What are the different types of Le Fort fractures?

Le Fort Fracture Classification

Three Main Types

Le Fort fractures are classified into three distinct patterns (I, II, and III) based on predictable lines of weakness in the midface, with each type involving progressively higher levels of facial disruption and the pterygoid plates in all three patterns. 1

Le Fort I (Transverse/Horizontal Fracture)

• Separates the entire alveolar process and palate from the upper craniofacial skeleton in a horizontal plane above the level of the maxillary tooth apices 2
• Involves the vault of the palate and inferior ends of the pterygoid processes as a single block 2
• Unique diagnostic feature on CT: fracture through the anterolateral margin of the nasal fossa 3
• Lowest severity pattern with mean ISS of approximately 18.8, though still significant 4
• Only 13.6% require tracheostomy 4
• Recent evidence suggests screening for blunt cerebrovascular injury (BCVI) even in Le Fort I fractures, though this remains controversial 1

Le Fort II (Pyramidal Fracture)

• Creates a pyramid-shaped segment involving the central midface extending from the nasal bridge through the medial orbital walls to the pterygoid plates 1
• Involves the nasal bones, medial orbital walls, and inferior orbital rims 1
• Unique diagnostic feature on CT: fracture through the inferior orbital rim 3
• Disrupts the infraorbital nerve, causing anesthesia of upper teeth, gingiva, upper lip, and lateral nose 1
• Significantly higher injury severity than Le Fort I (P < .0001) 4
• Only 9.1% require tracheostomy 4
• Mandatory BCVI screening with CT angiography per Eastern Association for Surgery of Trauma guidelines 1
• 4.5% mortality rate 4

Le Fort III (Craniofacial Disjunction)

• Complete separation of the midface from the cranial base, representing the most severe pattern 5
• Involves the zygomatic arches, orbital walls, nasal bones, and pterygoid plates 1
• Unique diagnostic feature on CT: fracture through the zygomatic arch 3
• Highest injury severity with significantly increased need for ICU admission and immediate operative intervention 4
• 43.5% require tracheostomy due to airway compromise 4
• 8.7% mortality rate 4
• Highly associated with cervical spine injury (7% incidence), intracranial injury (68% have associated head injury), and internal neck structure damage 1, 5
• Mandatory BCVI screening with CT angiography 1
• Higher probability of requiring neurosurgical intervention and vision-threatening ocular trauma 4

Critical Clinical Pearls

Diagnostic Approach

• MDCT maxillofacial without contrast is first-line imaging for all Le Fort fractures, providing superior osseous and soft-tissue delineation with thin-section acquisitions 1
• Use the unique CT features to establish tentative classification: anterolateral nasal fossa margin (I), inferior orbital rim (II), or zygomatic arch (III), then confirm with complete evaluation 3
• 3D reconstructions are critical for preoperative surgical planning 1
• Contrast CT is NOT useful for detecting facial injury 1

Management Priorities

• Airway control is the absolute priority, particularly in Le Fort II and III fractures where hemorrhage, edema, or anatomical disruption can compromise the airway 1
• Maintain systolic blood pressure >110 mmHg to prevent secondary brain injury, as mortality increases markedly below this threshold 1
• All Le Fort II and III fractures require CT angiography for BCVI screening—this is mandatory, not optional 1

Common Pitfalls

• Modern facial trauma frequently presents with asymmetrical or complex fractures rather than pure Le Fort patterns 6
• Delaying CT angiography in Le Fort II/III fractures is a critical error 1
• Allowing even a single episode of hypotension (SBP <110 mmHg) worsens neurological outcomes 1
• 95.5% of Le Fort fractures result from blunt trauma mechanisms 4