What are the different types of LeFort fractures?

Types of LeFort Fractures

LeFort fractures are classified into three distinct types (I, II, and III) based on progressively higher levels of midface involvement, all of which involve the pterygoid plates. 1

LeFort I (Transverse/Horizontal Fracture)

• LeFort I is a transverse fracture occurring above the level of the maxillary tooth apices, separating the entire alveolar process, palatal vault, and inferior pterygoid processes as a single block from the upper craniofacial skeleton. 2
• This fracture involves the anterolateral margin of the nasal fossa, which serves as the unique identifying component on imaging. 3
• The fracture line extends through the maxillary sinus and includes the lower maxilla. 1
• Recent evidence suggests that even LeFort I fractures warrant screening for blunt cerebrovascular injury (BCVI), based on analysis of 4,398 patients. 1

LeFort II (Pyramidal Fracture)

• LeFort II is a pyramidal fracture that extends through the nasal bones, medial orbital walls, inferior orbital rim, and maxillary sinuses, creating a pyramid-shaped mobile segment. 1
• The inferior orbital rim fracture is the unique identifying component that distinguishes this from other LeFort patterns. 3
• This fracture can disrupt the infraorbital nerve, causing anesthesia of the upper teeth, gingiva, upper lip, and lateral nose. 1
• The Eastern Association for the Surgery of Trauma mandates BCVI screening with CT angiography for all LeFort II fractures, as these are established risk factors for traumatic arterial dissection. 1
• Patients with LeFort II fractures have significantly higher Injury Severity Scores compared to LeFort I (p < 0.0001) and require more frequent ICU admission. 4

LeFort III (Craniofacial Disjunction)

• LeFort III represents complete craniofacial disjunction, with fracture lines extending through the zygomatic arch, orbital walls, nasal bones, and skull base, completely separating the midface from the cranium. 1
• The zygomatic arch fracture is the unique identifying component for this pattern. 3
• This is the most severe pattern with the highest morbidity and mortality, requiring intensive resuscitation and multidisciplinary management. 5
• LeFort III fractures have the highest rate of requiring surgical airway (43.5% tracheostomy rate versus 13.6% for LeFort I and 9.1% for LeFort II, statistically significant). 4
• These injuries are highly associated with cervical spine injuries (7% incidence), intracranial injuries (68% have associated head injury), and internal neck structure damage. 1, 5
• All LeFort III fractures require mandatory BCVI screening with CT angiography. 1

Key Diagnostic Approach

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

Critical Clinical Pitfalls

• Malocclusion is the essential clinical indicator of midface injury and must be evaluated in all suspected LeFort fractures through palpation, visual inspection, and assessment of occlusion. 6
• Delaying CT angiography for BCVI screening in LeFort II and III fractures is a critical error, as screening is mandatory, not optional. 1
• LeFort fractures occur in approximately 20% of facial fractures and result from high-velocity mechanisms, making associated injuries the rule rather than the exception. 5