Review Article

Bull Emerg Trauma 2017;5(4):221-230.

Le Fort Fractures: A Collective Review

Bradley J. Phillips1*, Lauren M. Turco2

Chief Surgeon, Baghdad Embassy Hospital, CHSi – US Department of State, USA

1

Department of Surgery, University of Kansas Medical Center, Kansas, USA

2

*Corresponding author: Bradley J. Phillips Received: July 7, 2017

Address: Chief Surgeon, Baghdad Embassy Hospital, CHSi - US Department of Revised: August 3, 2017
State, USA.
Accepted: August 11, 2017
e-mail: [email protected]

Le Fort fractures constitute a pattern of complex facial injury that occurs secondary to blunt facial trauma. The
most common mechanisms of injury for these fractures, which are frequently associated with drug and alcohol
use, include motor vehicle collisions, assault, and falls. A thorough search of the world’s literature following
PRISMA guidelines was conducted through PubMed and EBSCO databases. Search terms included “Le Fort
fracture”, “facial”, “craniofacial”, and “intracranial.” Articles were selected based on relevance and examined
regarding etiology, epidemiology, diagnosis, treatment, complications, and outcomes in adults. The analyzed
studies were published between 1980 and 2016. Initial data search yielded 186 results. The search was narrowed
to exclude articles lacking in specificity for Le Fort fractures. Fifty-one articles were selected, the majority of
which were large case studies, and collectively reported that Le Fort fractures are most commonly due to high-
velocity MVC and that the severity of fracture type sustained occurred with increasing frequency. It was also
found that there is a general lack of published Level I, Level II, and Level III studies regarding Le Fort fracture
management, surgical management, and outcomes. The limitation of this study, similar to all PRISMA-guided
review articles, is the dependence on previously published research and availability of references as outlined in
our methodology. While mortality rates for Le Fort fractures are low, these complex injuries seldom occur in
isolation and are associated with other severe injuries to the head and neck. Quick and accurate diagnosis of Le
Fort fractures and associated injuries is crucial to the successful management of blunt head trauma.

Keywords: Le Fort fracture; Facial trauma; Blunt head trauma.

Please cite this paper as:

Phillips BJ, Turco LM. Le Fort Fractures: A Collective Review. Bull Emerg Trauma. 2017;5(4):221-230. doi: 10.18869/acadpub.beat.5.4.499.

Introduction Fort fracture types involve the pterygoid processes

of the sphenoid bones and therefore, disrupt the

O riginally described by Rene Le Fort in 1901,

Le Fort fractures are specific facial bone
fracture patterns that occur in the setting of blunt
intrinsic buttress system to the midface-however
further differentiation of Le Fort types I, II, and III
depends on involvement of the maxillary, nasal, and
facial trauma (most commonly involving motor zygomatic bones [3-5]. Though mortality rates are
vehicle collision, assault, or falls) [1,2]. All Le low, these fractures seldom occur in isolation and

Journal compilation © 2017 Trauma Research Center, Shiraz University of Medical Sciences
Phillips BJ et al.

