A Le Fort fracture is a severe type of facial trauma involving the maxilla (upper jaw) and the bones of the middle third of the face. Named after French surgeon René Le Fort, who described these predictable patterns, the injury involves transverse fracture lines that separate a large section of the midface from the base of the skull. This separation always includes fractures of the pterygoid plates. The severity is defined by how high the fracture line travels and how much of the facial skeleton is detached.
The Three Levels of Lefort Fractures
The classification system divides Le Fort fractures into three types (I, II, and III), each representing a different level of horizontal separation of the midface from the cranium.
The Le Fort I fracture, often called a horizontal maxillary fracture, is the least severe. The fracture line runs horizontally above the roots of the teeth and across the floor of the nasal cavity, detaching the hard palate and the upper tooth-bearing segment. This results in the separation of the upper jaw as a single mobile unit.
A Le Fort II fracture is known as a pyramidal fracture because of its triangular shape, with the apex at the nasal bridge. The fracture line extends upward from the pterygoid plates, through the medial walls of the orbits, across the nasal bones, and involves the inferior orbital rims and floor. The entire central midface, including the nose and upper jaw, is detached in a single piece.
The most severe pattern is the Le Fort III fracture, which causes a complete craniofacial disjunction, separating the entire facial skeleton from the base of the skull. The fracture line travels through the zygomatic arches, the lateral and medial orbital walls, the nasofrontal suture, and the pterygoid plates. This extensive break results in the midface essentially “floating.”
Mechanisms of Injury
Le Fort fractures result from high-impact trauma, typically involving blunt force applied directly to the midface. The energy of the impact must be sufficient to overcome the strong bony buttresses. The severity of the fracture is often directly related to the velocity of the impact.
Common scenarios include motor vehicle accidents, falls from significant heights, or severe assaults involving rigid objects. Injuries caused by lower-energy impacts, such as a simple fall, are more likely to result in a less severe Le Fort I pattern. Forces directed straight-on tend to cause Le Fort I and II injuries, while a force directed slightly downward may result in the more severe Le Fort III separation.
Recognizing the Signs
The initial clinical presentation involves massive facial edema (swelling), sometimes leading to a characteristic “balloon face” appearance that can obscure underlying deformities. Extensive bruising (ecchymosis) frequently occurs around the eyes (periorbital ecchymosis) and within the mouth on the palate.
A hallmark of a Le Fort fracture is malocclusion, or the inability to close the jaw correctly, resulting from the fractured maxilla shifting out of position. Airway compromise is also a serious concern, particularly if the fractured midface segments are displaced backward, obstructing the upper airway.
In higher-level fractures (Le Fort II and III), a potentially life-threatening sign is cerebrospinal fluid (CSF) leakage. This may appear as clear fluid dripping from the nose (rhinorrhea) or ear (otorrhea), indicating a fracture extending into the base of the skull. Diagnostic imaging, most commonly a Computed Tomography (CT) scan with fine cuts, is necessary to confirm the specific fracture pattern, assess the degree of displacement, and plan treatment.
Treatment and Recovery
The immediate management of a Le Fort fracture focuses on securing the patient’s airway, as displacement of the maxilla and severe swelling can quickly lead to obstruction. This often necessitates immediate intubation or a surgical airway procedure like a tracheostomy. Once stabilized, the definitive treatment involves surgical intervention.
The primary goal of surgery is the precise restoration of the anatomical position of the fractured segments and the proper dental occlusion. This is achieved through Open Reduction and Internal Fixation (ORIF), which uses small titanium plates and screws to rigidly reattach the broken bones. Surgery is typically scheduled within 7 to 14 days of the injury to allow initial soft tissue swelling to subside and prevent fragments from healing in a displaced position.
Post-operatively, patients must follow a soft or liquid diet for four to six weeks to protect the healing bone. While rigid internal fixation has reduced the need for prolonged intermaxillary fixation, temporary wiring may still be used to ensure correct alignment of the teeth. Potential complications include malunion, where the bones heal incorrectly leading to long-term functional problems or cosmetic deformity, and infection at the fracture sites.