Facial fractures can alter appearance and compromise functions like breathing, eating, and vision. To categorize midface injuries, medical professionals use the Le Fort classification system. This system outlines specific fracture patterns in the middle third of the face, aiding in assessing severity and planning interventions.
Understanding Le Fort II Fractures
A Le Fort II fracture, also known as a pyramidal fracture, separates a significant portion of the midface from the skull base. This distinct break pattern extends from the nasal bones, through the medial orbital walls, across the orbital floor, and involves the inferior orbital rims. It then continues transversely through the posterior maxilla and the pterygoid plates. This creates a pyramid-like shape with its base at the upper teeth and apex near the nasal-frontal suture.
Unlike a Le Fort I fracture, which is a horizontal break separating only the hard palate and upper jaw, a Le Fort II fracture includes the nose and portions of the eye sockets. A Le Fort III fracture, the most severe type, involves a complete separation of the entire midface from the skull, extending through the cheekbones and zygomatic arches.
Causes and Identifying Signs
Le Fort II fractures commonly result from high-impact blunt force trauma to the midface. Common causes include motor vehicle accidents, direct physical assaults, falls, and facial trauma sustained during contact sports.
Signs and symptoms often include significant midface swelling and deformity, alongside bilateral bruising around the eyes (“raccoon eyes”). Patients may experience a clear fluid discharge from the nose (cerebrospinal fluid or CSF rhinorrhea), indicating a potential breach of the skull base. Misalignment of the teeth (malocclusion) is also frequent, as is numbness or altered sensation in the midface, including the upper lip. Mobility of the maxilla and nasal bones may also be observed.
Medical Assessment and Management
Diagnosis begins with a thorough physical examination to assess facial symmetry, swelling, bruising, and any obvious deformities or mobility of facial structures. Clinicians check for specific signs like periorbital ecchymosis, epistaxis, and malocclusion. A bimanual palpation, where the maxilla is gently manipulated while stabilizing the nasofrontal suture, helps determine mobility.
Imaging techniques are fundamental for confirming the diagnosis and mapping fracture lines. A non-contrast computed tomography (CT) scan with fine cuts, typically 1 mm or less, is the gold standard. This imaging provides detailed two-dimensional and three-dimensional views, invaluable for identifying the precise location and extent of fractures, including pterygoid plate involvement. Magnetic resonance imaging (MRI) may be used if soft tissue damage, such as optic nerve injury or muscle disorders, is suspected.
Treatment approaches vary depending on fracture severity and displacement. Non-surgical management might be considered for less severe cases with minimal displacement or good occlusion. However, most Le Fort II fractures require surgical intervention, typically open reduction and internal fixation (ORIF).
This procedure involves surgically exposing, repositioning, and stabilizing bone fragments using titanium plates and screws. The primary goals are to restore normal tooth alignment, re-establish facial height and projection, and restore midfacial bony supports. A multidisciplinary team, including oral and maxillofacial surgeons, otolaryngologists, and ophthalmologists, often collaborates to manage these complex injuries.
Healing and Long-Term Considerations
The healing process for a Le Fort II fracture generally involves a recovery period ranging from several weeks to a few months, depending on complexity and overall health. During this time, maxillomandibular fixation (MMF), which involves wiring the upper and lower teeth together to stabilize the jaw, may be used for about 4 to 8 weeks. Patients typically maintain a liquid or soft diet, and diligent oral hygiene is paramount.
Despite successful treatment, some individuals may experience long-term outcomes. Potential complications include persistent sensory changes, such as numbness in the midface or upper lip, and chronic pain. Cosmetic deformities, like a flattened midface or changes in facial shape, are possible if fractures are not perfectly realigned.
Vision issues, such as double vision (diplopia) or a sunken eye (enophthalmos), may arise if orbital structures were significantly damaged. Dental problems, including malocclusion or difficulty chewing, might also persist, sometimes requiring further intervention. Regular follow-up appointments are important to monitor healing, address emerging issues, and consider rehabilitation, which may include physical therapy.