lefort fractures are an important set of fractures to learn among midfacial fractues which requires a thorough anatomical knowlwdge for adequate management of patient as they suffer from mild to severe aesthetic deformities in addition to functional compromise which needs to be corrected with precise knowledge and care

1. LEFORT FRACTURES
DEPT. OF ORAL AND MAXILLOFACIAL SURGERY,
K. KRISHNA LOHITHA,Post Graduate

2. MIDDLE THIRD OF THE FACE
 The middle third of the face is the area bounded by:
 superiorly- by a line drawn from the
zygomaticofrontal suture accross the frontonasal
and frontomaxillary suture to the zygomaticofrontal
suture of the opposite side
 Inferiorly- by the occlusal plane or alveolar ridge
 Posteriorly- as far as the frontal bone above and
body of sphenoid below

3.  The maxilla represents the bridge between cranial base
superiorly and dentition inferiorly.
 Its intimate association with the oral cavity, nasal cavity and
orbits and the important structures adjacent to it make the
maxilla a functionally & cosmetically important structures.
 Fractures of these bones is potentially life threatening as well
as disfiguring.

4. BUTTRESSES OF FACIAL SKELETON
VERTICAL BUTTRESSES
 Nasomaxillary/ medial buttress
 Zygomaticomaxillary/ lateral buttress
 Pterygomaxillary/ posterior buttress
 The condyle and posterior ramus
HORIZONTAL BUTTRESSES
 Frontal buttress
 Zygomatic buttress
 Maxillary buttress
 Mandibular buttress

6.  ETIOLOGY
 RTA most common -40%
 Industrial mishaps -10%
 Assaults -15%
 Sports -25%
 Fall -10%
 EPIDEMIOLOGY :
o Most maxillary fractures occur in young men bw 16-40 years.
o Peak age 21 – 25years
o Male : Female – 4:1

7. HISTORY :
 The first clinical examination of a maxillary fracture was
recorded in 2500 BC.
 In 1822 Charles Fredrick William Reiche provided the
first detailed description of maxillary fractures.
 In 1823 Carl Ferdinand van Graefe described the use of a
head frame for treating a maxillary fracture
 In 1901 , Rene lefort carried out experienced studies on 32
cadaver heads by inflicting trauma to them.
 He then dissected the head region & discovered that the
fractures in the middle third of the face follow complex fracture
patterns which seen along the lines of weakness.
 Lefort noted that generally face was fractured & the skull was
not.
 He then stated that fractures occured through three weak
lines in the facial bony structures.
 From these lines lefort classification was devoloped.

8.  Classification :
 Erich (1942) – As per the direction of fractureline.
1. Horizontal fracture
2. Pyramidal fracture
3. Transverse fracture
 Depending on the relationship of fracture line to zygomatic
bone.
1. Subzygomatic
2. Suprazygomatic
 Depending on level of fracture line
1. Low level
2. Mid level
3. High level

9. By Rowe and Williams (1985)
1. central region
 a. Fractures of nasal bone l nasal septum
i) lateral nasal injuries
ii) anterior nasal injuries
 b. Fractures of frontal process of maxilla
 c. Fractures of type a & b which extend into ethmoid bone (
nasoethmoid)
 d.fractures of type a, b & c which extend into frontal bone
(fronto- orbito- nasal dislocation)
2. Lateral region
fractures involving zygomatic bone, arch, maxilla(
zygomatic complex) excluding the dento alveolar component

10. B. Fractures involving occlusion
 1. dentoalveolar fracture
 2. sub- zygomatic
 a. Lefort-I
 b. Lefort – II
 3. supra zygomatic
 c. Lefort III

11. MARCIANI MODIFICATION(1993)
 Lefort I : low maxillary fracture
 Lefort Ia : low maxillary/multiple segment fracture
 Lefort II : pyramidal fracture
IIa : pyramidal & nasal fracture
IIb : pyramidal & NOE fractures
 Lefort III :craniofacial dysjunction
IIIa: craniofacial dysjunction & nasal fractures
IIIb: craniofacial dysjunction & NOE fractures
 Lefort IV :lefort II& III & cranial base fracture
IVa :lefort IV with supraorbital rim fracture
IVb :lefort IV with anterior cranial base
IVc :lefort IV with anterior cranial base and orbital
wall fracture