are often associated with serious injuries of the head of the search process, totaling 51 studies (Figure
and neck [6]. Thus, the ability to quickly recognize 1). The 51 sources consisted of one Level II study,
and diagnose Le Fort fractures is crucial for proper thirty-six Level IV studies, and fourteen Level V
management of blunt-force facial trauma. articles (Tables 1 and 2). This review found Le Fort
fracture types I, II, and III occurred in 16%, 19%,
Methods and 30% of facial trauma cases (Table 3) and the
majority of these injuries were caused by high-
A comprehensive search of the world’s literature was velocity MVCs (Table 4).
conducted through PubMed and Elton B. Stephens
Co. (EBSCO) databases. Search terms included Table 1. Levels of Evidence
“facial injuries”, “Le Fort”, “facial”, “craniofacial”, Level of Description
and “intracranial” and the resultant articles were Evidence
then categorized according to PRISMA guidelines. I High-quality randomized controlled trials
All studies in English were screened by title and II Lesser-quality randomized controlled trials
abstract for relevance and sources discussing Le Fort III Retrospective comparative study; case control
fracture etiology, epidemiology, diagnosis, treatment, study; systematic review
complications, and outcomes in adults were selected. IV Case series
Studies were excluded due to inadequate study V Expert Opinion or case report
size, inclusion of pediatric populations, or lack of
relevance. The selections were then further limited
to those published between 1980 and 2016 resulting Discussion
in a narrowed reference list of 51 articles (Figure 1).
Background
Results Le Fort fractures constitute a subset of injuries that
result in discontinuity of the midface, a structure
An initial literature search for the term “facial comprised of the maxilla, inferiolateral orbital
injuries” returned 5,854 results. Next, a literature rims, sphenoids, ethmoids, and zygomas. Fracture
search containing “facial injuries” and “Le Fort” to these bones may result in disruption of the facial
returned 491 results. Finally, a literature search buttresses, which provide strength and rigidity to
containing “facial injuries” and “Le Fort” and “facial the facial skeleton. The facial skeleton contains
or craniofacial or intracranial” was done, yielding four paired vertical buttresses: the lateral, medial,
176 results. Of these studies, 46 met inclusion criteria and posterior maxillary, and posterior vertical
