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Facial fractures: Le Fort, zygoma, orbital floor, mandible and frontal sinus
All Le Fort fractures pass through the pterygoid plates and differ by the level of the line — I above the teeth, II a pyramid through the nose and orbit, III separation of the face from the skull; alongside, an orbital floor fracture with muscle entrapment needs urgent repair, and a frontal sinus fracture is treated by the wall involved and the drainage pathway.
Why it matters in the exam
Le Fort I — a horizontal line above the tooth roots through the nasal floor, with a "floating" palate; Le Fort II — a pyramid through the nasal bones, the maxillary frontal process, the medial orbital wall and floor and the inferior orbital rim; Le Fort III — craniofacial separation through the frontozygomatic suture, the lateral orbital wall and the zygomatic arch. A zygomatic fracture (ZMC) breaks four attachment points — the frontozygomatic suture, the zygomatic arch, the inferior orbital rim and floor, and the zygomaticomaxillary buttress — with cheek numbness (infraorbital nerve) and sometimes trouble opening the mouth (the arch presses on the coronoid process).
Orbital floor "blow-out" fracture: diplopia on upgaze, cheek numbness and a sunken eye (enophthalmos). Muscle entrapment (mainly inferior rectus) — especially in children, sometimes with a "white", quiet-looking eye and with nausea, vomiting and bradycardia from the oculocardiac reflex — requires urgent surgery. Other indications for repair: a large floor defect (over 50%) or enophthalmos over 2 mm. A retrobulbar haematoma with falling vision and a hard eye requires lateral canthotomy and cantholysis at once, even before imaging.
In the mandible, occlusion and mobility are checked; a fracture open to the mouth (through a tooth socket) receives antibiotics, and treatment is internal fixation or maxillomandibular fixation. In the frontal sinus: an anterior-wall fracture alone with displacement — repair for appearance; a displaced posterior-wall fracture with CSF leak — cranialisation; injury to the drainage pathway (nasofrontal outflow tract) — obliteration or follow-up with endoscopic opening, with today's trend toward conservative and endoscopic approaches. A mucocele can appear years after such a fracture. CT of the face is the central imaging in every fracture.
Key points
- Le Fort: I horizontal, II pyramid, III craniofacial separation.
- ZMC: four attachment points, cheek numbness.
- Orbital muscle entrapment → urgent surgery.
- Retrobulbar haematoma → canthotomy at once.
- Frontal sinus: by wall and drainage pathway.
Summary table
| Fracture | Line or clue | Treatment |
|---|---|---|
| Le Fort I | Horizontal above the teeth, floating palate | Internal fixation and normal occlusion |
| Le Fort II | Pyramid through the nose and orbit | Internal fixation, orbital assessment |
| Le Fort III | Craniofacial separation | Internal fixation, exclude CSF leak |
| ZMC | Cheek numbness, flattened cheek | Internal fixation when displaced |
| Orbital floor with entrapment | Diplopia, oculocardiac reflex | Urgent surgery |
| Frontal sinus | By wall and drainage pathway | Repair, cranialisation or obliteration |
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Sources
- AO Surgery Reference: Craniomaxillofacial trauma, 2023 — Midface, orbital and mandibular fractures
- Cummings Otolaryngology: Head and Neck Surgery, 7th edition (2021) — Maxillofacial trauma
- ATLS: Advanced Trauma Life Support Student Course Manual, 10th edition (2018) — Head and maxillofacial trauma
Sources are given for further reading; the text is written afresh and not copied from them.
Reviewed by the Examqo AI Professor · 2026-11-06. The text may contain errors; when in doubt, check the source.