Residency · Residency · Oral Maxillofacial Surgery

Midface Fractures: Le Fort Classification and Management

Overview

Le Fort fractures are fracture patterns of the midface involving separation of all or part of the maxilla from the skull base. Described by Rene Le Fort in 1901 based on cadaveric experiments with blunt force impacts to the face, in clinical practice fractures rarely follow pure Le Fort patterns -- most are combinations or incomplete. Management centers on restoring facial buttresses, projection, width, and occlusion.

Le Fort Classification

Le Fort I (Guerin Fracture / Transverse Fracture)

The Le Fort I is a horizontal fracture through the maxilla above the tooth apices. The fracture line passes through the lateral nasal wall, piriform aperture, anterior maxillary wall, zygomaticomaxillary buttress, pterygomaxillary junction, and lateral and medial pterygoid plates. Clinically, the maxilla is mobile (the palate rocks when grasped), and there is malocclusion, facial edema, and ecchymosis of the buccal sulcus. This pattern separates the tooth-bearing maxilla (dentoalveolar segment) from the upper midface.

Le Fort II (Pyramidal Fracture)

The Le Fort II is a pyramidal fracture through the midface. The fracture line passes through the nasal bridge, frontal process of the maxilla, lacrimal bone, inferior orbital rim and floor, zygomaticomaxillary buttress, pterygomaxillary junction, and pterygoid plates. Clinically, the maxilla is mobile along with the nasal dorsum, and there is periorbital ecchymosis (raccoon eyes), subconjunctival hemorrhage, infraorbital nerve numbness, dish-face deformity, and possibly CSF rhinorrhea. This pattern separates the central midface pyramid from the zygomas and frontal bone.

Le Fort III (Craniofacial Disjunction)

The Le Fort III represents complete separation of the midface from the cranial base. The fracture line passes through the nasofrontal suture, medial orbital wall, orbital floor, lateral orbital wall, zygomaticofrontal suture, zygomatic arch, pterygomaxillary junction, and pterygoid plates. Clinically, the entire midface is mobile, with massive facial edema, elongated face (dish-face), CSF rhinorrhea or otorrhea, subcranial air, bilateral periorbital ecchymosis, and increased intercanthal distance. This pattern separates the entire midface from the cranial base.

Clinical Reality

Pure Le Fort fractures are uncommon, and most injuries are asymmetric combinations. A patient may have a Le Fort I on one side and Le Fort II on the other. A split palate (sagittal maxillary fracture) frequently accompanies Le Fort patterns. Associated injuries include orbital fractures, NOE fractures, mandible fractures, and dental injuries.

<image>Illustrations of the three Le Fort fracture patterns (I, II, and III) shown on anterior and lateral views of the skull, with fracture lines highlighted in different colors, demonstrating the progressive levels of midfacial separation from the dentoalveolar segment (Le Fort I) through the pyramidal pattern (Le Fort II) to craniofacial disjunction (Le Fort III)</image>

Buttress System of the Midface

Vertical Buttresses

The nasomaxillary (medial) buttress extends from the piriform aperture through the frontal process of the maxilla and nasal bones to the frontal bone. The zygomaticomaxillary (lateral) buttress extends from the alveolar process through the maxillary body and ZM buttress to the zygoma and zygomaticofrontal suture. The pterygomaxillary (posterior) buttress connects the pterygoid plates to the posterior maxilla. These buttresses transmit occlusal forces superiorly to the skull base.

Horizontal Buttresses

The frontal bar connects the superior orbits across the glabella. The infraorbital rim and orbital floor form a horizontal strut connecting the medial and lateral orbital frameworks. The maxillary alveolus and palate form the inferior horizontal strut connecting the vertical buttresses. The zygomatic arch is the lateral horizontal strut.

Clinical Significance

Restoring the vertical buttresses is the priority in midface fracture repair, as they restore facial height and resist masticatory forces. Horizontal buttresses restore facial width and projection. Failure to restore buttresses results in midface retrusion, elongation, and widening.

Diagnosis

Clinical examination includes facial mobility testing (the Le Fort test, grasping the anterior maxilla and rocking while stabilizing the head), assessment of malocclusion, facial elongation, and midface retrusion. CT face with axial, coronal, and 3D reconstructions is the gold standard. CSF leak is evaluated with beta-2 transferrin testing. A complete ocular examination rules out globe injury and orbital involvement. Cervical spine evaluation is performed.

Management

Initial Management

Airway protection with endotracheal intubation is provided if compromised, avoiding nasal intubation in Le Fort II/III. Hemorrhage is controlled with nasal packing, balloon tamponade, or angioembolization for refractory bleeding. Temporary MMF (manual reduction or arch bars) provides patient comfort. Medical stabilization is completed before definitive repair.

Timing

Definitive repair is performed within 7-14 days of injury. Earlier repair is indicated for gross displacement, open fractures, or CSF leak. Initial swelling is allowed to subside when possible.

