Le Fort I Fracture

Le Fort I fracture is a horizontal fracture of the maxilla through the lower part of the bone, over the tooth apices, which separates the alveolar process, palate and lower nasal septum from the rest of the face. It is also known as a low or transverse maxillary fracture.

It results from a blow to the lower maxilla, such as a road traffic collision, fall or assault. It rarely occurs in isolation, and often with other facial fractures.

Pathophysiology. The fracture line runs from the piriform aperture, across the lateral maxillary wall and the maxillary sinus walls, to the pterygoid plates, usually involving the lower nasal septum and pterygoid junction.

The floating tooth bearing segment is pulled backward and downward by the pterygoid muscles and gravity, causing malocclusion with a posterior open bite.

Mobile upper dentition and palate on gentle rocking with the head stabilised, malocclusion with premature posterior contact or an anterior open bite, bruising of the upper vestibule, palatal and greater palatine haematoma (Guerin sign), epistaxis and upper lip swelling. The face is not lengthened and the orbit is not involved.

A dull sound when percussing the upper teeth (cracked pot sound) may be noted. Airway obstruction from blood and a soft palate pushed backward is possible.

Airway compromise, heavy bleeding, associated skull base or other facial fractures, and cerebrospinal fluid leak need urgent assessment.

• CT of the facial bones with 3D reconstruction, the investigation of choice.
• Clinical assessment of maxillary mobility with a hand on the upper incisors and the other hand over the nasal bridge, and of occlusion.
• Examination for associated injuries: Le Fort II or III, zygomatic complex, mandibular fracture, orbital injury and head injury.
• Cervical spine assessment depending on the mechanism.
• Tetanus status.

Differential diagnosis.

• Le Fort II and III fractures
• Dentoalveolar fracture
• Palatal split or sagittal maxillary fracture
• Zygomatic complex fracture
• Nasal fracture and septal haematoma
• Mandibular fracture with malocclusion
• Maxillary sinus wall injury

• Airway: bleeding and swelling can obstruct the airway, so use suction, positioning, and early anaesthetic input. Avoid blind nasal tubes and nasopharyngeal airways if skull base fracture is possible.
• Control bleeding: anterior and posterior nasal packing or balloon tamponade, and reduction of the fracture. Rarely, embolisation for persistent bleeding.
• Definitive treatment: open reduction and internal fixation through an intraoral vestibular incision with miniplates at the zygomaticomaxillary and piriform buttresses, with intermaxillary fixation used to set the occlusion at surgery, and kept for 1 to 4 weeks when needed. Undisplaced fractures can be managed with a soft diet and a short period of fixation.
• Antibiotics: amoxicillin with clavulanic acid 1.2 g intravenously every 8 hours for 24 hours perioperatively, with no routine extension unless infection exists. Clindamycin 600 mg intravenously every 8 hours in penicillin allergy. Reduce the dose of amoxicillin with clavulanic acid when eGFR is under 30.
• Nasal and sinus care: no nose blowing for 2 weeks, saline irrigation, and decongestant for 3 to 5 days (xylometazoline 0.1% one spray each nostril up to three times daily).
• Tetanus toxoid 0.5 mL intramuscularly if vaccination is incomplete or the last dose was over 10 years ago, with tetanus immunoglobulin 250 IU intramuscularly (500 IU after 24 hours or heavy contamination) when status is unknown or incomplete.
• Analgesia: paracetamol 1 g every 6 hours (maximum 4 g daily) with ibuprofen 400 mg every 8 hours with food when appropriate. Chlorhexidine 0.2% mouthwash.
• Soft diet for 4 to 6 weeks.
• Complications: malocclusion, malunion, nonunion, sinusitis, nasolacrimal duct injury, infection and nerve injury.

Monitoring. Review at 1 week, 2 weeks, 6 weeks and 3 months for occlusion, mobility, wound and sinus symptoms, with CT or radiographs at 6 weeks for union.

Referral and escalation. Refer to oral and maxillofacial surgery. Urgent referral for airway compromise, uncontrolled bleeding or associated facial and skull base fractures.