Le Fort fractures are a classification system for midface fractures. They were described in 1901 by French surgeon René Le Fort (1869–1951) based on 35 cadaver experiments. There are three types: type I (horizontal), type II (pyramidal), and type III (transverse = craniofacial separation). All types involve pterygoid process fractures, and the facial skeleton may separate from the skull base.
Le Fort fractures have been reported to account for 10–20% of all facial fractures. Large studies indicate that types I, II, and III each represent approximately 0.3–2.2% of all facial fractures, with type III being the rarest. The male-to-female ratio is 2.0–2.8:1, with a male predominance. Over age 70, the incidence becomes higher in women.
The incidence of traumatic brain injury (TBI) associated with Le Fort fractures is high; approximately 9–10% of patients with maxillofacial trauma have intracranial hemorrhage. In types II and III, the rate of neurosurgical intervention for TBI increases. Ocular injuries accompany 24–28% of facial fractures, and cervical spine fractures occur in 1.3% of all facial fractures.
Note that only about 24% of fractures strictly follow the Le Fort pattern; most are combinations of partial Le Fort types and other midface fractures.
Type I is a horizontal fracture of the maxilla including the maxillary dental arch, without involving the orbit. Type II is a pyramidal fracture line from the nasal root through the inferomedial orbit, involving the orbital floor and infraorbital rim. Type III is a transverse fracture extending from the medial orbital wall to the lateral orbital wall and zygomatic arch, resulting in separation of the entire midface from the skull base. For details, see “Pathophysiology and Detailed Mechanism” section.
Characteristic findings for each type are shown below.
Le Fort Type I
Edema of the lower maxilla: Swelling localized to the lower maxilla and upper lip.
Maxillary mobility: The entire maxillary dental arch is mobile.
Hard palate hemorrhage: Patchy hemorrhage of the hard and soft palate.
Epistaxis: Unilateral to bilateral. The orbit is not involved.
Le Fort II
Midface deformity: The nose and maxillary complex are mobile.
Periorbital findings: Bilateral periorbital edema and ecchymosis, bilateral subconjunctival hemorrhage (mainly medial).
Increased intercanthal distance: Traumatic telecanthus.
CSF leakage: Cerebrospinal fluid rhinorrhea or otorrhea (suggesting skull base fracture).
Le Fort III
Dish face: Marked facial edema with elongation and flattening of the face (dish face).
Raccoon eyes: Bilateral periorbital ecchymosis (panda eyes). Battle’s sign and hemotympanum may also occur.
Ophthalmic findings: Diplopia, enophthalmos, traumatic telecanthus, transient visual disturbance, bilateral circumferential subconjunctival hemorrhage.
CSF leakage: Highest rate in type III. May be accompanied by signs of increased intracranial pressure1).
In orbital wall fractures, restriction of extraocular muscle movement due to entrapment is the main cause of diplopia. When extraocular muscle entrapment is severe or in young patients, nausea and vomiting due to vagal reflex may occur. Injury to the second branch of the trigeminal nerve (infraorbital nerve) causes sensory disturbance of the nasal ala and upper lip. In large open fractures, enophthalmos becomes apparent after the acute phase.
In Le Fort II fractures, fractures of the orbital floor and infraorbital rim cause diplopia, subconjunctival hemorrhage, and periorbital edema. In type III, enophthalmos, traumatic telecanthus, and transient visual disturbance may also occur. Severe cases may involve injury to orbital soft tissues, extraocular muscles, and the optic nerve.
Le Fort fractures are caused by blunt facial trauma, and the mechanism of injury is classified into low-velocity and high-velocity.
The mechanisms of injury for each type are shown below.
| Type | Main Mechanism of Injury | Characteristics |
|---|---|---|
| Type I | Mainly low-velocity (56%) | Downward force on the maxillary teeth |
| Type II | Often high-velocity | Force at the level of the nasal bones. May involve the medial orbital wall and orbital floor. |
| Type III | High-velocity | Force at the level of the nasal root and orbit. May involve injury to orbital soft tissues, eyeball, and optic nerve. |
In developed countries, assault (39.7%), falls (27.9%), and traffic accidents (27.2%) are the main causes (Arslan et al. 2014). In developing countries, traffic accidents are the most common.
The main risk factors are as follows:
The primary survey (ABCDE) according to the ATLS protocol is the highest priority 1). Especially in types II and III, cervical spine immobilization is performed before proceeding to evaluation of maxillofacial fractures. The secondary survey evaluates the details of maxillofacial fractures.
History taking includes the cause of injury, magnitude of force, neurological changes (loss of consciousness, altered mental status), and alcohol/drug use history. The possibility of domestic violence or abuse is also investigated.
CT (with 3D reconstruction) is the standard imaging method 1). It is useful for evaluating the extent of fractures and associated injuries; brain CT, cervical spine CT, and cervical angiography should be added as appropriate.
