Le Fort I Fracture Line - Explained

What Is the Fracture Line?

Pathway of the Fracture Line (Step by Step)

1. Starts above the tooth apices - just above the root tips of the upper teeth, running horizontally.
2. Passes the lateral margin of the anterior nasal aperture - the fracture line continues at or near the edge of the piriform (pear-shaped) nasal opening.
3. Runs above the nasal floor - it stays superior to the floor of the nasal cavity.
4. Passes above the canine fossa - the shallow depression on the front of the maxilla, lateral to the canine tooth.
5. Traverses the lateral antral wall - crosses the outer wall of the maxillary sinus (antrum).
6. Goes below the zygomatic buttress - dips downward, passing below the thick bony pillar where the zygoma meets the maxilla.
7. Moves upward and posteriorly across the pterygomaxillary fissure - sweeps upward to reach the gap between the maxilla and the pterygoid plates.
8. Fractures the pterygoid laminae - breaks the pterygoid plates of the sphenoid at the junction of their lower third and upper two-thirds. This is a constant and defining feature of all Le Fort fractures.
9. Medial component (nasal wall) - from the same anterior starting point, the fracture also passes along the lateral wall of the nose, then curves behind the tuberosity of the maxilla to meet the lateral fracture line posteriorly.

Key Features

Diagram (Fig. 37)

Le Fort Fractures - Line by Line

Le Fort I - "Horizontal" or "Guerin's Fracture" (Lowest Line)

Le Fort II - "Pyramidal Fracture" (Middle Line)

Le Fort III - "Craniofacial Dysjunction" (Highest Line)

Quick Comparison Summary

• Bailey and Love's Short Practice of Surgery, 28th Ed., p. 433
• Scott-Brown's Otorhinolaryngology Head & Neck Surgery, p. 1243

"Traverses the lateral antral wall"

• A road traverses a mountain = the road crosses over the mountain
• The fracture traverses the orbital rim = the fracture line runs across/through the orbital rim

Le Fort II Fracture - Full Explanation

Fracture Line (Step by Step)

Step 1 - Frontonasal Suture (Starting Point)

"The fracture line runs below the frontonasal suture from the thin middle area of the nasal bones down on either side."

• Starts just below where the nasal bones meet the frontal bone (the bridge of the nose, near the nasion).
• Runs downward on both sides (bilateral from the start).
• The nasal bones here are thin, so they fracture easily.

Step 2 - Frontal Process of Maxilla + Lacrimal Bones

"Crossing the frontal process of the maxilla and passes anteriorly across the lacrimal bones, immediately anterior to nasolacrimal canal."

• The line crosses the frontal process of the maxilla (the upward extension of the maxilla that forms part of the inner orbital rim).
• Then passes across the lacrimal bones (paper-thin bones forming the inner medial wall of the orbit).
• It goes just in front of (anterior to) the nasolacrimal canal - the duct that drains tears into the nose.

Step 3 - Inferior Orbital Margin

"From this point the fracture line passes downward, forward and laterally crossing the inferior orbital margin, in the region of zygomaticomaxillary suture."

• The fracture turns downward, forward and laterally.
• Crosses the inferior orbital rim (lower edge of the eye socket) - this is a key feature that distinguishes Le Fort II from Le Fort I (which never reaches the orbit).
• Crosses in the area of the zygomaticomaxillary suture (where the cheekbone meets the maxilla).

Step 4 - Infraorbital Foramen

"It may or may not involve the infraorbital foramen."

• The infraorbital foramen is a small opening just below the eye socket where the infraorbital nerve exits.
• If the fracture passes through it, the patient gets numbness of the cheek, upper lip, and upper teeth on that side.
• This involvement is variable - not always present.

Step 5 - Lateral Wall of the Antrum (Maxillary Sinus)

"The fracture line now extends downward and forward and laterally to traverse the lateral wall of the antrum, just medial to the zygomaticomaxillary suture line."

• Fracture descends and crosses the lateral wall of the maxillary sinus (antrum).
• It travels just medial to (inside of) the zygomaticomaxillary suture.
• At this point, the path is similar to Le Fort I below.

Step 6 - Zygomatic Buttress

"As in Le Fort I fracture, this fracture line passes beneath the zygomatic buttress."

• Just like Le Fort I, it dips below the zygomatic buttress (the thick bony pillar at the corner of the maxilla and zygoma).
• This means the zygomatic bone itself is NOT involved - it remains attached to the skull. This is what separates Le Fort II from Le Fort III.

Step 7 - Pterygomaxillary Fissure + Pterygoid Laminae

"But after that, it inclines rather more abruptly than in the former instance, traversing the pterygomaxillary fissure at a higher level and fracturing the pterygoid laminae approximately midway from its base."

• After the zygomatic buttress, the fracture angles upward more steeply than in Le Fort I.
• Traverses the pterygomaxillary fissure at a higher level than Le Fort I.
• Fractures the pterygoid plates at approximately their midpoint (compared to lower third junction in Le Fort I).
• This is the constant posterior landmark - all Le Fort fractures involve the pterygoid plates.

Step 8 - Nasal Septum (Completes the Pyramid)

"Separation of the entire pyramidal block from the base of the skull is completed via the nasal septum."

• The two lateral fracture lines are connected medially by fracture of the nasal septum (middle portion).
• This completes the pyramidal block - the entire central midface is now detached.

Clinical Features of Le Fort II

Key Memory Point

• Apex = nasal bridge (frontonasal suture)
• Sides = pass through lacrimal bones → inferior orbital rim → lateral antral wall
• Base = same as Le Fort I (below zygomatic buttress)
• Always ends posteriorly at the pterygoid plates

The Optimal Revision Schedule

The Forgetting Curve (Ebbinghaus)

• After 1 hour - you forget ~50%
• After 1 day - you forget ~70%
• After 1 week - you forget ~90%

Practical Tips for Medical Students

1. Active recall over passive re-reading - close the book and write/say what you remember. This is 3x more effective than re-reading.
2. Use flashcards (Anki) - it automates the spaced repetition schedule for you based on how well you recalled each card.
3. Teach it out loud - explaining a topic (like Le Fort fractures) in your own words is the strongest form of revision.
4. Don't revise what you already know well - spend time on weak areas, not comfortable ones.
5. Interleave topics - mix different subjects in one session instead of doing one topic for hours. It feels harder but retention is better.

For Exams Specifically

• 6+ months out: Learn and do 1st-3rd revisions
• 1 month out: 4th revision of all topics
• 1 week out: Quick 5th pass - focus on weak spots only
• Night before: Only revise things you are shaky on - do NOT cram new material