LeFort II fracture is a type fracture affecting the middle third of the face. The fracture affects multiple facial bones and is also termed as pyramidal or subzygomatic fracture. It is caused due to a violent force from a forward direction. Generally the force may be delivered at the level of the nasal bones. Therefore it is sometimes referred to as a broken nose but this is an inaccurate term. The affected structures in the fracture line includes frontal process of the upper jaw (maxilla), lacrimal bones, nasal bones, zygomatic buttress and pterygomaxillary fissure area.
LeFort II fractures are associated with gross swlling affecting the middle third of the face which is commonly referred to as ‘balloon face’ or ‘moon face’. The swelling develops within a short time after the injury. The area surrounding the eye on both sides shows ecchymosis and edema. The ecchymosis tpresents as black eye.The swelling around eyes develops rapidly after the injury.
Hemorrhages seen on the conjunctiva of both the eyes are confined to the median half. The fracture near the nasal bones and frontonasal suture causes depression of the nasal bridge, leading to nasal disfigurement and a flat appearance to the face. If the fractures fragment is depressed backwards, dish face deformity is seen. When the fractured segment gets impacted against the cranial base then the face appears shortened and anterior open bite is experienced by the patient.
There is usually dental malocclusion and complications such as airway obstruction may arise if the fractured segment gets displaced in posterior and downward direction, impinging on the dorsum of the tongue. Few patients with LeFort II fractures may present with bilateral bleeding form the nose and difficulty in speech and jaw movements. Anesthesia or tingling sensation of the cheek may also be associated symptoms.
The main cause of LeFort II fractures is application of violent force usually from a frontal direction which sustained by the central region of the middle third of the face. A force at downward direction at the nose level is also capable of producing LeFort II fracture. The fracture is generally pyramidal in shape and the area of application of the force is larger. The injury is generally caused by blunt objects and may be associated with falls. The typical instances of trauma to middle third of the face include altercations and vehicle accidents.
As the fracture lies very close to the orbit (socket for the eye) the patient should be examined for signs of visual disturbances such as double vision. Cerebrospinal fluid (CSF) leak are one of the major complications associated with LeFort II fractures. The cerebrospinal leak should also be diagnosed using fluorescent dyes, laboratory analysis and other diagnostic tests. The life threatening complications such as airway obstruction should be corrected immediately.
The treatment varies according to presence and extent of the associated complications. X-rays and CT scans are performed to visualized the full extent of the fracture and determine the approach to treatment. The general approach includes zygomatic arch suspension or frontal bone suspension. Removal of the impaction of the fractured segment using special forceps can also be carried out. Intraosseous wiring may be done at the inferior margins of the orbit. Malocclusions that develops may require orthodontic corrections in later stages of the treatment.