and 5 supplemental articles were identified outside mandibular buttresses and four paired vertical

Figure 1. PRISMA-Based Approach

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 Le Fort fractures

Table 2: Le Fort Fractures, 1980-2016, Level II and IV Evidence

Author Year N Level of Evidence
Soong 2014 98 II
Steidler 1980 240 IV
Hendrickson 1998 376 IV
Garri 1999 194 IV
Gassner 1999 562 IV
Girotto 2001 334 IV
Jarupoonphol 2001 64 IV
Maladiere 2001 140 IV
Amin 2002 12 IV
Adebayo 2003 443 IV
Al Ahmed 2004 230 IV
Bagheri 2005 67 IV
Bell 2006 281 IV
Chen 2006 62 IV
Deogratius 2006 314 IV
Holmgren 2007 145 IV
Salonen 2007 155 IV
Lee, KH 2009 2581 IV
Lee, S 2009 121 IV
Guven 2010 16 IV
Salonen 2010 727 IV
Kummoona 2011 673 IV
Mohajerani 2011 243 IV
Zandi 2011 263 IV
Adeyemo 2012 156 IV
Ykeda 2012 277 IV
Hasler 2012 24000 IV
Bellamy 2013 3291 IV
Mundinger 2013 4398 IV
Beogo 2014 227 IV
Kaul 2014 542 IV
Patil 2014 50 IV
Petola 2014 374 IV
Rajkumar 2015 119 IV
Roumeliotis 2015 150 IV
Ruslin 2015 707 IV
Oliveira-Campos 2016 50 IV
McRae 2000 – V
Tibesar 2001 1 V
Brown 2004 – V
Mulholland 2005 – V
Rhea 2005 – V
Carinci 2008 117 V
Fraioli 2008 – V
Lee, C 2008 – V
Noffze 2011 – V
Lo Casto 2012 – V
Patel 2012 – V
Winegar 2013 – V
Devine 2013 1 V
Kunz 2014 – V

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Phillips BJ et al.

Table 3. Le Fort Fracture Incidence

Year Author Specific to Le Fort FX N total LFI (%) LF II (%) LF III (%)
1980 Steidler Yes 240 57 (23.8) 138 (57.5) 45 (18.8)
2001 Jarupoonphol Yes 64 16 (25) 35 (54.7) 7 (10.9)
2003 Adebayo No 443 26 (5.9) 60 (13.5) 8 (1.8)
2004 Al Ahmed No 230 68 (29.4) 27 (10.7) 0
2005 Bagheri Yes 67 22 (32.8) 22 (32.8) 23 (34.3)
2006 Deogratius No 314 10 (3.2) 3 (0.9) 2 (0.6)
2010 Salonen No 727 44 (6) 36 (5) 22 (3)
2011 Mohajerani No 243 26 (10.7) 29 (11.9) 17 (7)
2012 Adeyemo No 156 18 (11.5) 19 (12) 4 (2.5)
2013 Bellamy Yes 3291 691 (21)a 780(23.7)a 1876 (57)a
2014 Kaul No 542 47 (7.7) 78 (14.4) 18 (3.3)
2014 Peltola No 374 38 (10.2) 39 (10.4) 36 (9.6)
2014 Soong No 98 19 (19.4)b 6 (6.1)b 0b
2015 Roumeliotis No 150 39 (26) 7 (4.7) 4 (2.7)
2016 Oliveira-Campos No 50 11 (22) 26 (52) 3 (6)
TOTAL     6989 1132 (16.2) 1305 (18.7) 2065 (30)
a
Some patients sustained different grade fractures on contralateral sides, thus the total percent of patients with Le Fort fractures
is >100%. bThese are the reported isolated Le Fort fractures, 10 patients had fractures involving multiple levels, including 4 LFIII
fractures. Additional information was not available, so it was not included in analysis

