Its a Clinical Presentation of Midface fractures-specifically, Lefort fractures. Classification, Anatomical Landmarks, Clinical Features, Diagnosis & Management protocols are discussed.

2. INTRODUCTION
• René Le Fort was a French Scientist
• In 1901, described Lefort classification of
midface fracture.
• Experimented with 32 cadavers. Those
cadaver heads were subjected to various
types of trauma.
• Soft tissues of those heads were then
removed and the bones were examined.
René Le Fort (1869-1951)

3. INTRODUCTION
• Le Fort stated that fractures occurred
through three weak lines in the facial
bony structure:
1. Those that protect the cranial cavity
2. Those that circumscribe the midface,
3. And those that cut across the face.
• From these three lines, the Le Fort
classification system was developed
René Le Fort (1869-1951)

4. LEFORT CLASSIFICATION
Lefort III Fracture
(Suprazygomatic /High level
Fracture or craniofacial
Dysjunction)
Lefort I Fracture (Low
level/ Guerin fractures or
Floating Maxilla)
Lefort II Fracture
(Pyramidal Fractures)

5. LEFORT I FRACTURE
This is a horizontal fracture above the level of the nasal floor. The fracture line
extends backwards from the lateral margin of the anterior nasal aperture
below the zygomatic buttress to cross the lower third of the pterygoid laminae.
The fracture also passes along the lateral wall of the nose and the lower third of
the nasal septum to join the lateral fracture behind the tuberosity.

6. CLINICAL FEATURES
LEFORT I

7. CLINICAL FEATURES (LEFORT I)
• Swelling of the upper lip and cheeks

8. CLINICAL FEATURES (LEFORT I)
• Ecchymosis in the maxillary buccal sulcus.

9. CLINICAL FEATURES (LEFORT I)
• Nasal Blockage

10. CLINICAL FEATURES (LEFORT I)
• Guerin sign: Ecchymosis in the palate in the area of greater
palatine foramen bilaterally

11. CLINICAL FEATURES (LEFORT I)
• Occlusion: Anterior open bite.
Posterior gagging.
• Teeth fracture

12. CLINICAL FEATURES (LEFORT I)
• Palatal fracture: Commonly, Mid palatal split

13. CLINICAL FEATURES (LEFORT I)
• Cracked-pot sound
• Floating maxilla
• Palpation reveals tenderness and step deformity along the
pyriform aperture, buccal sulcus and tuberosity regions.

14. LEFORT II FRACTURE
This fracture runs from thin middle area of the nasal bones or frontonasal junction
crossing the frontal processes of the maxilla, into the medial wall of each orbit, crosses
the lacrimal bone behind the lacrimal sac— turns forward to cross the infraorbital
margin—slightly medial to or through the infraorbital foramen—extends downwards
and backwards across the lateral wall of the antrum—below the zygomaticomaxillary
suture—middle one-third of the pterygoid laminae horizontally.
Separation of the block from the base of the skull is completed via the nasal septum
and may involve the floor of the anterior cranial fossa.

15. LEFORT III FRACTURE
Fracture line
• Anteriorly: The fronto nasal suture—transversely backwards, parallel with base
of the skull, to full depth of the ethmoid bone including the cribriform plate.
• Posteromedially: Within the orbit—the fracture passes below the optic foramen
into the posterior limit of the inferior orbital fissure. Then Backwards across the
maxillary fissure to fracture the roots of the pterygoid laminae

16. LEFORT III FRACTURE
• Posterolaterally: From the orbit—inferior orbital fissure—lateral wall of
orbit into the frontozygomatic suture.
In addition, fracture of the zygomatic arch is an integral part of Le Fort III
completing the separation of facial bones from cranium.

17. CLINICAL FEATURES
LEFORT II & LEFORT III

18. COMMON CLINICAL FEATURES OF
LEFORT II & LEFORT III FRACTURES
• Swelling: Gross oedema of the middle third of the face gives an appearance
of ‘moon facies’’
• Deformity of nose, Epistaxis, Nasal obstruction

19. COMMON CLINICAL FEATURES OF
LEFORT II & LEFORT III FRACTURES
• Bilateral circumorbital or periorbital oedema, ecchymosis
giving an appearance of ‘raccoon eyes’.

