A Le Fort fracture of the skull is a classic transfacial

fracture Fracture is the separation of an object or material into two or more pieces under the action of stress. The fracture of a solid usually occurs due to the development of certain displacement discontinuity surfaces within the solid. If a displ ...

of the midface, involving the

maxillary bone The maxilla (plural: ''maxillae'' ) in vertebrates is the upper fixed (not fixed in Neopterygii) bone of the jaw formed from the fusion of two maxillary bones. In humans, the upper jaw includes the hard palate in the front of the mouth. The t ...

and surrounding structures in either a horizontal, pyramidal or transverse direction. The hallmark of Lefort fractures is traumatic ''pterygomaxillary separation'', which signifies fractures between the pterygoid plates, horseshoe-shaped bony protuberances which extend from the inferior margin of the

maxilla The maxilla (plural: ''maxillae'' ) in vertebrates is the upper fixed (not fixed in Neopterygii) bone of the jaw formed from the fusion of two maxillary bones. In humans, the upper jaw includes the hard palate in the front of the mouth. T ...

, and the maxillary sinuses. Continuity of this structure is a keystone for stability of the midface, involvement of which impacts surgical management of trauma victims, as it requires fixation to a horizontal bar of the

frontal bone The frontal bone is a bone in the human skull. The bone consists of two portions.'' Gray's Anatomy'' (1918) These are the vertically oriented squamous part, and the horizontally oriented orbital part, making up the bony part of the forehead, ...

. The pterygoid plates lie posterior to the upper dental row, or alveolar ridge, when viewing the face from an anterior view. The fractures are named after French

surgeon In modern medicine, a surgeon is a medical professional who performs surgery. Although there are different traditions in different times and places, a modern surgeon usually is also a licensed physician or received the same medical training as ...

René Le Fort (1869–1951), who discovered the fracture patterns by examining crush injuries in

cadavers A cadaver or corpse is a dead human body that is used by medical students, physicians and other scientists to study anatomy, identify disease sites, determine causes of death, and provide tissue to repair a defect in a living human being. Stud ...

Signs and symptoms

Le Fort I – Slight swelling of the upper lip,

ecchymosis A bruise, also known as a contusion, is a type of hematoma of tissue, the most common cause being capillaries damaged by trauma, causing localized bleeding that extravasates into the surrounding interstitial tissues. Most bruises occur close ...

is present in the buccal sulcus beneath each zygomatic arch, malocclusion, mobility of teeth. Impacted type of fractures may be almost immobile and it is only by grasping the maxillary teeth and applying a little firm pressure that a characteristic grate can be felt which is diagnostic of the fracture. Percussion of upper teeth results in cracked pot sound. Guérin's sign is present characterised by ecchymosis in the region of greater palatine vessels. Le Fort II and Le Fort III (common) – Gross edema of soft tissue over the middle third of the face, bilateral circumorbital ecchymosis, bilateral subconjunctival hemorrhage, epistaxis, CSF rhinorrhoea, dish face deformity, diplopia, enophthalmos, cracked pot sound. Le Fort II – Step deformity at infraorbital margin, mobile mid face, anesthesia or paresthesia of cheek. Le Fort III – Tenderness and separation at frontozygomatic suture, lengthening of face, depression of ocular levels ( enophthalmos), hooding of eyes, and tilting of occlusal plane, an imaginary curved plane between the edges of the incisors and the tips of the posterior teeth. As a result, there is gagging on the side of injury.

Diagnosis

Diagnosis is suspected by physical exam and history, in which, classically, the hard and

soft palate The soft palate (also known as the velum, palatal velum, or muscular palate) is, in mammals, the soft tissue constituting the back of the roof of the mouth. The soft palate is part of the palate of the mouth; the other part is the hard palat ...

of the midface are mobile with respect to the remainder of facial structures. This finding can be inconsistent due to the midfacial

bleeding Bleeding, hemorrhage, haemorrhage or blood loss, is blood escaping from the circulatory system from damaged blood vessels. Bleeding can occur internally, or externally either through a natural opening such as the mouth, nose, ear, urethra, vag ...

and swelling that typically accompany such injuries, and so confirmation is usually needed by

radiograph Radiography is an imaging technique using X-rays, gamma rays, or similar ionizing radiation and non-ionizing radiation to view the internal form of an object. Applications of radiography include medical radiography ("diagnostic" and "therapeut ...

or CT.