Table 4. Le Fort Fracture Etiology and Concomitant Injuries, 1980-Present

Author Year Specific N Most Common M:F Ratio Most Common Most Common
to Le Fort Age Group Etiology Concomitant
Fracture? (years) Injury
Steidler 1980 Yes 240 20-29 (39%) 4.9:1 MVA (80.8%) Nasal Fracture
(60.6%)
Girotto 2001 Yes 334   3:01 MVA (71.1%)  

Jarupoonphol 2001 Yes 664 21-30 (54.7%) 5.4:1 MVA (90.6%) Mandible Fracture
(28.1%)
Adebayo 2003 No 443 30 4.7:1 MVA (55.5%) Craniocerebral
(18%)
Al Ahmed 2004 No 230 20-29   MVA (75%)  
Bagheri 2005 Yes 67 LFI: 37.3 LFI: 2.6:1 MVA (58.2%)  
LFII: 42.5 LFII: 6.3:1
LFIII: 39.8 LFIII: 10.5:1
Deogratius 2006 No 314 20-29 (41.1%) 3:01 Assault (57.6%)  

Salonen 2010 No 727 37 (male); 4:01    

41 (female)
Mohajerani 2011 No 243 20-29 (39.5%) 4.29:1 MVA (65%) Mandible Fracture
(25.5%)
Adeyemo 2012 No 156 21-30 (36.5%) 3.7:1 MVA (93%)  

Ykeda 2012 No 277 20-39 (44%) 3:01 Assault (30.3%)  

Bellamy 2013 Yes 3291 39.6   MVA (40.8%)  

Kaul 2014 No 542 31-40 (36.3%) 3.7:1 MVA (56.8%) Pelvis and Limb
Fractures (64.0%)
Patil 2014 Yes 50 21-30 (54%) 11.5:1 MVA (78%)  

Roumeliotis 2015 No 150 40 11.5:1 Low-velocity Trauma  

[Fall <1 story or
Assault] (63%)
Oliveira- 2016 No 50 21-30 (38%) 9:01 MVA (32%) Zygoma Fracture
Campos (36.5%)

224  Bull Emerg Trauma 2017;5(4)

 Le Fort fractures

buttresses: the upper maxillary, lower transverse complications including extra-ocular muscle injury,
maxillary, upper mandibular, and lower transverse orbital hematoma, globe rupture or impingement,
mandibular buttresses [7] (Figure 2). Disruption and optic nerve damage. Furthermore, damage to the
of these rigid structures may produce the midface medial maxillary buttress has been associated with
instability and potential facial deformity associated epistaxis, cerebral spinal fluid (CSF) rhinorrhea,
with Le Fort fractures. lacrimal duct and sac injury, medial canthal tendon
Le Fort I fractures are horizontal fractures of the injury, and sinus drainage obstruction [4] (Figure 3).
anterior maxilla that occur above the palate and Le Fort III fractures involve the nasal bones,
alveolus and extend through the lateral nasal wall medial, inferior, and lateral orbital walls, pterygoid
and the pterygoid plates. These fractures result processes, and zygomatic arches, which results in
in mobility of the tooth-bearing maxilla and hard complete separation of the midface from the cranium.
palate from the midface and are associated with These fractures affect the medial maxillary, lateral
malocclusion and dental fractures [7] (Figure 3). maxillary, upper transverse maxillary, and posterior
Le Fort II fractures are pyramidal in shape and maxillary buttresses. Similar to Le Fort II fractures,
involve the zygomaticomaxillary suture, nasofrontal they can be associated with orbital complications and
suture, pterygoid process of the sphenoid, and the CSF rhinorrhea [3-5,8] (Figure 3).
frontal sinus. These fractures cause disruption of Though these fractures are defined by the collection
the medial, lateral, upper transverse, and posterior of bones involved, Patil et al. found that only 24% of
maxillary buttresses and produce discontinuity of the Le Fort fractures followed the classically described
inferomedial orbital rims. Involvement of the orbit fracture patterns [9]. In this study, a majority of
seen in such fractures may lead to the development of midfacial fractures (56%) partially resembled classic