20. COMMON CLINICAL FEATURES OF
LEFORT II & LEFORT III FRACTURES
• Bilateral Subconjunctival haemorrhage
• ‘Dish face’ deformity (concave profile) with lengthening of the face

21. COMMON CLINICAL FEATURES OF
LEFORT II & LEFORT III FRACTURES
• CSF rhinorrhoea
• Enophthalmos, limitation in ocular mobility from muscle entrapment and
diplopia are possible findings
• Retropositioning of the whole maxilla and posterior gagging of the
occlusion are seen creating anterior open bite.
• Restricted Mouth Opening
• Mobility of the maxilla
• Subcutaneous emphysema is sometimes evident by crepitus felt on palpation

22. SPECIFIC CLINICAL FEATURES OF
LEFORT II FRACTURES
• Anaesthesia or paraesthesia of the cheek
• Step deformity at the infraorbital rims or nasofrontal junction.
• Telecanthus , Epiphora
• Zygoma and arch are intact, no loss of malar prominence unless
associated with ZMC fractures
• Ecchymosis or haematoma is seen in the buccal sulcus opposite to the
maxillary first and second molar teeth

23. • Midline or paramedian split of the palate with mucosal tear.
• Tenderness with step deformity at zygomatico-maxillary buttress
regions.
• Mobility of midface detectable at nasal bridge & Infraorbital
margins.
• Nasal Bones move with midface as a whole but often otherwise
intact.
SPECIFIC CLINICAL FEATURES OF
LEFORT II FRACTURES

24. • Hooding of eyes
• Occular signs-
- Enophthalmos,
- Hypoglobus,
- Diplopia
- Anti mongoloid slant
• Saddle nose deformity .
• Loss of lateral facial projection from zygomatic arch fractures.
• Profuse CSF rhinorrhea
SPECIFIC CLINICAL FEATURES OF
LEFORT III FRACTURES

25. • Tilting of the occlusal plane with gagging of one side when
lateral displacement is present.
• Tenderness and step deformity present at
- Frontozygomatic suture,
- Zygomatic arch
- Nasal bridge.
• Mobility of whole facial skeleton as a single block.
SPECIFIC CLINICAL FEATURES OF
LEFORT III FRACTURES

26. CLINICAL EXAMINATION OF LEFORT FRACTURES
Maxillary fractures are distinguished into Le Fort I, II & III based on the classical mobility
• Step 1: Left palm is placed over the forehead, with the thumb over right lateral orbital rim
(frontozygomatic junction), index finger over left frontozygomatic junction or alternatively
the frontonasal junction can also be assessed simultaneously.

27. CLINICAL EXAMINATION OF LEFORT FRACTURES
• Step 2: The maxilla is grasped firmly at the anterior portion of alveolus and not
the teeth. The maxilla is checked for mobility with concurrent mobility in bilateral
frontozygomatic junction.

28. CLINICAL EXAMINATION OF LEFORT FRACTURES
• Step 3: Frontonasal junction at the root of nose is grasped with left thumb and index
finger while palm stabilises the cranium at forehead.
• Step 4: Repeat step 2 checking for dental segment maxilla mobility with concurrent mobility
in frontonasal junction.

29. CLINICAL EXAMINATION OF LEFORT FRACTURES
• Step 5: Place two fingers as of left hand one on each infraorbital rim, all the time
palm stabilizes the cranium at forehead.
• Step 6: Repeat step 2 and check for concurrent mobility felt at both infraorbital rims.

30. Comparison of site of mobility- evident in different fracture levels
CLINICAL EXAMINATION OF LEFORT FRACTURES
Maxillary
dental
mobility
Frontonasal
junction
Infraorbital
rim
Frontozygomatic
junction
Lefort I + - - -
Lefort II + + + -
Lefort III + + + +

31. INVESTIGATIONS
Conventional Radiograph
Computed Tomography ( CT Scan)

32. CONVENTIONAL RADIOGRAPH
Common conventional radiograph done for midface fractures are-
• Occipito-Mental View (Standard 0° projection)
• Waters’ view (30° OM view)
OM views are most preferred to see Lefort fractures
• Caldwell view (PA view) : To see the nasal & orbital Structures
• Lateral view : To see inward of outward displacement
• Orthopentomogram (OPG): To see teeth & associated structures
• Submentovertex view: Base of the Skull & Zygomatic arch can be seen

33. COMPUTED TOMOGRAPHY ( CT SCAN)
• Conventional radiographic examination is uncertain and sometimes
misleading.
• CT scan of the face provides a vivid evaluation of facial pathology.
• Axial, Coronal & Sagittal views provide 3 dimensional views of a
specific location in the maxillofacial region.
• 3D reconstruction of the CT scan aids in diagnosis and treatment
planning.

34. Computed Tomography ( CT Scan)
CT Scan coronal section and 3D reconstruction showing loss of
continuity in anterolateral wall of sinus, lateral wall of nasal
cavity with paramedian palatal split

35. Computed Tomography ( CT Scan)
Right Le Fort I and II combination fracture, right nasal bone
fracture and left high Le Fort I fracture with midpalatal split along
with mandibular symphysis fracture. Note: pterygoid plate
fracture.

