Influence of Skull Base or Frontal Bone Fracture on the Result of Treatment for Le Fort Type Maxillofacial Fractures: Outcomes of Le Fort IV Fractures

Dear Editor,

Le Fort fractures often extend to the skull base and/or frontal bone, which sometimes results in cerebral spinal fluid (CSF) leakage.[1] These more severe fractures were so-called “Le Fort IV fracture.”[2,3] The purpose of this study was to investigate the clinical features of Le Fort IV fractures.

A retrospective review of 19 patients with Le Fort type fractures who were treated in our Medical Center from 2008 to 2017 was conducted. Nine patients were defined as Le Fort IV fracture (Le Fort IV group), and one with Le Fort III, three with Le Fort II, and six with Le Fort I (Le Fort I–III group). Seven of the 9 Le Fort IV patients developed CSF leakage [Table 1].

Table 1.

Cases of Le Fort type fracture

Sex/Age	Le Fort type	Mechanism of injury	Associated injury	Treatment for Liquorrhea	Pre-surgical days	Hospitaliz-ation days	Prognosis and aftereffects
57M	IV	Motor vehicle traffic accidents	Liquorrhea, Optic canal fracture, Abdominal hemorrhage	-	13	33	Jejunum stoma, Facial nerve palsy
23M	IV	Motor vehicle traffic accidents	Liquorrhea, Limbs fractures	-	10	44	Pseudo-joint of femur
51M	IV	Vehicle accidents-(tractor)	Liquorrhea, Liver injury, Optic canal fracture, Femur fracture	Frontal muscle flap transfer	15	56	Facial nerve palsy, Double vision
68M	IV	Workmen’s industrial accidents	Liquorrhea,		7	31	None
42M	IV	Motor vehicle traffic accidents	Liquorrhea, Temporal bone fracture	Spinal drainage	18	35	None
75M	IV	Falls	None	-	11	18	None
64M	IV	Motor vehicle traffic accidents	Rib fractures, Thyroid cartilage fractures, Mandibular fracture	-	14	27	None
35M	IV	Falls	Liquorrhea, Temporal bone fracture, Mandibular fracture	Frontal muscle flap transfer	19	41	None
19M	IV	Motor vehicle traffic accidents	Liquorrhea, Tension pnuemothorax	-	5	42	None
42M	III	Falls	Limbs fractures, Hemopneumothorax, Mandibular fracture	-	No surgery	-	Die of fat embolism
29M	II	Motor vehicle traffic accidents	Limbs fractures, Mandibular fracture	-	2	18	None
61M	II	Motor vehicle traffic accidents	None	-	6	14	None
57M	II	Motor vehicle traffic accidents	Abdominal hemorrhage, Mandibular fracture	-	4	26	Jejunum stoma
29M	I	Motor vehicle traffic accidents	Mandibular fracture	-	4	30	None
23M	I	Motor vehicle traffic accidents	Mandibular fracture	-	10	21	None
44M	I	Falls	None	-	9	18	None
45M	I	Assault	None	-	3	16	None
43M	I	Falls	Lung injury, Patella fracture, Mandibular fracture	-	2	44	None
50M	I	Motor vehicle traffic accidents	Limbs fractures, Cerebral vein thrombosis, Disseminated intravascular coagulation	-	No surgery	-	Die of cerebral vein thrombosis

We investigated several clinical results in both groups.

1. Associated injury: the most frequent associated injury was another head and neck fractures, followed by extremity fractures, thoracic injuries, and abdominal injuries, which showed a similar tendency in both groups [Figure 1]

2. Presurgical waiting days and hospitalization periods: the mean period to reduction surgery from injury in patients with Le Fort IV group was 12 ± 4.7 days, and it was 6.0 ± 3.1 days in those with Le Fort I–III. The mean period of hospitalization in patients with Le Fort IV group was 37 ± 11.0 days, and it was 29 ± 10.0 in those with Le Fort I–III. Patients with Le Fort IV fracture required a significantly longer preoperative (P = 0.02) and hospitalization (P < 0.05) period (Wilcoxon signed-rank test). The mean time to discharge from reduction surgery in patients with Le Fort IV fracture was 25 ± 11.0 days, and it was 25 ± 11.5 in those with Le Fort I–III, which showed no significant differences between the two groups (P = 0.35, Wilcoxon signed-rank test)

3. Prognosis and aftereffects: all patients in the Le Fort IV group survived, however, two in the Le Fort I–III group died. There was no statistically significant difference in mortality between these groups (P > 0.10, Chi-square test).

Figure 1.

Differences in associated injuries in Le-Fort IV and I–III fracture groups

In our patients, 7 of 13 with Le Fort II or III fracture developed cranial base fracture, suggesting that the frequency of Le Fort IV fracture is high contrary to our expectations. The skull base fractures are of marked interest for physicians because it usually results in leakage of CSF and meningitis.[4] Once CSF is confirmed, nonsurgical therapy is instigated in most patients, however, if CSF leakage continues for >1 week, lumbar drainage and/or surgical repair are required.[3,5]

Our study showed that there was no statistically significant difference in the frequency of mortality or aftereffects between Le Fort IV and Le Fort I–III groups. Only the presurgical waiting and hospitalization periods were longer in the Le Fort IV group because it takes about 1 week to control the CSF leakage. Thus, once successful treatment of liquorrhea is achieved, Le Fort IV fracture can be treated like any other surgical reduction of Le Fort I–III fractures.

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Conflicts of interest

There are no conflicts of interest.