Signs and symptoms peculiar to Le Fort III fractures

Superficially the Le Fort III fracture appears very similar to the Le Fort II fracture, but it is usually obvious that the injury is very much more severe. It is, however, very unusual to find a Le Fort III fracture occurring in isolation. A frontal blow of sufficient force to separate the facial bones at the Le Fort III level, usually produces coexistent fracture at Le Fort II and I levels together with extensive comminution of the nasal complex. Indeed, in injuries of this severity the Le Fort classification becomes meaningless other than as a general guide to the fracture pattern. An isolated Le Fort III fracture is most likely to be produced by an oblique blow from a lateral direction, in which case there may be tilting and some lengthening of the facial skeleton due to separation at the frontozygomatic suture line.

The clinical features of the Le Fort III fracture are then superficially similar to the Le Fort II with the following differences:

1. There is tenderness and often separation at the frontozygomatic sutures. The amount of separation may not be symmetrical in which case the facial skeleton will be tilted to the side opposite to the direction of the fracturing force.

2. Separation of both frontozygomatic sutures produces lengthening of the face and lowering of the ocular level, due to the fracture passing above Whitnall's tubercle, removing the support given to the eye by Lockwood's suspensory ligament. As one or both eyes drop, the upper lid follows the globe down, producing unilateral or bilateral pseudoptosis described as 'hooding' of the eyes.

3. A complete fracture at the Le Fort III level cannot occur without fracture of each zygomatic arch. Coincident independent fracture of one or other zygomatic complex occurs almost invariably. The displacement of the zygomatic complex will be detectable by palpation, which will reveal flattening and a step deformity at the infra-orbital margin. The arch of the zygoma will exhibit tenderness and some deformity in a pure Le Fort III fracture.

4. If a finger and thumb are placed over the frontonasal suture region, and the dento-alveolar portion of the upper jaw is grasped with the other hand, movement of the entire face can be demonstrated. As mentioned previously the zygomatic bones may often be independently mobile.

5. Intra-orally there is gagging of the occlusion in the molar area, as in other fractures of the mid-face. When lateral displacement has taken place, the molar teeth will be found to be gagged on one side only with a posterior open bite on the opposite side, and deviation of the upper midline. The entire occlusal plane may have dropped, holding the mandible open, a dramatic but rather unusual finding.

6. A very loose Le Fort III fracture is usually associated with disruption of the cribriform plate area, and this type of fracture may therefore produce a profuse cerebrospinal fluid rhinorrhoea. In this situation the possibility of an intracranial aerocele must be considered seriously, and serial radiographs of the skull should be taken during the first few days after injury.

Summary of possible clinical findings in an isolated Le Fort III fracture

1. Tenderness and separation at frontozygomatic suture.

2. Tenderness and deformity of zygomatic arches.

3. Lengthening of face.

4. Depression of ocular levels.

5. Enophthalmos.

6. Pseudoptosis or 'hooding' of eyes.

7. Lengthening and sometimes extreme disorganization of nasal skeleton.

8. Often profuse cerebrospinal fluid rhinorrhoea.

9. Tilting of the occlusal plane with gagging on one side only.

10. Lateral displacement of midline of upper jaw.

11. Mobility of whole of facial skeleton as a single block.