36. MANAGEMENT OF
LE FORT FRACTURES

37. MANAGEMENT OF LE FORT FRACTURES
The aims of the treatment are as follows:
1. Restoration and preservation of functions of the vital structures mainly by establishing
normal skeletal architecture.
2. Re-establishing dental occlusion, ocular position, ocular mobility and orbital volume is
the primary concern of the surgeon. The two areas of reference for reconstruction are
cranium and dental occlusion.
3. IMF/MMF is done to restore the dental occlusion; it is done prior to the surgery to protect
the masticatory function. MMF/IMF may be performed before or during the fracture repair,
it may be removed immediately after the surgery or left in place postoperatively
GENERAL PRINCIPLES

38. • The timing of surgery is controversial.
• Some support immediate repair in a stable patient.
• Preferably, the fracture repair can be delayed 7–14 days allowing edema to subside.
• Delaying surgery beyond two weeks is not encouraged due to risk of fibrosis and
healing process taking place at the fractured site.
• Further, late repair is difficult to operate because of the contraction of the soft tissue
envelope. The results of such surgeries are not satisfactory.
• But, when the patient is hemodynamically unstable or has an increased intracranial
pressure (ICP), the time of surgery is deferred.
TIMING OF THE SURGERY

39. 1. Airway maintenance
The reduction of fractures of the middle third requires GA, which can be
administered through nasal intubation (Le Fort I), submental or
tracheostomy (Le Fort II and III). Oral intubation can be indicated when there
is extensive soft tissue injury to the nose.
2. Complexity of fractures
• Le Fort fractures often do not present as a fracture of single block of bone.
• They often present as a complex of Le Fort I, II and III types of fractures, which
is extremely complicated.
CHALLENGES ASSOCIATED WITH TREATMENT
OF MIDDLE THIRD FRACTURE

40. 3. Fixation
• Fixation requires an immobile point for support.
• As the mandible is movable, it is not possible to fix the fractured maxilla to the
mandible to stabilize the middle third of the facial skeleton.
• To avoid this, following accurate reduction using mandible as a guide, the middle third
must be immobilized by attaching it to a fixed point. The stable point is the bone superior
to the fracture.
• The stable bone is used to suspend the fracture segment (e.g. Circum zygomatic
suspension for Le Fort I—where the zygoma is used as a stable bone) or fixation (e.g.
zygomatico-maxillary and piriform buttress bone is used as points of fixation in Le Fort
I).
CHALLENGES ASSOCIATED WITH TREATMENT
OF MIDDLE THIRD FRACTURE

41. • Surgical approach of choice for Le Fort III and
sometimes Le Fort II (for frontonasal
fracture fixation).
• Provides complete degloving of the entire
frontal area including the lateral orbital wall
and rim, nasofrontal area and the zygomatic
arches.
VARIOUS SURGICAL APPROACHES FOR REDUCTION AND FIXATION
BICORONAL AND HEMICORONAL

42. Indication
• Le Fort I, II, III combined fractures.
• The technique involves a wide labio-
vestibular incision in combination with
release of soft tissue envelope around the
piriform margin and nasal skeleton.
• This approach allows access to the
anterior surface of maxillae, infraorbital
rims, body of zygoma and the entire
nasal skeleton.
VARIOUS SURGICAL APPROACHES FOR REDUCTION AND FIXATION
MIDFACIAL DEGLOVING

43. Indication
• Le Fort II, III.
• These approaches are widely used for
reduction and fixation of the infraorbital
rim.
• Also facilitates the orbital floor
reconstruction in orbital blowout
fractures.
• Though the subciliary approach has less
risk to the cornea and a relatively quick
technique it has high risk of ectropion
and visible scar.
VARIOUS SURGICAL APPROACHES FOR REDUCTION AND FIXATION
TRANSCONJUNCTIVAL & SUBCILIARY

44. • Transconjunctival approach is scarless,
does not create ectropion and provides
approach to the infraorbital rim alone.
• However, when combined with lateral
canthotomy, it can be used to approach
the frontozygomatic suture too.
• This approach is therefore advantageous
since it avoids a second approach.
VARIOUS SURGICAL APPROACHES FOR REDUCTION AND FIXATION

45. • For lateral orbital rim fracture (Fronto-
Zygomatic Suture) in Le Fort III direct
fixation, Le Fort II and I indirect (Adam)
suspension.
VARIOUS SURGICAL APPROACHES FOR REDUCTION AND FIXATION
LATERAL EYEBROW APPROACH

46. • For access to the anterolateral walls of
maxilla in Le Fort I and II fracture
reduction and direct fixation as well as in
indirect suspension.
VARIOUS SURGICAL APPROACHES FOR REDUCTION AND FIXATION
TRANSORAL APPROACH