Figure 2. Vertical and Transverse Buttress Systems

Figure 3. Le Fort Fracture Patterns

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Phillips BJ et al.

Le Fort fracture patterns but were associated with [23,24]. Falls resulting in facial trauma had a 43.9%
additional mid-face fractures including naso-orbito- incidence of Le Fort fractures, occurred from an
ethmoid, palatal, zygomaticomaxillary, or dento- average height of 7.3 meters, and were associated
alveolar fractures [8]. An additional 20% of facial with extremity, head, or chest injuries 9.8% of the
fractures were comminuted and did not follow Le time [25-27]. Sports-related facial trauma had a
Fort fracture lines at all [9]. As a majority of these greater frequency of Le Fort fractures in high-speed
fractures were caused by MVCs, the high forces sports such as mountain-biking and skiing [28].
involved may be responsible for this deviation from Specifically, Maladière et al. found that there was an
the classically described fracture patterns. This increased incidence of Le Fort fractures in mountain
deviation indicates the need for a revised classification bikers when compared to cyclists (15.2% vs. 3.7%),
system that includes unilateral, comminuted, pan- likely due to the high velocity and dangerous terrain
facial fractures, and associated skull base and mixed associated with mountain biking compared to
dentition fractures [8]. cycling. Conversely, lower velocity maxillofacial
In 2008, Carinci et al., [8] proposed a classification fractures typically occurred in the setting of contact
system that uses seven designated Midface Regional sports such as soccer and rugby [28].
Units (MRU): a single nasal unit, and two paired Drug and alcohol use has been documented in
alveolar, paranasal, and zygomatic units. Using this 28-45% of traumas that result in facial fracture
system, fractures are classified by the number of and has been associated with more severe Le Fort
MRUs involved (Table 5). Le Fort I fractures are fracture types [6,10,14,26,28]. One study found that
classified as F2 or F3 (two alveolar fractures), while positive screens for drug or alcohol use were present
Le Fort II and III fractures are categorized as F4. Le in 13.6%, 18.1%, and 52.1% of Le Fort I, II, and
Fort II fractures contain five MRUs (two alveolar, III fractures [6]. Another study identified positive
two paranasal, and one nasal fracture) and Le Fort III screens for drug and alcohol in 52% of severe and/or
fractures contain all seven MRUs. This classification comminuted Le Fort III fracture patients compared
system shows that there is a high correlation between to 32% in Le Fort I and II fracture patients [13].
the number of MRUs involved, the number of surgical
interventions required, and the number of post- Diagnosis
surgical complications developed [9]. Diagnosis of Le Fort fractures is made through
physical examination and utilization of imaging. It
Etiology is important to note that though physical examination
Trauma velocity has been associated with the findings such as raccoon eyes and midface mobility
type and severity of Le Fort fractures. Low- support the diagnosis of Le Fort fracture, they may
velocity trauma mechanisms, defined as a fall from not always be present and should not be overly relied
standing height or blunt assault, were responsible on for diagnosis. Additionally, providers should
for 56% of Le Fort I fractures. High-velocity avoid assuming bilateral symmetry or terminating
trauma mechanisms, defined as falls from greater the diagnostic process after identification of a single
than one story or high-speed MVCs, were more Le Fort fracture, as these classic fracture patterns
closely associated with Le Fort II and III fractures. are not always followed when injury is associated
Higher grade Le Fort fractures were also associated with high-velocity traumas [29].
with increased rates of concomitant head and neck Several radiologic features should trigger further
injuries that most commonly involved skull fracture evaluation for Le Fort fractures. The most important
(40.7%), closed head injury (5.4%), and cervical feature is the presence of a pterygoid fracture, which
spine injury (5.4%.) [10,11]. is found in all Le Fort fractures types. Other signs
MVCs, assault, and falls were the most common that should prompt the provider to investigate further
etiologies of facial fractures [2,6,8,12-22] (Table 4). for signs of Le Fort fracture include fractures of the
In developing countries, MVCs represented a higher lateral nasal wall, inferior orbital rim, lateral orbital
proportion of fractures compared to all other causes wall, and the zygomatic arch [4].
[14]. Facial trauma that occurred secondary to assault Paranasal sinus effusions may be a useful indicator
commonly resulted in isolated low-energy nasal, to determine whether or not a Le Fort fracture is
orbital or ZMC fractures, however Le Fort I, II, and present. In patients with facial trauma secondary to
III fractures were identified in 6%, 5%, 3% of cases MVCs, a clear sinus sign (CSS) was associated with a