12. HENDRICKSON CLASSIFICATION OF PALATAL FRACTURES
Type I : alveolar
Ia : anterior alveolar ( incisors)
Ib : postrior alveolar (premolar& molar)
Type II : sagittal
Type III : parasagittal
Type IV : para alveolar
Type V : complex
Type VI : transverse

14. LEFORT I FRACTURE
 Horizontal fracture of maxilla
 guerin’s fracture
 Floating frcture
 Low level fracture
 Pterygomaxillary dysjunction
 Subzygomatic fracture( lefort I & lefort II)

15. LEFORT 1 FRACTURE
 Violent force over a more extensive area above the
level of the teeth will result in lefort I fracture
 Horizontal fracture line is seen above the apices of
maxillary teeth, detaching the tooth bearing portion
of maxilla from rest of the facial skeleton
 The fractured fragment is freely mobile and
displacement depends on the direction of force
 Depending upon the displacement, a variety of
occlusal disharmony can be seen

17.  The fracture line commences at the lateral margin of the anterior
nasal aperture , passes above nasal floor, and it passes laterally
above the canine fossa and traverses the lateral antral
wall,dipping down below the zygomatic buttress and then
inclines upward and posteriorly across the pterygomaxillary
fissure to fracture the pterygoid laminae at the junction of their
lower third and upper two thirds.
 At the same time, from the same stating point , the fracture also
passes along the lateral wall the nose to join the lateral line of
fracture behind the tuberosity.

18. LEFORT 1 FRACTURE
 Mostly bilateral
 Sometimes unilateral depending upon the
displacement, direction and severity of force
 May occur as single entity or with lefort I and II
fractures

19. SIGNS AND SYMPTOMS OF LEFORT I FRACTURE
 EXTRAORALLY
 Slight swelling and edema of the lower part of the
midface and the upper lip
 Epistaxis
 Pain and mobility
 Air emphysema in some cases
 Incresed vertical dimension of face

20. INTRAORALLY
 Floating maxilla
 Impacted or telescopic fracture
 Anterior open bite
 Disturbed occlusion
 Ecchymosis
 Cracked pot sound
 Midpalatal split in some cases
 GUERIN’S SIGN

21. LEFORT II FRACTURE
 Pyramidal or sub zygomatic fracture
 Violent force in the central region extending from
glabella to the alveolus results in pyramidal fracture

23.  The fractre line runs below the frontonasal suture from the thin
middle area of the nasal bones down on the either side ,
crossing the frontonasal process f the maxillae and passes
anteriorly across the lacrimal bones anterior to nasolacrimal
canal.
 From this point the fracture passes downward , forward and
laterally crossing the inferior orbital margin in the region of
zygomaticomaxillary suture.
 It may or may not involve the infra orbital foramen.
 The fracture line extends downward and forward and lateral to
the transverse wall of the antrum , just medial to the
zygomaticomaxillary suture line -extends on to ptreygoid
laminae in its middle portion
 Postromedially- separation of block from skull base is completed
via nasal septum and may involve floor of ant cranial fossa

25. SIGNS AND SYMPTOMS OF LEFORT II FRACTURE
EXTRAORALLY
 Balooning or moon face
 Dish face deformity
 Bilateral circumorbital edema or echymosis(black eye)
 Subconjunctival ecchymosis
 Edema of the conjunctiva or chemosis
 Detection of step deformity in the bone of infra orbital margin
 Mobility of the midface
 Anaesthesis or parasthesia of cheek
 Possible diplopia
 CSF rhinorrhea
 No tenderness over or disorganization and mobility of zygomatic bones
and arch
 Elongation or lengthening of face
 Emphysema of soft tissues
 Nasal disfigurement

27. INTRAORALLY
 Derranged occlusion
 Posterior gagging of occlusion with retropositioning
of maxillae with anterior open bite
 Airway obstruction
 Extensive bruising of soft palate, midplalatine split

28. LEFORT III FRACTURE
 High level fracture
 Transverse fracture
 Suprazygomatic fracture
 Craniofacial dysjunction
 Due to severe impact from the lateral surface