Orbital CT should focus not only on fracture findings but also on soft tissue findings such as extraocular muscles, orbital fat, and hemorrhage. Do not make orbital assessments based solely on brain CT. If a metallic foreign body is suspected, CT is mandatory, not MRI.
For Le Fort II and III fractures, the following ophthalmic evaluations are essential:
Pterygoid process fractures are sensitive for Le Fort fractures but not specific. In reality, only 24% of fractures follow an exact Le Fort pattern, requiring flexible interpretation in clinical judgment.
CT (with 3D reconstruction) is the standard and is optimal for evaluating the extent of fractures and associated injuries. Orbital CT must also pay attention to soft tissue findings; brain CT alone is insufficient. Dedicated CT is required to rule out associated intracranial and cervical spine injuries 1).
Prioritize primary survey according to the ATLS protocol 1).
Severe Le Fort fractures require collaboration among multiple specialties 1). Ophthalmology, ENT, neurosurgery, maxillofacial surgery, plastic surgery, vascular surgery, and ICU work together for management.
The surgical goal is to fix unstable fracture fragments to stable structures and restore facial projection, occlusion, nasal structure, and orbital structure.
The recommended order of reconstruction follows “bottom to top and outside in” (Vujcich & Gebauer 2018)1).
The timing of surgery is determined based on the following criteria.
Immediate Repair
Extraocular muscle entrapment + oculocardiac reflex: Extraocular muscle entrapment on CT/MRI with non-resolving oculocardiac reflex (bradycardia).
White-eyed blowout: Combination of trap-door fracture in children + muscle entrapment + oculocardiac reflex.
Globe subluxation: Subluxation of the globe into the maxillary sinus (rare).
Within 2 Weeks
Symptomatic diplopia + entrapment: Symptomatic diplopia with positive forced duction test or evidence of entrapment on CT, with poor improvement over time.
Large orbital floor fracture: Accompanied by hypoglobus or progressive infraorbital hypoesthesia.
Early enophthalmos or facial asymmetry: Requires early intervention as spontaneous resolution is unlikely.
Emergency (Pediatric)
Closed fracture with entrapment in children: Closed fractures with entrapment of extraocular muscles are indications for emergency surgery.
Diplopia is most severe immediately after injury and may improve slightly over time, but often does not resolve completely.
Fracture repair techniques are as follows:
Strabismus surgery is required in 7–24% of orbital floor fracture cases. Adjustable sutures are useful, but complete resolution of diplopia is often difficult due to multifactorial and incomitant causes.
Immediate repair is necessary if there is extraocular muscle entrapment with oculocardiac reflex (bradycardia). Surgery within 2 weeks is recommended for symptomatic diplopia with positive forced duction test. Closed fractures with entrapment in children are indications for emergency surgery. Large fractures or early enophthalmos and downward displacement also require management within approximately 2 weeks.
The skull is composed of 22 bones (14 facial bones and 8 cranial bones). The facial bones consist of two maxillae, two zygomatic bones, two nasal bones, the mandible, two lacrimal bones, two palatine bones, two inferior nasal conchae, and the vomer.
The facial skeleton is composed of vertical and horizontal buttresses. Vertical buttresses are stronger than horizontal buttresses; horizontal structures support the vertical ones but are weaker.
An overview of each buttress is shown below.
| Type | Buttress Name | Course |
|---|---|---|
| Vertical (4 pairs) | Nasomaxillary (medial maxillary) | Anterior maxillary alveolar process → nasomaxillary junction → glabella |
| Vertical (4 pairs) | Zygomaticomaxillary (lateral maxillary) | Lateral alveolar process → zygomatic bone → lateral orbital wall and zygomatic arch |
| Vertical (4 pairs) | Pterygomaxillary (posterior maxillary) | Posterior wall of maxillary sinus → base of pterygoid process |
| Horizontal (5) | Frontal bar | Along the supraorbital rim |
| Horizontal (5) | Upper transverse maxillary | Along the infraorbital rim |
Blunt ocular trauma causes increased intraorbital pressure and direct force, leading to orbital wall fractures. The medial orbital wall and infraorbital groove are common fracture sites because the bone is thin at these locations. Entrapment of extraocular muscles at the fracture site is the main cause of diplopia. Even if the orbital septa (thin septa) of orbital fat are entrapped near the extraocular muscles, eye movement restriction can occur.
Pswarayi & Burns (2022) reported a case of a 44-year-old male with multiple facial fractures including Le Fort III fracture 1). On arrival, he was in shock (HR 31 bpm, BP 53/32 mmHg, SpO2 74%). Systematic resuscitation based on the ATLS protocol and a multidisciplinary approach led to successful survival. Staged surgery was planned according to the “bottom to top and outside in” reconstruction principle.