Table 5. Midface Regional Unit Classification System

Fracture Description/ Midface Regional Units Involved Corresponding Le Fort
F in situ Fracture without fragment mobility --
F1 1 --
F2 2 LeFort I
F3 3 LeFort I
F4 ≥4 LeFort II and LeFort III

226  Bull Emerg Trauma 2017;5(4)

 Le Fort fractures

lack of fracture in 73%. Though the lack of paranasal of cases, 30% of cases were managed conservatively,
sinus effusion does not rule out a midfacial fracture and the remaining 10% of cases required no
(sensitivity of 76.7%, specificity of 73.2%), Le Fort treatment. Open fixation for Le Fort fractures at the
I, II, and III fractures were associated with paranasal zygomatic buttress, zygomaticomaxillary suture, and
sinus effusions in 100% of cases [25]. the frontozygomatic suture provides stable fixation
When visualizing Le Fort fractures, 2-D CT and sufficient anatomic repositioning when indicated
imaging is preferable to 3-D CT because it provides [22]. Le Fort fractures are frequently accompanied by
increased detail of fracture lines and associated soft fractures of the hard palate, dentoalveolar unit, and
tissue injuries [8]. However, 3-D CT is capable of the mandible. This creates another set of challenges
identifying Le Fort fractures that are not obviously when attempting repair, as normal occlusion must be
be seen on single 2-D cuts and may be helpful for restored before the upper midface can be anchored to
surgical planning [10]. Multidetector CT (MDCT) is the maxilla. Furthermore, if there are concomitant
considered the imaging modality of choice because zygomaticomaxillary complex, naso-orbito-ethmoid,
it produces high-resolution images and also allows or frontal sinus fractures, reconstruction of the
for 3-D rendering. This facilitates identification of frontal bar should be completed before resuspension
small fracture lines and differentiation of soft tissue of the midface takes place [4].
and bone injury [25]. Upon review of the literature, most Le Fort I
fractures were accessed surgically through a
Management gingivo-buccal sulcus approach, while Le Fort II
Hospitalization was required for 84.5% of and III fractures often required additional subciliary
maxillofacial fracture patients [2]. The percentages or transconjunctival approaches [4]. A coronal
of Le Fort I, II, and III fracture patients taken approach offers wide exposure of the zygomatic
directly to the OR were 9.1%, 27.3%, and 26.1%, the arch in Le Fort II and III fractures, but can result
average hospital length of stay for each patient was in complications secondary to the dissection of
nine days, and each patient underwent an average neurovascular structures [22].
of 1.7 operations [6]. Minimally invasive surgical approaches provide an
Tracheostomy is an effective and safe way of alternate method for surgical management of Le Fort
securing airway management in the setting of severe fracture types II and III as they can be accessed via
facial trauma. One study found that tracheostomy lateral eyebrow, intraoral vestibular, and subciliary
was required in 22.4% of all Le Fort fracture patients approaches. All 10 patients with Le Fort fractures
and 43.5% of Le Fort III fracture patients [11]. The treated by this approach in a 2010 study experienced
need for tracheostomy has been associated with effective aesthetic results-no complications were
poorer outcomes as the mortality rate for patients observed [33]. Endoscopic zygomatic arch repair
that did not require tracheostomy was 0%, while allows for dissection of the deep temporal fascia to
the mortality rate for those requiring tracheostomy protect the facial nerves. An endoscopic approach
was 7.2% [30]. Tracheostomy can often be avoided is not indicated if concomitant fractures necessitate
through utilization of fiber optic intubation raising a coronal flap for repair [34]. Minimally
techniques. Contraindications to endotracheal invasive approaches require increased operative
intubation include concomitant cervical spine injury time, specific training, and specialized equipment,
or blast injuries affecting the face [31]. Retromolar but the potential to conserve facial neurovasculature
intubation, orotracheal intubation secured in is worth considering when managing Le Fort
the retromolar space, allows for intraoperative fractures [34].
mandibulomaxillary fixation and dental occlusion Surgeon preference for the different plating
[26]. Submental intubation allows for unimpeded systems varies, but generally 1.5-2.0 mm plates
access of both the midface and the oral cavity are adequate for fixation of the buttresses. Smaller
[32]. Nasotracheal intubation in the setting of plates may be used at the infraorbital rim, nasal root,
facial fracture is contraindicated as it can result in frontozygomatic region, and zygomatic arch where
sinus infection, mediastinal emphysema, and most less strength is needed and bone grafts may be used
importantly, accidental intracranial intubation [26]. to bridge bony defects present in the buttresses.
The goals for surgical management of Le Fort Management of fractures involving the hard palate
fractures include restoration of facial projection, has traditionally been accomplished with a palatal
height, and proper occlusion [4,31]. Preservation of splint and arch bars, however Hendrickson states
midface structure is dependent on vertical buttress that rigid internal fixation may eliminate the need
repair and restoration of midface aesthetics is achieved for palatal splinting and provide greater stability and
through repair of horizontal buttresses. Surgical accuracy for alignment [31,35].
repair traditionally follows the sequence of arch bar Permanent rigid fixation has been implicated in cases
placement, fracture exposure, fracture reduction, of poor skeletal development. Up to 12% of titanium
malocclusion repair, plate fixation, and soft tissue implants used for facial fractures require removal,
repair [31]. This review found that Le Fort fractures generally due to palpable hardware, pain, plate or
required open reduction and internal fixation in 60% screw loosening or migration, infection, dehiscence,