30.  Frontonasal suture-accross nasal bones, lacrimal bones, orbital
plate of ethmoid(medial wall of orbit) – optic foramen-
downwards and laterally to posterior end of inferior orbital
fissure
 2 pathways of fracture lines
- -The first part descends accross pt aspect of maxilla accross
pterygomaxillary fissure and fractures the root of pterygoid
plates
- - the next fracture line runs accross the lat wall of the orbit
separating the zygomatic bone from frontal bone at FZ region

31. SIGNS AND SYMPTOMS OF LEFORT I FRACTURE
EXTRAORALLY
 Tenderness and separation at FZ suture
 Lengthening of face
 One or other zygomatic complex fracture with displacement
 Flattening and a step deformity at the infra orbital margin
 Movement of entire facial skeleton as a single block
 Enopthalmos
 Hooding of the eyes
 Profuse CSF rhinorrhoea and CSF otorrhoea
 Panda facies
 dish face deformity
 Battle’s sign
 Orbital dystopia with associated antimongoloid slant
 Flattening, widening and deviation of nasal bridge

36.  INTRAORALLY
 Derranged occlusion
 Posterior gagging of occlusion with retro positioning
of maxillae and anterior open bite
 Airway obstruction
 Sagittal fracture of the palate – variant of lefort III
fracture

37. CSF RHINORRHOEA

38. MANAGEMENT OF PATIENT WITH MIDFACE INJURIES
 1. EMERGENCY CARE & STABILIZATION
 2. INITIAL ASSESSMENT
 3. DEFINITIVE TREATMENT
 4. REHABILITATION

39. 1.. EMERGENCY CARE & STABILIZATION
 Preserve the airway.
 Control of haemorrhage.
 Prevent or control shock.
 C – spine stabilization.
 Control of life threatning injuries.
 Head injuries , chest injuries , compound limb
fractures, intra abdominal bleeding

40. 2.INITIAL ASSESSMENT OF MAXILLOFACIAL INJURIES
 HISTORY: nature of & exact time
 CLINICAL EXAMINATION: physical signs
 RADIOGRAPHIC EXAMINATION
 SPECIAL INVESTIGATION
 Impressions taken : For study model
To determine occlusion
Fabricate capsplints

41. CLINICAL ASSESSMENT OF MIDFACE
FRACTURES
 Extra-oral & Intra-oral examination.
 Inspection.
 Palpation.

42. EXTRAORAL EXAMINATION
Inspection of midface-
 Swelling & Facial Asymmetry.
 Bruising of upper lip and lower half of mid-face.
 Bilateral Circum-orbital Ecchymosis ( Racoon’s eye).
 Periorbital Oedema.
 Subconjunctival Hemorrhage. Cerebrospinal fluid
rhinorrhoea
 Lengthening of Midface
 Depressed midface (dish face)
 Saddle shaped depression of nose
 Enophthalmos
 Proptosis
 Diplopia

43. Subconjunctival hemorrhage-
 • Localized (black eye) confined to preseptal soft tissues
 (Also seen in anterior cranial fossa, orbital & zmc
fractures.)
Cerebrospinal Fluid Rhinorrhoea
 -Watery nasal or postnasal salty discharge
 (Ring Test- but it lacks sensitivity & specificity

44. PALPATION -
 1. Subcutaneous Emphysema – Crepitus
 2. Tenderness
 3. Step Deformity
 4. Abnormal Mobility of bone
 5. Impairment of sensation

45. INTRAORAL EXAMINATION
INSPECTION
 1.Disturbed occlusion (posterior occlusal gagging, open
bite)
 2. Haematoma intraorally over root of zygoma
 3. Haematoma in palate (Guiren’s sign)
 4. Fractured cusps of teeth
 5. Midline diastema

46. PALPATION
 Mobility of whole of tooth bearing segment of upper
jaw elicited at dentoalveolar segment in lefort I

47.  Mobility of whole of the upper jaw (free-floating) elicited at
infraorbital margin in Le Fort II fracture.

48.  Mobility of whole of the upper jaw (free-floating) elicited at
fronto-zygomatic suture in Le Fort III fracture.

49. RADIOGRAOHIC INVESTIGATIONS
 CT scan
 3D CT scan
 Waters view
 PA skull view
 Reverse townes projection
 True Lateral view
 Soft tissiue lateral
 Intra oral occlusal radiographs
 Orthopantomogram
 submento vertex view