48. • In loosely mobile fracture, finger
manipulation is sufficient for reduction.
• In reduction of impacted fractures, Rowe’s
disimpaction forceps is used. The
unpadded blade is passed into the nostril
and padded blade into the mouth and the
palate is grasped tightly in between.
• The operator now stands behind the
patient, grasps the two forceps and
manipulates to disimpact the maxilla and
bring it to place.
LE FORT I FRACTURE MANAGEMENT
1. REDUCTION

49. • Then, a rocking motion with constant
anterior traction frees the impacted
segment.
• In the figure shown, the maxillary
dentulous fragment mobilized by
downward and anterior traction
LE FORT I FRACTURE MANAGEMENT

50. • Fixation may be by direct or indirect
means.
• Direct fixation involves transoral
exposure of the fracture line and
miniplate fixation at the buttress bone
(lateral piriform rim and zygomatico-
maxillary buttress).
• Indirect fixation involves suspension and
MMF for 4–6 weeks of immobilisation.
LE FORT I FRACTURE MANAGEMENT
2. FIXATION

51. • Undisplaced Le Fort I with minimal occlusal discrepancy—simple MMF for 4
weeks or direct fixation with no MMF.
• Displaced mobile Le Fort I with anterior open bite—direct fixation or indirect
suspension with MMF.
• Comminuted fractures where plate or wire fixation not feasible— MMF and
suspension.
• In an edentulous patient, if intraosseous fixation is not feasible, a custom
acrylic occlusal splint or patient’s own denture is used to determine the vertical
dimension.. After rigid fixation, the MMF can be removed at the end of the procedure.
LE FORT I FRACTURE MANAGEMENT

52. • Disimpaction is similar as in Le Fort I fracture using Rowe’s disimpaction forceps.
• Extreme care should be taken because this fracture usually involves base of the
skull, which might be further disrupted if manipulated indiscriminately.
• Whenever this fracture is present along with Le Fort I type, disimpaction of the
tooth-bearing portion can be done with the help of Rowe’s disimpaction forceps,
but it might be difficult to mobilise the remaining fragment.
• Mobilisation of this remaining fragment can be carried out by grasping the nasal
septum with Asch’s or Walsham’s forceps and simultaneously exerting forward
finger pressure from behind the soft palate.
LE FORT II FRACTURE MANAGEMENT
1. REDUCTION

53. • Fixation may be by direct or indirect
means.
• Direct involves miniplate fixation at the
ZM buttress, infraorbital rim and
frontonasal junction including nasal
bones.
• Indirect involves suspension and MMF
for 4–6 weeks of immobilisation
LE FORT II FRACTURE MANAGEMENT
2. FIXATION

54. • Undisplaced Le Fort II with minimal occlusal discrepancy—circum zygomatic
suspension with MMF for 4 weeks or direct fixation at zygomaticomaxillary
buttress alone may suffice.
• Displaced mobile Le Fort II with anterior open bite—direct fixation or indirect
suspension (Adams) with MMF.
• Comminuted fractures where plate or wire fixation not feasible— MMF and
suspension.
• The associated complications such as CSF rhinorrhoea, lacrimal obstruction
require appropriate management.
LE FORT II FRACTURE MANAGEMENT

55. • Le Fort III fractures usually occur in association with other fractures of the
facial skeleton such as nasoethmoidal, zygomatic, orbital and Le Fort type I.
• When Le Fort III fractures occur in isolation the displacement is minimal and
reduction is established by exposing the frontozygomatic suture.
• The management includes semi rigid fixation at frontozygomatic, frontonasal,
orbital floor reconstruction, zygomatico-maxillary buttresses, zygomatic
arch and maintaining occlusion.
• The associated complications such as CSF rhinorrhoea, lacrimal obstruction
require appropriate management.
LE FORT III FRACTURE MANAGEMENT

56. • Inadequately reduced fractures
may result in ‘facial’ deformity.
COMPLICATIONS OF LEFORT FRACTURES

57. • Late enophthalmos develops as a consequence
of expansion of the orbital volume.
COMPLICATIONS OF LEFORT FRACTURES
• Infraorbital depression following untreated Le Fort II
fracture

58. • Obstruction of the nasolacrimal duct due to Le Fort II fractures
results in epiphora, dacryocystitis (an infected mucocele).
• Failure of recovery of oculomotor nerve and abducens nerve
result in strabismus, ptosis and diplopia.
• Paraesthesia in the distribution of the ophthalmic and maxillary
branches of the trigeminal nerve.
• Fractures involving cribriform plate of ethmoid may result in
anosmia.
• Nonunion might occur in cases of extensively comminuted fractures.
COMPLICATIONS OF LEFORT FRACTURES

59. • Malocclusion and soft tissue entrapment • Palatal fistula (oronasal communications)