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Phillips BJ et al.

or thermal sensitivity. Biodegradable hardware is an necessary when evaluating a patient with midface
alternative that provides sufficient stability to facilitate fractures [42].
fracture healing, yet reabsorbs quickly enough to Dental injuries are associated with Le Fort
prevent a foreign body reaction. An additional fractures at higher rates than when compared to all
advantage of biodegradable hardware is that is does facial fractures (47.7% vs. 23.2%.) [43]. This is likely
not require removal if it becomes loose [36]. attributed to the fact that the zygomatic complex
Other less common surgical techniques, including is the facial bone most susceptible to fracture, yet
screw-wire osteotraction, crewe halo and box frame requires bigger insult (due to its location) for dental
techniques, and wire fixation, were noted in our injury to be involved. Blunt facial trauma has been
review of the literature. Screw-wire osteotraction associated with internal carotid injuries in 1.2%
(SWOT) is traditionally used in treatment of lower of cases, and specifically internal carotid artery
facial fractures, however it has been successfully injuries were found in 6.9%, 5.6%, and 3.0% of Le
applied to Le Fort injuries [37]. Crewe halo frame Fort I, II, and III fracture patients [44]. The Eastern
and box frame techniques have also been utilized Association for the Surgery of Trauma (EAST)
to allow for triple rigid fixation for Le Fort II or III recommends screening for internal carotid injury
fractures without the need for incisions [38]. Wire in asymptomatic patients with significant blunt
fixation is also a promising alternative in developing traumatic head injuries including Le Fort II and III
countries where hardware can be prohibitively fracture patients [44].
expensive [11].
In a randomized controlled trial, there was no Outcomes
significant difference in rate of infection between Mortality rates of facial trauma patients depend on
patients treated with 24 hours of post-operative the mechanism of injury, location and severity of
antibiotics and those treated with 5 days of post- injury, and presence of associated injuries. Complex
operative antibiotics [39]. Post-operative infections facial fractures, including Le Fort fractures, had
were detected in 4% of all zygoma and Le Fort a mortality rate of 11.6%, compared to 5.1% seen
fracture patients, with an equal number of infections in simple midface fractures. Le Fort I, II, and III
occurring in both the one-day and five-day groups. fractures had mortality rates of 0%, 4.5%, and 8.7%,
All Le Fort fracture infections were associated with respectively and Le Fort II fractures were associated
Le Fort I fractures treated by open reduction internal with a 1.94-fold increased mortality risk when
fixation (ORIF) through an intraoral approach. compared to simple facial fractures [21]. Le Fort
Factors such as body mass index (BMI), implant fractures are associated with significant morbidity,
type, presence of multiple fractures, and smoking including the development of visual problems (47%),
history had no impact on the rates of post-operative diplopia (21%), epiphora (37%), difficulty with
infection [39]. breathing (31%), and difficulty with mastication
(40%) [13]. Patients with severe or comminuted Le
Concomitant Injuries Fort fractures have been reported to have higher
Patients with facial fractures should be evaluated levels of injury-related disability [13]. Fewer patients
for potential cervical spine and head injuries, with a Le Fort III or comminuted fracture were
especially when the injury has been sustained from able to return to work compared with those that
a high velocity mechanism [40]. Le Fort fractures, had sustained Le Fort I or II (58% vs. 70%.) [13].
specifically, have been associated with spinal fracture Satisfactory outcomes with regards to function and
or dislocation (1.4%) and cervical cord injury (1%) aesthetics were achieved in 89.1% of patients, while
[40]. Higher grade Le Fort fractures (types II and long term infection, temporary temporomandibular
III) have been associated with a 2.88-fold and 2.54- joint stiffness, or facial deformity were seen in 10.9%
fold increased risk of concomitant intracranial of patients [14].
injuries, and of facial fracture patients requiring
neurosurgical intervention, 70% had sustained Le Conclusion
Fort III fractures [10,11,21].
Ocular injuries including periorbital edema, Le Fort fractures are specific patterns of facial
subconjunctival ecchymosis, chemosis, diplopia, bone fractures that develop secondary to blunt
retrobulbar hemorrhage, optic nerve compression, facial trauma. While mortality rates due to Le Fort
traumatic mydriasis, and retinal detachment have fractures themselves are low, these injuries rarely
been associated with 8.3% and 6.7% of Le Fort II occur in isolation and are frequently associated
and III fracture cases [41]. Of the ocular injuries with other severe injuries to the head and neck. The
associated with midface fractures, 4.5% required ability to quickly and accurately diagnose Le Fort
ophthalmologic surgical intervention for either fractures is crucial to the successful management
lens dislocation or ruptured globe repair. Retinal of blunt facial trauma patients. Our review found
detachment leading to blindness was present in that there is a lack of published data regarding Le
0.84% of these patients [42]. Because of the potential Fort fracture management, especially reporting on
for ocular injury, a thorough ocular examination is the usage of minimally invasive surgical techniques

228  Bull Emerg Trauma 2017;5(4)

 Le Fort fractures

and long term outcomes. Further research is needed Compliance with Ethical Standards
to determine the optimal management plans for
these patients. All authors state clearly that we have nothing to
disclose regarding potential conflicts of interest.
Acknowledgments This collective review study did not directly involve
Human Participants and/or Animals. As such,
The authors would like to thank the following informed consent was not required. This article does
residents and students for their help and assistance not contain any studies with human participants or
with this manuscript: S. Typher, E. Samlowski, E. animals performed by any of the authors. External
Murray, and S. Holzmer. sources of funding were not used in either the
preparation or submission of this manuscript.
Funding
External sources of funding were not used in either Conflicts of Interest: None declared.
the preparation or submission of this manuscript.

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