fort classifications and often occur in combination with other craniofacial trauma. Nevertheless, the Le Fort type fracture classification is still used today as a starting point for describing midface fractures for communication, documentation, and treatment planning.
Classification
Traditionally, Le Fort described three types of fractures. All three fractures involve the nasal septum and the pterygoid plates.
The Le Fort I fracture (horizontal maxillary fracture) consists of a horizontal fracture through the pterygoid plates and maxillary bone between the hard palate and the orbits. Involvement of the nasal aperture differentiates this fracture from the other two Le Forts. Historically, this fracture was eponymically known as a Guérin fracture.
The Le Fort II fracture (pyramidal fracture) includes a fracture line from one of the lateral vertical buttresses across the maxillary bone, extending into the inferior orbital rim and crossing the midline (either through the nasal root or nasal bones). The defining feature of this fracture pattern is involvement of the inferior orbital rim. When viewed from the front, this fracture is classically shaped like a pyramid.
The Le Fort III fracture (transverse fracture) occurs at the level of the skull base, resulting in complete craniofacial separation of the midface from the base of the skull. The fracture line extends through the zygomatic arch, the pterygoid plates, the lateral and medial orbital walls, the nasal bones, and the nasal septum. The salient feature of these fractures is that they invariably involve the zygomatic arch, or cheek bone. These are the most extensive of the Le Fort fractures and often require open surgical intervention.
Patient Evaluation
Initial Evaluation Every trauma patient presenting to the hospital should first be evaluated according to the Advanced Trauma Life Support (ATLS) protocol, which follows the ABC's (airway, breathing, circulation) of trauma. This includes ensuring the patient is able to breathe, confirming that the patient is actively breathing, and identifying and minimizing major bleeding. Le Fort fractures have the potential to obstruct a patient's airway for a variety of reasons, preventing him or her from being able to breathe. Medical providers should be prepared for emergency airway management should the patient develop an obstructed airway due to bleeding or swelling. Other life-threatening injuries, including those to the brain, spine, or abdomen, should receive prompt evaluation by the appropriate medical specialist.
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