Classification

There are three types of Le Fort fractures. As the classification increases, the anatomic level of the maxillary fracture ascends from inferior to superior with respect to the maxilla: * Le Fort I fracture (horizontal), otherwise known as a ''floating palate'', may result from a force of injury directed low on the maxillary alveolar rim, or upper dental row, in a downward direction. The essential component of these fractures, in addition to pterygoid plate involvement, is involvement of the

lateral Lateral is a geometric term of location which may refer to: Healthcare *Lateral (anatomy), an anatomical direction * Lateral cricoarytenoid muscle * Lateral release (surgery), a surgical procedure on the side of a kneecap Phonetics *Lateral co ...

bony margin of the nasal opening. They also involve the medial and lateral buttresses, or walls, of the

maxillary sinus The pyramid-shaped maxillary sinus (or antrum of Highmore) is the largest of the paranasal sinuses, and drains into the middle meatus of the nose through the osteomeatal complex.Human Anatomy, Jacobs, Elsevier, 2008, page 209-210 Structure It i ...

, traveling through the face just above the

alveolar ridge The alveolar process () or alveolar bone is the thickened ridge of bone that contains the tooth sockets on the jaw bones (in humans, the maxilla and the mandible). The structures are covered by gums as part of the oral cavity. The synonymous ...

of the upper dental row. At the midline, the inferior nasal septum is involved. Historically, it has also been referred to as a Guérin fracture, although this name is less commonly used in practice. * Le Fort II fracture (pyramidal) may result from a blow to the lower or mid maxillary area. In addition to pterygoid plate disruption, their distinguishing component is involvement of inferior orbital rim. When viewed from the front, the fracture is classically shaped like a pyramid. It extends from the nasal bridge at or below the nasofrontal suture through the superior medial

wall A wall is a structure and a surface that defines an area; carries a load; provides security, shelter, or soundproofing; or, is decorative. There are many kinds of walls, including: * Walls in buildings that form a fundamental part of the s ...

of the maxilla, inferolaterally through the

lacrimal bone The lacrimal bone is a small and fragile bone of the facial skeleton; it is roughly the size of the little fingernail. It is situated at the front part of the medial wall of the orbit. It has two surfaces and four borders. Several bony landmarks of ...

s which contain the tear ducts, and inferior orbital floor through or near the

infraorbital foramen In human anatomy, the infraorbital foramen is one of two small holes in the skull's upper jawbone (maxillary bone), located below the eye socket and to the left and right of the nose. Both holes are used for blood vessels and nerves. In anatomica ...

. * Le Fort III fracture (transverse), otherwise known as ''craniofacial dissociation'', may follow impact to the nasal bridge or upper maxilla. The salient feature of these fractures, beyond pterygoid plate involvement, is that they invariably involve the

zygomatic arch In anatomy, the zygomatic arch, or cheek bone, is a part of the skull formed by the zygomatic process of the temporal bone (a bone extending forward from the side of the skull, over the opening of the ear) and the temporal process of the zygo ...

, or cheek bone. These fractures begin at the nasofrontal and frontomaxillary sutures and extend posteriorly along the medial wall of the orbit, through the nasolacrimal groove and ethmoid air cells. The sphenoid is thickened posteriorly, limiting fracture extension into the optic canal. Instead, the fracture continues along the orbital floor and infraorbital fissure, continuing through the lateral orbital wall to the zygomaticofrontal junction and zygomatic arch. Within the nose, the fracture extends through the base of the perpendicular plate of the ethmoid air cells, the

vomer The vomer (; lat, vomer, lit=ploughshare) is one of the unpaired facial bones of the skull. It is located in the midsagittal line, and articulates with the sphenoid, the ethmoid, the left and right palatine bones, and the left and right max ...

, which are both part of the nasal septum. As with the other fractures, it also involves the junction of the pterygoids with the maxillary sinuses. CSF rhinorrhea, or leakage of the nutrient laden fluid that bathes the brain, is more commonly seen with these injuries due to ethmoid air cell disruption, as the air cells are located immediately beneath the skull base.

Treatment

Treatment is surgical, and usually is able to be performed once life-threatening injuries are stabilized, to allow the patient to survive the general anesthesia needed for maxillofacial surgery. First a ''frontal bar'' is used, which refers to the thickened frontal bone above the frontonasal sutures and the superior orbital rim. The facial bones are suspended from the bar by open reduction and internal fixation with

titanium Titanium is a chemical element with the symbol Ti and atomic number 22. Found in nature only as an oxide, it can be reduced to produce a lustrous transition metal with a silver color, low density, and high strength, resistant to corrosion i ...

plates and screws, and each fracture is fixed, first at its superior attachment to the bar, then at the inferior attachment to the displaced bone. For stability, the zygomaticofrontal suture is usually replaced first, and the palate and alveolar ridge are usually fixed last. Finally, after the horizontal and vertical maxillary buttresses are stabilized, the orbital fractures are fixed last.

References

External links