TRAUMATIC CONDITIONS OF THE FACE AND MOUTHMaxillofacial and Dental Emergencies 433Le Fort middle-third of face fractures
DIAGNOSIS
These complicated fractures are usually bilateral and are divided into three
groups:
1 Le Fort I
(i) This is due to a blow to the maxilla causing a horizontal fracture
separating the alveolar bone and teeth from the maxilla.
(ii) There is epistaxis and malocclusion, and crepitus may be elicited.
2 Le Fort II
(i) This is a pyramidal fracture extending up from a Le Fort I
fracture to involve the nasal skeleton and the middle of the face.
The middle of the face is thus ‘stove in’, elongating the face and
causing malocclusion.
(ii) The airway may be compromised and cerebrospinal fluid (CSF)
may leak from the nose.
3 Le Fort III
(i) This fracture displaces the entire mid-facial skeleton from the
base of the skull (craniofacial dysjunction).
(ii) There is massive facial swelling and bruising, and often brisk
pharyngeal bleeding that may cause haemorrhagic shock. The
airway is again in danger.
4 Remember that the blow to the face may have caused an additional head,
base of skull or cervical spine injury.
(i) Stabilize the airway and treat shock as a priority.
(ii) Request a head, cervical spine and facial bones CT scan as
indicated, once the patient has been stabilized.
MANAGEMENT
1 Attend urgently to the airway and bleeding.
(i) Sometimes, if the face is stove in, manually lifting the whole
segment forwards relieves the airway.
(ii) Call immediately for senior ED doctor help if there is difficulty
maintaining an adequate airway, and prepare for orotracheal
intubation or even a cricothyrotomy.
(iii) Pack inside the oral and or nasal cavity if bleeding is torrential.
2 Refer all mid-face fractures immediately to the maxillofacial surgery or ENT
team.