Shahid R. Aziz

Department of Oral and Maxillofacial Surgery, Rutgers University School of Dental Medicine, Camden, New Jersey, USA

Reduction of displaced fractures and restoration of occlusion and facial aesthetics.

Indications for Reduction of Le Fort Fractures

1. Malocclusion
2. Mobility at the fracture site: Le Fort I (mobility of the maxilla), Le Fort II (mobility of the nasal-maxillary complex), and Le Fort III (craniofacial disjunction—mobility of the facial skeleton from the lateral orbital rims to the maxilla)
3. Significant aesthetic deformity

Contraindications

1. Nondisplaced fractures with no malocclusion
2. Contraindications to general anesthesia (medically unstable for treatment)

Anatomy

• Le Fort I fracture: Transverse fracture of the maxilla separating the maxillary alveolus from the pterygoid plates, lateral antral wall, lateral nasal wall, and lower third of the septum
• Le Fort II fracture: Pyramidal fracture extending from the pterygoid plates superiorly across the lateral antral wall, extending through the infraorbital foramen and medial orbital floor, and posterior to the lacrimal bone, through the nasal bones, and terminating at the nasofrontal suture
• Le Fort III fracture: “Craniofacial disjunction”—fracture extending from the pterygoid plates through the zygomaticotemporal and zygomaticofrontal sutures through the lateral orbital wall and posterior orbital wall, and posterior to the lacrimal bone, through the nasal bones, and terminating at the nasofrontal suture

See Figure 14.1 for a comparison of Le Fort fracture patterns.

Le Fort Fracture Signs and Symptoms

• Le Fort I fracture: Maxillary mobility, malocclusion, maxillary buccal vestibule and palatal ecchymosis, maxillary crepitus and upper lip and midface edema
• Le Fort II fracture: Nasal-maxillary complex mobility, malocclusion, maxillary buccal vestibule and palatal ecchymosis, V2 paresthesia or anesthesia, loss of anterior-posterior dimension of the midface, nasal asymmetry, epistaxis, cerebrospinal fluid (CSF) rhinorrhea, epiphora, subconjunctival hemorrhage, diplopia, enophthalmus, midface and periorbital edema, midface crepitus and ecchymosis
• Le Fort III fracture: Complete mobility of the anterior facial skeleton inferior to the zygomaticofrontal suture (craniofacial disjunction), V2 paresthesia or anesthesia, nasal asymmetry, epistaxis, CSF rhinorrhea, epiphora, subconjunctival hemorrhage, traumatic telecanthus, enophthalmus, diplopia, dystopia, increase in the vertical dimension of the face, tenderness and palpation of fractures at the lateral orbital rim, midface and periorbital edema and midface and periorbital crepitus and ecchymosis

Le Fort Reduction Technique

1. Preoperative antibiotics are given to cover sinus flora and wound contamination.
2. The airway is secured via nasal intubation, tracheostomy, or submental intubation.
3. The patient is prepped and draped to include both the oral cavity and the maxillofacial skeleton.
4. Local anesthesia containing a vasoconstrictor is injected into sites of incision placement.
5. Maxillary and mandibular arch bars are placed, and the pre-traumatic occlusion is reestablished. The placement of maxillomandibular fixation (MMF) may be difficult, depending on the displacement of the fractures. For grossly displaced Le Fort fractures, Rowe disimpaction forceps may be used to aid in the mobilization and reduction of the maxilla. When placing the patient into MMF, the fractured maxilla is neutrally set to mandible to ensure proper seating of the condyles.
6. Fractures are typically reduced and fixated with a bottom-to-top rationale. After the establishment of MMF, the mandible is internally fixated prior to fixation of the Le Fort fractures.
7. After the occlusion has been reestablished (and, if necessary, the mandible has been fixated), all facial fractures are exposed. A high maxillary buccal vestibular incision is used in all three types of Le Fort fractures (Figure 14.3). Le Fort II and III fractures are approached through a variety of incisions to include subciliary, transconjunctival, superior blepharoplasty, lateral brow, and coronal. Care should be taken to identify and preserve the infraorbital neurovascular bundles.
8. Once all fractures are exposed, manual reduction is employed, and the fractures are stabilized with rigid internal fixation. Fractures are ideally plated along the natural horizontal and vertical buttresses of the face. Depending on the surgeon’s preference and the comminution of the fractures, MMF may be utilized for 4–6 weeks without internal fixation. Howeve/>
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