Fraktur Maksilofasial (LeFort)

01Pathophysiology

LeFort fractures represent a classification of midface fractures based on lines of structural weakness in the maxillary complex. When a significant blunt force impacts the midface, the energy propagates through predictable pathways of least resistance, producing one of three fracture patterns. In clinical practice, mixed or asymmetric patterns are common (e.g., LeFort II on one side and III on the other), but exams typically test pure, symmetric types.

The pterygoid plates of the sphenoid bone are involved in all three LeFort types. This is the single most testable anatomical fact. The pterygoid plates serve as the posterior buttress of the maxilla, and their fracture is what allows the anterior midface to become mobile. If pterygoid plates are intact on imaging, the fracture does not meet criteria for any LeFort classification.

In LeFort I, the fracture line runs horizontally above the alveolar ridge, crossing through the piriform aperture (anterior nasal floor), the lateral wall of the maxillary sinus, and posteriorly through the pterygoid plates. The result is a free-floating hard palate and dentoalveolar segment. The patient presents with malocclusion, and when you grasp the upper teeth and push, the palate moves independently while the nose and orbital rims remain stable.

In LeFort II, the fracture line ascends in a pyramidal shape. It begins at the nasofrontal junction (bridge of the nose), crosses through the medial orbital wall (lamina papyracea and lacrimal bone), continues along the inferior orbital rim (orbital floor), descends through the anterolateral maxillary wall, and exits posteriorly through the pterygoid plates. This separates the central maxilla along with the nose as a single pyramidal fragment. The clinical consequence is that the nose and maxilla move together on palpation, but the zygomatic arches and lateral orbital rims remain stable. Infraorbital nerve (V2) hypoesthesia is classic because the fracture crosses the infraorbital foramen or canal. Bilateral periorbital ecchymosis and subconjunctival hemorrhage are typical.

In LeFort III, the fracture line extends through the nasofrontal suture, across the medial orbital wall, through or near the orbital apex, across the lateral orbital wall, and through the zygomatic arch and pterygoid plates bilaterally. This completely separates the entire midface from the skull base, which is why it is called craniofacial disjunction. The entire face appears elongated and flattened ("dish face" deformity). CSF rhinorrhea occurs because the fracture extends near the cribriform plate, risking dural tear. The clinical test reveals that the entire midface (including the zygomas and orbits) moves relative to the frontal bone and cranium.

The pathophysiology of airway compromise is critical to understand. In all LeFort types, the mobile midface segment can be displaced posteriorly and inferiorly by gravity (especially in supine patients) or by the force of injury itself, physically obstructing the nasopharynx and oropharynx. This explains why airway management is always the first priority, and why these patients may require early intubation or even surgical airway if orotracheal intubation is not possible.

Hemorrhage is another major concern. The midface has a rich blood supply from the internal maxillary artery and its branches, and disruption of these vessels can cause life-threatening posterior epistaxis.

02Classification and Clinical Manifestation

Mobility Testing

03Diagnostic Workup

CT of the face with thin-cut axial images and multiplanar reformations is both the best initial test and the most accurate test for diagnosing and classifying LeFort fractures. There is no separate "screening" versus "confirmatory" test in this scenario. When a patient presents with midface trauma and suspected fracture, CT is ordered directly.

The most important finding to look for on CT is bilateral pterygoid plate fractures. Without pterygoid plate involvement, the fracture is not classified as a LeFort fracture, regardless of what the anterior fracture pattern looks like. This is the point that distinguishes a true LeFort from an isolated maxillary wall fracture, zygomatic fracture, or naso-orbito-ethmoid (NOE) fracture.

For LeFort II and III, the examiner may test your ability to identify orbital floor fractures (which can cause diplopia from inferior rectus entrapment or infraorbital nerve injury) and CSF rhinorrhea (which requires identification and potentially delayed surgical repair). A halo sign on bedsheet testing (clear fluid with a double ring) is a bedside clue, but beta-2 transferrin is the confirmatory laboratory test for CSF.

Always assume concomitant injuries are present until proven otherwise. A CT of the head should be obtained to evaluate for intracranial hemorrhage, especially in LeFort II and III where the fracture extends toward the skull base. A cervical spine evaluation is mandatory in all high-energy facial trauma.

04Management & Treatment

Airway management is always the first step. On exam vignettes, if a patient with severe midface trauma presents with stridor, gurgling, or inability to maintain the airway, the correct "next best step" is to secure the airway. A critical trap: never perform nasotracheal intubation in a patient with a suspected LeFort II or III fracture (or any suspected skull base fracture), because the tube can be inadvertently passed through the fractured cribriform plate into the cranial vault.

Hemorrhage from midface fractures can be severe due to disruption of the internal maxillary artery and its branches. Initial management involves anterior and posterior nasal packing. A posterior pack can be achieved using a Foley catheter inserted through the nose, inflated in the nasopharynx, and pulled anteriorly to tamponade bleeding. If packing fails, angiographic embolization of the internal maxillary artery by interventional radiology is the next step.

ORIF is the definitive treatment for all LeFort fractures. Surgery is typically delayed until soft tissue swelling subsides (usually 7 to 14 days post-injury), unless there is an urgent indication such as airway compromise that cannot be managed conservatively, uncontrollable hemorrhage, or open fracture with contamination. The goal of surgery is to restore the normal midface height, projection, width, and dental occlusion by plating the fractured buttresses.

CSF rhinorrhea is managed conservatively in the majority of cases. Elevation of the head of bed to 30 degrees, avoidance of straining, and time will allow most dural tears to seal. Persistent leaks beyond 7 to 10 days may require surgical dural repair. The role of prophylactic antibiotics to prevent meningitis remains debated, and current evidence does not strongly support routine use.

05Differential Diagnosis & Distractors

06Traps & High-Yield Pearls

The most common way students get LeFort questions wrong is by failing to associate bilateral pterygoid plate fractures with the LeFort classification. A vignette may describe a complex midface fracture on CT, and the question asks "what finding confirms this is a LeFort fracture?" The answer is always pterygoid plate involvement. Students who focus only on the anterior fracture lines and overlook the pterygoid plates will misclassify or fail to identify the pattern.

A second frequent error is selecting nasotracheal intubation for airway management in a patient with suspected skull base fracture. This is a classic "next best step" trap. The vignette will describe signs of a basilar skull fracture (periorbital ecchymosis, CSF rhinorrhea, hemotympanum), and the correct airway approach is orotracheal intubation or, if that fails, a surgical airway.

Students also confuse LeFort II and III. The key discriminator is zygomatic arch and lateral orbital rim involvement: if the zygoma moves with the maxilla, it is LeFort III (craniofacial disjunction). If the zygoma remains stable and only the central maxilla and nose move, it is LeFort II (pyramidal fracture).

Finally, do not forget the associated injuries. A vignette may test whether you order a CT of the head or cervical spine in addition to facial imaging. High-energy midface trauma warrants a systematic trauma evaluation, and the best answer will often include ruling out intracranial hemorrhage and C-spine injury before focusing on fracture repair.

The core competency being tested with LeFort fractures is your ability to (1) classify the fracture type based on anatomical landmarks and physical exam mobility findings, (2) identify the unifying feature of all three types (pterygoid plate fractures), and (3) prioritize airway management over definitive surgical repair in the acute setting.