Facial trauma with skull fractures: difference between LeFort fracture I, II and III

By Cristiano Antonino On May 4, 2022

LeFort fracture (also called Le Fort fracture) is a medical term for a group of fractures involving the bones of the skull that typically occur in facial trauma and are potentially very dangerous for the survival of the patient

This type of fracture is named after René Le Fort, the French surgeon who first classified them in the first half of the 1900s

Dr Le Fort identified the presence of 3 pairs of resistance pillars (even and symmetrical) that characterise the middle third of the face.

These are:

anterior (naso-frontal) pillar: starts at the piriform opening and follows the medial orbital frame, surrounding the canine region inferiorly;
lateral pillar (zygomatic): from the molar region it follows the lateral wall of the orbit;
posterior pillar (pterygomatic): from the tuberosity of the maxilla it leads to the pterygoid processes of the sphenoid bone.

Fracture lines in facial trauma tend to occur at the periphery of the areas traversed by these trajectories, resulting in the different types of LeFort fracture.

Causes and risk factors of LeFort fractures

LeFort fractures are most often caused by direct trauma to the face and head in general, for example in road accidents, and are often associated with a variety of other injuries to the rest of the body.

LeFort fractures can also be favoured by a variety of factors, such as

local factors: non-specific and specific infectious processes, malignant and benign tumours, cysts, dental retention;
general factors: osteomalacia and osteopetrosis, hyperparathyroidism, senile osteoporosis, occupational phosphorus or fluoride toxicosis.

In this case we speak of pathological fractures, i.e. fractures occurring in tissues affected by internal structural failure due to an underlying pathology that may be systemic or local.

Diagnosis of LeFort fractures

The diagnosis of LeFort fractures is made through an objective examination (in which the palate is often unnaturally mobile) supported by a CT scan of the head and neck, which in most cases is able to clearly show the type of fracture.

For fractures to be classified as LeFort, they must involve the pterygoid processes of the sphenoid, which are visible posterior to the maxillary sinuses in an axial CT scan, and inferior to the orbital rim in a coronal projection.

LeFort I fracture (low or horizontal fracture)

LeFort I fracture, also known as a low or horizontal fracture, can result from a downward force on the alveolar border of the maxilla.

It is also known as Guérin’s fracture, or floating palate, and usually involves the lower portion of the pyriform opening.

The fracture extends from the nasal septum to the lateral edges of the piriform opening, travels horizontally above the tooth apices, crosses under the zygomatic-jaw suture and crosses the sphenoid-jaw suture to interrupt the pterygoid processes of the sphenoid.

The symptoms of a LeFort I are mainly

slight swelling of the upper lip
ecchymosis in the upper fornix under the zygomatic arches,
malocclusion,
dental mobility.

Guérin’s sign is present, characterised by ecchymosis in the region of the greater palatine vessels.

LeFort I fractures may be almost immobile, and the characteristic screeching can only be perceived by applying pressure to the teeth of the upper arch.

Percussion of the upper jaw teeth reveals a sound known as a foul pot.

Some symptoms may be present in both LeFort I and LeFort II, such as:

soft tissue oedema in the middle third of the face;
bilateral circumorbital ecchymosis;
bilateral subconjunctival haemorrhage;
epistaxis;
cerebrospinal fluid rhinorrhoea;
diplopia;
enophthalmos.

LeFort II fracture (medium or pyramidal fracture)

LeFort II fracture, also called medium or pyramidal fracture, may result from trauma to the middle or lower jaw, and usually involves the lower edge of the orbit.

This fracture is pyramidal in shape, extending from the root of the nose, at or just below the naso-frontal suture, through the frontal processes of the maxillary bone, then laterally and downward through the lacrimal bones and the lower floor of the orbit, reappearing through or near the infraorbital foramen and inferiorly through the anterior wall of the maxillary sinus; it then proceeds below the zygomatic bone, through the pterygomaxillary fissure to terminate on the pterygoid processes of the sphenoid.

The symptoms of a LeFort II are mainly:

step on infraorbital rim;
middle portion of the face mobile;
anaesthesia or paresthesia of the cheek (from damage to the infraorbital nerve);
thick pan sound.

LeFort III fracture (high, transverse fracture or craniofacial disjunction)

LeFort III fracture, also called high, transverse or craniofacial disjunction, usually involves the zygomatic arch.

It can occur as a result of impact on the root of the nose or the upper part of the jawbone.

This fracture begins at the fronto-maxillary suture and the naso-frontal suture and extends posteriorly along the medial wall of the orbit through the nasolacrimal groove and the ethmoid.

The thickness of the sphenoid posteriorly usually prevents continuation of the fracture into the optic canal.

The fracture then continues along the floor of the orbit, along the inferior orbital fissure and continues superiorly and laterally through the lateral wall of the orbit, through the zygomatic-frontal suture and the zygomatic arch.

Within the nose, a branch of the fracture extends through the base of the perpendicular lamina of the ethmoid, through the vomer and into the pterygoid processes at the base of the sphenoid.

This type of fracture predisposes the patient more to cerebrospinal fluid rhinorrhoea than the other two.

The symptoms of a LeFort III are mainly

softness and separation of the zygomatic-frontal suture;
elongation of the face;
depression of the eye levels;
enophthalmos;
inability to keep the eyelids open;
alteration of the occlusal plane.

Therapy of LeFort fractures

Treatment involves reduction, restraint or osteosynthesis or cerclage surgery.

Which doctor treats LeFort fractures?

The treatment of this type of fracture is mainly the responsibility of the maxillofacial surgeon, a doctor who specialises in the surgical treatment of a large number of traumas and injuries affecting the mouth, jaw, face and neck.

The treatment of a LeFort fracture, given the possible involvement of the palate, teeth, brain and – ultimately – the aesthetic problems in the face that it causes, involves, in the various stages of the therapeutic process, a team that includes a large number of specialists in various medical fields, such as neurologists, neurosurgeons, orthopaedists, dentists, ENT specialists, plastic surgeons, physiatrists, physiotherapists, speech therapists and psychologists.

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