50. DEFINITIVE TREATMENT
A. Preoperative planning:
1. Type of fixation
2. open/ closed reduction
3. Type of IMF
4. Need for tracheostomy
B. Timing of pre operative procedure
minimal fractures taking less operative time can be
performed during emergency management being
performed in operation theatre
It is quite wrong at this time, to embark on any operative
procedure which cannot be accomplished in a limited
period of time.
Timing of midfacial # : optimum time: 5-8th postop time

51. C.OPERATIVE PROCEDURE
1. tracheostomy
2. facial lacerations:Ideally these should be sutured before
too much oedema has occured; that is within 1-8 hours of
injury.
3. reduction of associated mandibular #
4. Occlusion:
 extractions if needed
 arch bars/ cap splints for mandible
 For maxilla after reduction of fracture
5.Zygomatic fractures
eg: lefort # displaced posteriorly, allowing medial rotation
of zygomatic bones
Dx: lateral disimpaction & forward movement of maxilla

52. 6. Disimpaction & reduction of maxilla
 Rowes disimpaction forceps
 Walsham nasal forceps
 Hayton williams forceps( palatal #)
 Initial traction: downward displacement of pterygoid
plates by cocking the wrists upwards
 Then traction in downward and forward direction to
mobilise maxilla parallel to
base of skull
Rocking and rotational
movements –
final disimpaction

53. 7. Open reduction
8. Skeletal fixation
9. Temporary IMF
10. Nasal fractures
11. Definitive IMF
D. IMMEDIATE POST OP CARE

54. E.POST OP MANAGEMENT:
 1. General management
 2. Maxillofacial management
 check external skeletal fixation for stability
 IMF for rigidity
 oral hygiene
 sutured lacerations, surgical wounds &
incisions should be scrupulously clean
 timing of suture removal
 change of nasal plaster
 chemosis: 1% chloramphenicol ointment

55.  4. REHABILITATION:
 A. General rehabilitation
 B. Maxillofacial rehabilitation
 Secondary correction of facial scars
 Pschyartric support
 Restoration of teeth

56. MANAGEMENT OF LEFORT FRACTURES
BASIC PRINCIPLES
1. reduction
2. fixation
3.immobilization
4. rehabilitation

57. REDUCTION
 Restoration of the fractured fragments to their
original anatomical position
 Two types
 closed reduction
 open reduction

58. CLOSED REDUCTION
Alignment without visualisation of the fracture line
i) reduction by manipulation
ii) Reduction by wires
iii) Reduction by using maxillary disimpaction forceps
iv) reduction by traction
OPEN REDUCTION
 Surgical reduction allows visual identification of fractured
fragments

59. FIXATION
 In this phase, fractured fragments are fixed in their
normal anatomical relationship to prevent
displacement and acheive proper approximation
 Types
 Direct skeletal fixation
 indirect skeletal fixation ( intra oral or extra oral)

60. DIRECT SKELETAL SUSPENSION
 1. external – Device is outside the tissues but
inserted into the bone percutaneously
 Eg: bone clamps and pins
 2. internal – devices are totally enclosed within the
tissues and uniting the bone ends by direct
approximation
 Eg: transosseous wiring and plating system

61. IMMOBILIZATION
INTERNAL FIXATION:
1. DIRECT OSTEOSYNTHESIS
a. Transosseous wiring at fracture sites
i. High level (frontozygomatic and frontonasal)
ii. Mid level ( orbital rim/ zygomatic buttress)
iii. Low level ( alveolar/ midpalatal)
b. Miniplates
c. Transfixation with kirschner wire or steinmann pin
i. Transfacial
ii. Zygomatic – septal
2. SUSPENSION WIRES TO MANDIBLE
a. Frontal – central / lateral
b. Circumzygomatic
c. Zygomatic
d. Infra orbital
e. Pyriform aperture
3. SUPPORT
a. Antral pack
b. Antral balloon

62. EXTERNAL FIXATION
1. CRANIOMANDIBULAR
a. Box frame
b. Halo frame
c. Plaster of paris headcap
2. CRANIOMAXILLARY
a. Supra orbital pins
b. Zygomatic pins
c. Halo frame’
3. SUSPENSION BY CHEEK WIRES FROM HALO
FRAME OR HEAD CAP

63. TRANSOSSEOUS WIRING
1.Maxillary (Lefort –I )
2. Zygomaticomaxillary (Lefort –II)
3. Frontonasal (LeFort &III)
4. Zygomaticofrontal (Lefort III)
5. Zygomatic bone (comminuted)

64. Disadvantages -
 Non rigid type of osteosynthesis
 No 3 dimensional stability, it provides only
 monoplane traction.
 IMF is always needed
 Interfragmentary pressure can not be controlled.
 Under functional stress, wire loses rigidity, direction
 control and surface contact.
 Delayed healing because of micromovement at
fracture site.