Surgical Principles

Exposure

The upper buccal sulcus incision is the standard approach for the anterior maxilla, piriform rim, and zygomaticomaxillary buttress. A subtarsal or transconjunctival incision provides access to the infraorbital rim and orbital floor. A lateral brow or upper blepharoplasty incision accesses the zygomaticofrontal suture. A coronal incision provides wide exposure for Le Fort III, NOE fractures, and frontal sinus access. Existing lacerations are used when advantageous.

Reduction

MMF is applied first to establish the occlusion, as the mandible guides maxillary position. Fracture segments are then reduced to their anatomic positions, with alignment of the vertical and horizontal buttresses.

Sequencing

The bottom-up approach establishes occlusion with MMF, fixates the maxilla at the buttresses, and works superiorly: dental arch/occlusion (MMF), palatal fracture repair if present, ZM buttress and piriform rim (vertical buttresses), infraorbital rim, zygomaticofrontal suture, and nasofrontal area. An alternative top-down approach in Le Fort III establishes a stable cranial reference first.

Fixation

For Le Fort I, miniplates are placed at the piriform rim bilaterally and ZM buttress bilaterally, providing four-point fixation that restores vertical buttress continuity, using 1.5 or 2.0 mm miniplates with monocortical screws. For Le Fort II, fixation is placed at the nasofrontal area, infraorbital rim, and ZM buttress, with additional fixation at the piriform rim and possible orbital floor repair. For Le Fort III, fixation is placed at the zygomaticofrontal suture, zygomatic arch, nasofrontal suture, and infraorbital rim, with reconstruction of the medial and lateral orbital walls. Craniotomy may be required for associated skull base injuries, and a coronal approach is typically needed.

Bone Grafting

Comminuted areas or bone loss at the buttresses may require grafting. Calvarial bone graft (outer table harvest during a coronal approach) or iliac crest graft for larger defects may be used.

Split Palate (Sagittal Maxillary Fracture)

Split palate occurs in 8-25% of Le Fort fractures, separating the palate into two halves and widening the maxilla. It must be reduced and fixated before addressing the Le Fort pattern. A palatal splint or arch bar/wire fixation stabilizes the dental arch, and miniplate fixation at the piriform rim helps maintain reduction.

<image>Intraoperative photograph showing the surgical approach for Le Fort fracture repair via an upper buccal sulcus incision exposing the anterior maxillary wall, piriform rim, and zygomaticomaxillary buttress with miniplates applied at the four-point fixation sites (bilateral piriform rim and bilateral zygomaticomaxillary buttress) following reduction and establishment of MMF</image>

Post-Operative Management

MMF is released within 1-2 weeks if rigid fixation is adequate, with guiding elastics maintained for 4-6 weeks. A soft diet is followed for 6-8 weeks. Sinus precautions include no nose blowing, open-mouth sneezing, and no straw use. Perioperative antibiotic coverage is standard, though an extended course is controversial. Follow-up imaging is obtained at 6 weeks. Patients are monitored for malocclusion, midface retrusion, and nasal obstruction.

Complications

Malocclusion is the most common complication and may require orthodontic treatment or revision surgery. Midface retrusion results from inadequate projection restoration. Nasal obstruction occurs from comminution of the nasal septum or piriform area. Infraorbital nerve paresthesia is common and usually improves over 6-12 months. Sinusitis involves the maxillary or ethmoidal sinuses. CSF leak is usually self-limiting, though persistent leak may require repair. Plate palpability or exposure occurs in thin patients. Anosmia results from cribriform plate injury in Le Fort II/III. Epiphora results from lacrimal system injury in Le Fort II. Nonunion is rare with adequate fixation.

Clinical Pearls

The Le Fort classification is a useful framework, but clinical fractures are almost never pure patterns -- the CT should be read, not the textbook. Establishing the correct occlusion with MMF is the foundation of midface fracture repair; if the occlusion is wrong, everything else will be wrong. Vertical buttress restoration should be prioritized as it resists masticatory forces and maintains facial height. A palatal split should always be checked for, as an unrecognized sagittal maxillary fracture will result in a widened maxillary arch and malocclusion. Le Fort II and III fractures are associated with skull base fractures and CSF leaks, warranting a high index of suspicion. Postoperative elastics are critical for guiding the occlusion during healing. Nasal intubation should be approached with caution in Le Fort II/III patterns due to the risk of intracranial passage through a disrupted skull base. Comminuted midface fractures may benefit from a coronal approach for wide exposure and access to calvarial bone graft.

References

• Manson PN, et al. Midface fractures: advantages of immediate extended open reduction and bone grafting. Plast Reconstr Surg. 1985.
• Gruss JS, Mackinnon SE. Complex maxillary fractures: role of buttress reconstruction and immediate bone grafts. Plast Reconstr Surg. 1986.
• Markowitz BL, et al. Management of the medial canthal tendon in nasoethmoid orbital fractures. Plast Reconstr Surg. 1991.
• Le Fort R. Etude experimentale sur les fractures de la machoire superieure. Rev Chir. 1901.
• Donat TL, et al. Facial fracture classification according to skeletal support mechanisms. Arch Otolaryngol Head Neck Surg. 1998.
• Follmar KE, et al. Repair of Le Fort fractures. Facial Plast Surg. 2015.

Read this lecture as Markdown