Le Fort Fractures

Le Fort Fractures are complex fractures of the midface introduced by René Le Fort who studied cadaver skulls that were subjected to blunt force trauma in 1901. The most common mechanisms of injury for these fractures, which are frequently associated with drug and alcohol use, include motor vehicle collisions, assault, and falls. 

René Le Fort identified the innate lines of weakness of the midfacial bone that form typical fracture patterns known as Le Fort I, II and III fracture levels today.

Le Fort classification does not take into account any degree of comminution or displacement. In high-energy trauma other fracture lines, especially in the naso-ethmoid complex, with severe displacement of fragments may appear. To give you an internationally wellaccepted tool to describe midface fractures the following paragraphs may act as common all-purpose classifications. More distinct descriptions may be used by specialized maxillofacial surgeons, but may be less useful in general communication.

See Also: Hangman’s Fracture

Important clinical signs for Le Fort fractures

• Unstable maxilla/midface
• Malocclusion with deviation or frontal open-bite situation (non-occlusion)
• Hollow sound when clicking on upper teeth
• Raccoon sign (Le Fort II and III)
• Blood in maxillary sinus (haematosinus) on radiographs (Le Fort I and II, often also in Le Fort III)
• Unstable nasal bridge (Le Fort II and III)
• Tangible steps along: zygomatic maxillary buttress (Le Fort I and II), infraorbital rims (Le Fort II), lateral orbital rims (Le Fort III)
• Impaired eyeball motion (Le Fort II and III)

Required plain radiographs (CT scan in axial and coronal planes is preferred when available)

1. Occipitomental projection
2. Axial view of zygomatic arch
3. Panoramic view (orthopantomography)

Le Fort Fractures Types

Le Fort Fracture I

The Le Fort I fracture level (horizontal) describes the separation of the complete maxilla from the rest of the midfacial skeleton. Le Fort I fractures may result from a force of injury directed low on the maxillary alveolar rim in a downward direction. The fracture extends from the nasal septum to the lateral pyriform rims, travels horizontally above the teeth apices, crosses below the zygomaticomaxillary junction and traverses the pterygomaxillary junction to interrupt the pterygoid plates.

Le Fort Fracture II

The Le Fort II fracture level (pyramidal) describes the separation of the maxilla together with the medial face complex up to the nasal bridge from the rest of the midfacial skeleton, thus forming a pyramidal shape. A Le Fort II fracture may be the result of a blow to the lower or midmaxilla.

The fracture pattern extends from the nasal bridge at or below the nasofrontal suture through the frontal processes of the maxilla, inferolaterally through the lacrimal bones and inferior orbital floor and rim through or near the inferior orbital foramen, and inferiorly through the anterior wall of the maxillary sinus; it then travels under the zygoma, across the pterygomaxillary fissure and through the pterygoid plates.

Le Fort Fracture III

The Le Fort III fracture level (transversal) describes the complete separation of the midfacial skeleton from the neurocranium. Le Fort III fractures, also termed craniofacial disjunctions, may follow impact to the nasal bridge or upper maxilla. These fractures start at the nasofrontal and frontomaxillary sutures and extend posteriorly along the medial wall of the orbit through the nasolacrimal groove and ethmoid bones.

The thicker sphenoid bone posteriorly usually prevents continuation of the fracture into the optic canal. Instead, the fracture continues along the floor of the orbit along the inferior orbital fissure and continues superolaterally through the lateral orbital wall, through the zygomaticofrontal junction and the zygomatic arch. Intranasally, a branch of the fracture extends through the base of the perpendicular plate of the ethmoid, through the vomer and through the interface of the pterygoid plates to the base of the sphenoid.

References & More

1. Le Fort R. Etude expérimentale sur les fractures de la máchoire supérieure. Revue Chirurgique de Paris 1901;23:208–27, 360–79, 479–507.
2. Kim DW, Egan KK, Tawfilis AR, et al. Facial trauma, maxillary and Le Fort fractures. http://www.emedicine. com/plastic/TOPIC481.HTM
3. Phillips BJ, Turco LM. Le Fort Fractures: A Collective Review. Bull Emerg Trauma. 2017 Oct;5(4):221-230. doi: 10.18869/acadpub.beat.5.4.499.. PMID: 29177168; PMCID: PMC5694594. Pubmed
4. Patel BC, Wright T, Waseem M. Le Fort Fractures. [Updated 2023 Apr 3]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK526060/
5. Mercer’s Textbook of Orthopaedics and Trauma, Tenth edition.