LE FORT I,II,III #s

/CLASSIFICATION /CLINICAL
FEATURES/INVESTIGATIONS
 CONTENTS
• INTRODUCTION
• DEFNITIONS
• CLASSIFICATIONS
• CLINICAL EXAMINATION
• SIGNS & SYMPTOMS
• INVESTIGATIONS
• BIBLIOGRAPHY
 ROWE & KILLEY[1968]
INCIDENCE
• Zygomatic bone & arch 336 53%
• Premaxilla 58 9.2
• u/l lefort I 24 3.8
• u/l lefortII 13 2.6
• Le fort I 27 4.2
• Le fort II 53 8.4
• Le fortI & II 36 5.7
• Le fort III 23 3.6
• Le fort I & III 12 1.9
• Le fort I,II, III 3 .47
• Nasal # 44 6.9
Classifications
Lefort classification (Rene Lefort 1901)
• Lefort I (low level/Guerin)
• Lefort II (Pyramidal/Sub-zygomatic)
• Lefort III (transverse or supra zygomatic)

Modification of Lefort fracture (Marciani 1993)

• Lefort I – Low maxillary #
• Ia – Low maxillary # Multiple Segment
• Lefort II – Pyramidal #
• II a – Pyramidal # and nasal #
• II b – Pyramidal # and NOE #
• Lefort III – Craniofacial dysjunction.
• III a – Craniofacial dysjunction and nasal bone #
• III b – Craniofacial dysjunction and NOE #
• Lefort IV – Lefort II or III #cranial base #
• IV a – Supra orbital rim #
• IV b – Ant cranial fossa and supra orbital rim #
• IV c – Ant cranial fossa and orbital wall #
Erichs classification (1942)
Direction of # line
• Horizontal #
• Pryamidal #
• Transverse #
c) Depending on relationship of # line to zygomatic bone.
• Below the zygomatic bone – Sub zygomatic #
• Above or including the zygomatic bone– Supra
zygomatic #
d) Level of # line
• Low level #
• Mid level #
• High level #
Le Fort I, Horizontal, Floating palate
Le Fort II, pyramidal, Floating maxilla
Le Fort III, Transverse, Floating face
Rowe and Williams classification (1985)
Fracture not involving occlusion
• Central (# nasal bone, septum, frontal process of
maxilla)
• Lat region (# zygomatic bone, arch and maxilla)
Fracture involving occlusion
• Dento alveolar
• Sub zygomatic
• Supra zygomatic
Facial buttresses
PILLARS[H & V BUTTRESSES]
Sutures of the skull
Pterygoid plate
The hallmark of Lefort fractures
is traumatic pterygomaxillary
separation, which signifies
fractures between the
pterygoid plates
CLINICAL EXAMINATION
LE FORT I
LE FORT II
LE FORT III
Lefort I fracture
• floating palate, may result from a force of injury directed low
on the maxillary alveolar rim, or upper dental row, in a
downward direction. The essential component of these
fractures, in addition to pterygoid plate involvement, is
involvement of the lateral bony margin of the nasal opening.
They also involve the medial and lateral buttresses, or walls,
of the maxillary sinus, traveling through the face just above
the alveolar ridge of the upper dental row.
Clinical features:

• Edema

• Echymosis in the labial and buccal vestibule

• Bilateral epistaxis

• Mobility of the upper dentoalveolar portion.

• Pain while speaking and moving jaw

• Disturbed occlusion, anterior openbite

• Cracked pot sound.

Lefort II #
• pyramidal fracture, with the teeth at the pyramid base, and
nasofrontal suture at its apex
• fracture arch passes through the posterior alveolar ridge,
lateral walls of maxillary sinuses, inferior orbital rim and nasal
bones
• uppermost fracture line can pass through the nasofrontal
junction or the frontal process of the maxilla
• It results from a blow to the lower or mid
maxillary area. In addition to pterygoid plate
disruption, their distinguishing component is
involvement of inferior orbital rim.
Clinical Features
• Gross edema
• Mobility of the midface
• Bilateral circumorbital edema and ecchymosis
• Bilateral sub conjuctival haemorrhage on the medial
half of the eye
• Bridge of the nose is depressed
• Ballooning of the face, moon face
• Lengthening or elongation of the face
• Shortening of face and open bite, in case of impaction
of fracture fragment in to the cranial base
 c/f…
• Bilateral epistaxis
• Difficulty in mastication and speech
• Loss of occlusion
• Airway obstruction
• CSF leak
• Step deformity at the infraorbital margin.
• Anesthesia or Paresthesia of the cheek, infraorbital one
• Dish face deformity
Periorbital edema, ecchymosis
Ballooning of the face : moon face
CSF rhinorrhea: Halo/double ring sign
Lefort III #
• craniofacial disjunction
• transverse fracture line passes through nasofrontal
suture, maxillo-frontal suture, orbital wall, and zygomatic
arch/zygomaticofrontal suture
• because of the involvement of the zygomatic arch, there is a
risk of the temporalis muscle impingement
• unsurprisingly type III fractures have the highest rate of CSF
leak
Clinical Features
• Gross edema
• Bilateral circumorbital ecchymosis
• Bilateral subconjuctival hemorrhage
• Dish face deformity
• Epistaxis,
• CSF rhinorrhoea
• Gaging of occlusion

Clinical features of Lefort III alone

• Tenderness at fronto zygomatic suture
• Deformity of zygomatic arch.
• Depression of occular level
• Enophthalmus
• Nasal disorganisation.
• CSF rhinorrhoea
• Mobility of the whole facial skeleton as a single block.
INVESTIGATIONS
RADIOGRAPHS
• Occipitomental view
• Occlusal view of maxilla
• Waters projection ( sinus view )
• Lateral oblique view
 CT Scan
 3 D Recon
NORMAL WATER’ S VIEW
WATER’S VIEW [4 S s]
LATERAL OBLIQUE VIEW
CALDWELL VIEW
SUBMENTO VERTEX
CT & 3D