Le Fort fracture of skull
The Le Fort (or LeFort) fractures are a pattern of midface fractures originally described by the French surgeon,
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.[3]
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).[2][3][4]
The maxillary bone contains important anatomical structures which are prone to injury during trauma. The
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.[2][5][6]
Classification
History and Modern Day Use
The Le Fort fractures are a pattern of midface fractures originally described by the French surgeon,
Classification
Traditionally, Le Fort described three types of fractures. All three fractures involve the nasal septum and the pterygoid plates.[2]
- The Le Fort I fracture (horizontal maxillary fracture) consists of an axial (horizontal) fracture through the
- 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).[5] The defining feature of this fracture pattern is involvement of inferior orbital rim.[5] 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.[2][3] The fracture line extends through the zygomatic arch, the pterygoid plates, the lateral and medial orbital walls, the nasal bones, and the nasal septum.[2][5] The salient feature of these fractures is that they invariably involve the zygomatic arch, or cheek bone.[5] These are the most extensive of the Le Fort fractures and often require open surgical intervention.[3]
Patient Evaluation
Initial Evaluation
Every trauma patient presenting to the hospital should first be evaluated according to the
Symptoms and Exam Findings
After the initial evaluation is complete and the patient is
If the surgeon suspects a Le Fort fracture, they may test for abnormal movement of the maxillary bone by planting one hand on the patient's forehead and using the other hand to press on the roof of the patient's mouth.[1] Movement in the maxillary bone either in isolation or with the nose is suggestive of a Le Fort I or II fracture, respectively.[1]
The cranial nerves (CNs) should be examined if the patient is awake and able to participate in the exam process.[2] The CN exam evaluates facial movement and sensation. Special attention should be made to the fifth CN (CNV) as one of its branches (the infraorbital nerve) courses through the maxillary bone.[2] If this nerve is injured during trauma, it can result in numbness or tingling around the nose or within the mouth.[2]
The surgeon will also examine the patient's mouth for bleeding, swelling, cuts, foreign objects, changes in bite, and newly lost teeth. Additionally, an eye exam assessing vision and pupillary response may be warranted, especially in Le Fort II and III fractures due to the involvement of the orbit.[2] If there is suspicion that the skull base has been injured, such as during a Le Fort III fracture, the patient should be examined for clear drainage from the ear or nose which may be caused by a cerebrospinal fluid (CSF) leak.[2][6] Abnormal findings during these mouth, eye, ear, or nose exams may require further evaluation.
Signs Indicating Further Evaluation
If it was determined that the patient lost a tooth during the inciting trauma, the tooth's location should be identified as it could have become lodged in the airway, aspirated into the lungs, or swallowed.[1] If there is concern for an aspirated tooth, an x-ray can confirm the tooth's location.[1][6] If the eye exam reveals abnormalities in either vision or the pupillary response, prompt evaluation by a neurosurgeon and an ophthalmologist should occur.[2] Skull base injuries can result in a cerebrospinal fluid (CSF) leak, which can present as a clear, metallic-tasting liquid draining from the nose or the ear.[2] If a CSF leak is suspected, the patient should be evaluated by a neurosurgeon.[6]
Diagnosis
Although diagnosis can be suspected by history and physical exam, imaging is required for an accurate diagnosis. A
Treatment
Goals of Intervention
The primary goal of any intervention is to ensure that a patient is able to eat and speak. This is done by re-establishing occlusion (alignment of upper and lower teeth) and stabilizing facial biomechanics (via the vertical and horizontal facial buttresses discussed previously) to support chewing.[1] Other goals of intervention include restoring cosmetic deformities from the trauma, but this should never be prioritized over re-establishing occlusion.[1]
Maxillomandibular Fixation
Open Reduction and Internal Fixation
Open reduction and internal fixation (ORIF) is a surgical term that refers to open surgical repair of broken bones. It is required for correction of complex Le Fort fractures affecting facial function or involving neurological complications (visual changes, CSF leak).[6] ORIF is especially important for repairing unstable facial buttresses in order to allow the patient to tolerate chewing. Plates and screws are often permanently fixated to facial bones to stabilize the lateral and medial vertical buttresses bilaterally.[2] Bone grafts may also be required to stabilize the buttresses.[2] ORIF can be used in isolation or in combination with maxillomandibular fixation (MMF) in treating Le Fort fractures.[6] Following surgery, patients may require up to six weeks of rest before they are able to return to the demands of their daily life.[6] As all patients heal slightly differently, ORIF may result in a less-than-ideal correction of facial bones, resulting in poor occlusion or facial asymmetries. Furthermore, as with any surgery, ORIF comes with risk of scarring, nerve injury, and infection.[2]
Role of Antibiotics
The role of
Prognosis
Longterm outcomes of Le Fort fractures depend on the severity and location of the fracture. The most common complication of Le Fort fractures include imperfect fracture reduction resulting in poor dental occlusion.[2] Other longterm effects of Le Fort fractures include various nerve injuries, either from the inciting injury or from surgical correction, resulting in facial movement and sensory deficits.[2] If one or both of the maxillary sinuses are injured during the trauma, it can result in chronic sinus infections or injuries to the eye which may require further surgical correction.[2] Le Fort III fractures that injure the optic nerve or the extraocular muscles that move the eye may result in visual defects.[2]
See also
- Facial trauma
- René Le Fort
- Zygomaticomaxillary complex fracture
- Oral and maxillofacial surgery
- Mandibular fracture
- Le Fort osteotomy