65. PLATES & SCREWS FOR MIDFACE FRACTURES
 Stainless steel mini-plating system
 Titanium mini-plating system
 Vitallium, Cobalt chromium, molybdenum alloy
plates
 Bioresorbable plating system
Advantages –
 1. Simple & less intraoperative time
 2. Intraoral approach is sufficient
 3. Postoperative IMF is not needed or period of
 IMF is reduced.
 4. Three dimensional stability and early return of
 function.

66. CIRCUMZYGOMATIC SUSPENSION- OBSWEGESOR

67. INFRAORBITAL
SUSPENSION
PYRIFORM APERTURE
SUSPENSION

69. DISADVANTAGES OF SUSPENSION WIRING
 Incomplete fixation of fractured fragments
 Insufficient visualization of fractures by closed
Reduction
 Compression against the cranial base
 No 3-dimensional stability
 Patients dislike intra-oral splints as it hinders
 oral hygiene maintainence.

70. BOX FRAME

71. HALO FRAME LEVANT FRAME

72. PLASTER OF PARIS HEADCAP

73. TREATMENT OF LEFORT I FRACTURES
 Aim : to reestablish
anterior projection
transverse width
occlusion
Undisplaced lefort I: MMF for 4 weeks
direct mini plate fixation with no MMF
Displaced lefort I : direct miniplate fixation
indirect suspension with MMF
Comminuted : MMF and suspension
Suspension wires in lefort I: zygomatic
infraorbital
pyriform aperture

75. TREATMENT OF LEFORT II FRACTURES
Undisplaced lefort II with minimal occlusal discrepancy:
 Circumzygomatic suspension with MMF for 4 weeks
 Direct fixation at ZM buttress
Displaced mobile lefort II with anterior open bite
 Direct fixation or indirect suspension with MMF

77. TREATMENT OF LEFORT III FRACTURES
Team approach
 neurosurgery
 ophthalmology
 oral & maxillofacial surgery
AIM:
 Reestablishment of intercanthal distance
 Infraorbital rim fixation
 Orbit is reconstructed
 Occlusion
 Intubation must not interfere with ability to use IMF
 Exposure and visualisation of all fractures

79. APPROACHES TO LEFORT FRACTURES
 1.Supraorbital eyebrow incision (Lefort III)
 2. Subciliary incision (LeFort II & III)
 3. Median lower lid (LeFort II & III)
 4. Infraorbital incision (LeFort II & III)
 5. Transconjunctival (LeFort II )
 6. Zygomatic arch
 7. Transverse nasal (LeFort II & III)
 8. Vertical nasal incision (LeFort II & III)
 9. Medial orbital incision.
 10. Intra-oral vestibular incision. (LeFort I)

81. COMPLICATIONS
 Non union
 Delayed union
 Mal union
 Infection
 Plate exposure
 Occlusal derangement
 Facial assymetry
 Meningitis
 Injury to lacrimal system
 Neurological complications

82. REFERENCES
 RJ FONSECA – TRAUMA VOL 2
 Peterward Booth – vol 1
 Rowe and Williams – vol 2
 Killey’s fracture of the middle third of the facial
skeleton

83. INITIAL MANAGEMENT
 The primary survey progresses in a logical manner based on
the ABC’s & D.E.
 Airway maintenance with cervical spine control.
 Breathing and adequate ventilation.
 Circulation with contol of hemorrhage.
 The letters D & E have also been added.
 Degree of consciousness
 Exposure of patient via complete undressing to avoid
overlooking injuries camoflaged clothing.

84. EMERGENCY CARE
 .
EVALUATE THE AIRWAY
 Existence & identification of obstruction
 Manually clear of fractured teeth, blood clots, dentures.
 Endotracheal intubation & packing of oronasal airway.