Presentation

Le Fort Type I

Le Fort type I presents as a swollen upper lip, anterior open bite malocclusion, ecchymosis of the maxillary buccal vestibule and palate, and mobility of the maxilla.

Le Fort Type II

With a Le Fort type II fracture, there is significant deformity and swelling, widening of the intercanthal space (nasal septum fracture), mobility of the maxilla and nose as a combined segment, as well as bilateral periorbital edema and ecchymosis (raccoon eyes), epistaxis, anterior open bite malocclusion, ecchymosis of the maxillary buccal vestibule and palate, and possible CSF rhinorrhea. Since the fracture involves the inferior orbital rim and floor, there may be sensory deficits in the infraorbital region extending inferiorly to the upper lip.

Le Fort Type III

The most significant clinical findings are demonstrated by bilateral periorbital edema and ecchymosis (raccoon eyes), ecchymosis of the maxillary buccal vestibule and palate, lengthening of facial height- elongation and flattening of the face (dish-face deformity), orbital hooding, enophthalmos, ecchymosis over the mastoid region (Battle’s sign), CSF rhinorrhea, CSF otorrhea, and hemotympanum.

The initial evaluation of patients with maxillofacial trauma should follow advanced trauma life Support (ATLS) protocols. The primary survey includes airway and cervical spine stabilization, breathing and ventilatory support, attention to circulation and hemorrhage control, disability and neurologic evaluation, and exposure and environment control.

Airway obstruction associated with fractures of the midfacial skeleton can be life-threatening if not recognized promptly and treated appropriately. Orotracheal intubation is required when intranasal damage is a possibility. Airway obstruction in Le Fort injuries mainly occurs due to multiple sources bleeding into the upper airway, as well as midface altered airway anatomy. Beware that the risk of life-threatening hemorrhage in Le Fort II and III injuries is higher than that associated with other facial injuries.

Maxillofacial trauma is an obvious threat to the patient's airway; therefore, a rapid evaluation must be performed to determine the need for a definitive airway. The concept of the definitive airway in cases of maxillofacial trauma is probably much more critical as compared to trauma to other body parts; therefore, an emergency airway may be required.

In a patient with complex maxillofacial trauma, cervical spine fracture should always be considered unless proven otherwise. Therefore, the cervical spine must be protected while providing airway management.

During the secondary survey, the assessment of maxillofacial fractures is performed after initial stabilization and resuscitation of the multisystem trauma patient. An ophthalmologic evaluation is required in Le Fort II and III fractures with orbital involvement. This should be completed before surgery to ensure there is no globe injury.

The mobility of the face should be tested on both sides as well as in the midline. The type of Le Fort fracture is determined by which regions are mobile.

• Le Fort I: Mobility of the maxilla; maxilla is free from the rest of the facial bones (floating palate) 
• Le Fort II: Mobility of the maxilla and nose as a combined segment 
• Le Fort III: Mobilized segment to include the maxilla, nose, and zygomas

A CT scan of facial bones is required to fully and adequately assess the extent of bone and soft tissue involvement. Plain radiographs are not sufficient for evaluation. Beware that penetrating trauma to the midface may involve injury to the brain and major vascular structures. Therefore, a CT scan of the head and diagnostic angiography should also be considered.

The initial evaluation and stabilization should be performed in conjunction with a trauma surgeon. Definitive surgery should be performed after stabilization when life-threatening injuries are addressed. Le Fort fractures require fixation of unstable fracture segments to stable structures. [10][11][12]The goals of fracture management are to:

• Restore the facial projection and the involved sinus cavities
• Reestablish proper occlusion of teeth; note that proper repair cannot be performed without good occlusion
• Restore the integrity of the nose and orbit

Le Fort fractures may be associated with other injuries such as dental or alveolar ridge fractures (alveolar and palatal fractures are commonly associated with all types of Le Fort fractures and make the repair more difficult and complex), cerebrospinal fluid leaks, and severe epistaxis.

In type III, significant facial swelling, deformity, and orbital ecchymosis are almost always present.

Antibiotic prophylaxis in patients with CSF leak remains controversial and should be considered at the discretion of the treating neurosurgeon.

• Acute subdermal hematoma

• Child abuse

• Domestic violence

• Elder abuse

• Frontal fracture

• Globe rupture

• Mandible dislocation

• Mandible fracture

• Neck trauma

• Retinal detachment

The outcome is dependent on the mechanism of injury, location, and severity of injury, and presence of associated injuries. The mortality rate for Le Fort fracture is higher than simple midface fracture.

• Cerebrospinal fluid (CSF) leak (primarily type II and type III fractures)
• Epistaxis is commonly associated with Le Fort type II and III fractures

Early consultation with a facial surgeon when evaluating a patient with severe facial trauma is essential.

In the presence of a CSF leak, neurosurgical consultation should be obtained early.

In the presence of orbital involvement, an ophthalmologic evaluation should be obtained.

Le Fort fractures rarely occur in isolation; always evaluate for other injuries. Le Fort-type fractures should be suspected if a pterygoid fracture is noted on a facial CT scan. These 3 fracture types may occur in combination either on the ipsilateral or contralateral side. The management goals are the restoration of form and function.

LeFort fractures are not uncommon and often present to the emergency department. Because these fractures are also associated with other facial, skull and ocular injuries, an interprofessional team must be involved. The trauma surgeon should call the appropriate specialist after workup. The decision to operate on these patients depends on the stability of the fracture, compromise of neural and ocular elements, and bleeding. Even after treatment the recovery is often prolonged and most patients do have some residual neurological or visual deficit. The role of the primary care provider and nurse practitioner is to educate patients on safety in sports, wearing seatbelts while driving and wearing helmets when riding motorbikes.[13]