ORBITALTRAUMA
INDIAN DENTAL ACADEMY
Leader in continuing dental education
www.indiandentalacademy.com

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Introduction :
Anatomical region of clinical and surgical interest
“Cross roads” , signposts - complex
injuries needs ad...
Orbit :
 Bony vault houses eyeball
 Quadrangular based pyramid
 Average volume - 30cc,globe - 7cc (1/4)
 Growth comple...
Orbital injuries :
 Alone or associated with others
 Low impact force - floor,NOE
 High impact force - roof,supraorbita...
Principles of ATLS :
 Airway
 Breathing
 Circulation
 Disability management & drainage
 Exposure & examine
www.indian...
Examination :
 Inspect ocular damage
 Lacerations - eyelid,lacrimal,cornea
 Oedema & circumorbital ecchymosis
 Subconj...
Cont :
 Posterior limit defined

- conjunctival

 Posterior limit ill-defined - orbital wall #
 Medial wall - ecchymosi...
Scoring system - BADACT :
 Blow out
 Acuity
 Diplopia
 Amnesia
 Comminuted Trauma
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Pupils :
 Effort made to record size
 Reaction to illumination
 Swollen lids difficult to perform
 Fixed dilated pupil...
Light reflex :

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Surgical anatomy : Lateral wall
 By zygoma & greater wing sphenoid
 Inclined 45* - orbital apex,90*- each other
 FZ sut...
Medial wall :
 By very thin plate of ethmoid
 Anterior & posterior ethmoidal foramen
 Weakened by nasolacrimal apparatu...
Roof :
 Reinforced by greater wing of sphenoid
 Mainly of frontal bone - anterior cranial fossa
 Rim thick becomes thin...
Floor :
 Orbital portion of maxilla & zygoma
 Posteriorly by small piece of palatine bone
 Triangular -“Guitar plectrum...
Cont :
 Not horizontal slopes upwards & medially 45*
ascends posteriorly at 30*
 Weakened by presence of groove
 Blow-o...
Orbital rims :
 Supero lateral & inferior - thicker
 Part posterior to it and medial - thinner
 Floor & medial - common...
Inferior orbital rim :
 Unable to withstand force
 Depression - origin of inferior oblique
 # often leads to diplopia
...
Soft tissues : Eyelids
 Skin is thin - very lax areolar tissue
 Careless dissection -“Button-holing”
 Rich arterial & v...
Nerve injury :
 Anastomosis between sensory & motor
 Opening principally by levator
 Innervation - occulomotor - ptosis...
Orbicularis oculi :
 3 parts
 Orbital ,palpebral , lacrimal
 Lateral eyebrow incision - parallel to palpebral
 In line...
Levator palpebrae superioris :
 From under surface of lesser wing
 Divides into 2 lamella
 Upper attached to tarsal pla...
Orbital septum :
 Skeletal framework of eyelids
 Membraneous sheet attached to lacrimal crest
& orbital rims
 Thickened...
Palpebral ligaments :
 By fibrous extensions of tarsal plates
 Lateral canthus - Y shaped
Superficial bundle - frontal p...
Cont :
 Small muscle from inferior orbital rim to
posterior limb against lacrimal sac
 Enables lower eyelid movement - e...
Medial canthoplasty :

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Tenons capsule :
 Applied like bursa to eyeball
 Thickened both sides - check ligaments
“Suspensory ligament of lockhoo...
Periorbital fat :
 Cushion against which eye rotates
 Balance of fat with others - AP position of globe
 Many fibrous s...
Extraocular muscles :
 4 recti - “annulus of zinn” at back of orbit
 Superior oblique - lesser wing of sphenoid
 Inferi...
Cont :

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Optic nerve :
 Extension of brain - bathed with CSF
 Considerable mobility within orbit - escape trauma
 Dural sheath f...
Cont :

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Blood vessels :
 Retina - central artery of retina
 Multiple posterior short ciliary branches encircle
optic nerve
 Ent...
Assessment :
 Opthalmic assessment
 Orthoptic test
 Plain radiographs
 Ultrasound
 Sinuscopy
 CT , MRI , Stereolithi...
Plain radiographs :
 OM view - 10 , 30
 Optic foramen - beam upwards & medially from PA
 Waters view - roof & floor
 C...
Ultrasound :
 Occasionally used
 Orbital floor & medial wall
 Disruption of lens & inner surface of globe
 Opthalmic a...
CT :
 Gold standard , investigation of choice
 Both soft tissues & orbital wall
 Volume assessment - biplanar CT - enop...
Spiral 3D CT :
 More accurate
 Lacks definition - thin bones
 Stereolithic models very useful
 CT navigation device - ...
Cont :

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MRI :
 Soft tissue injury & entrapment
 Radiolucent foreign body - wood
 Unresolving orbital emphysema
 Potential for ...
Colour doppler :
 Provides 2D image
 Assessment of blood flow
 For post traumatic high flow cavernous fistula
 Angiogr...
Cover test :
 Diplopia & hypoglobus
 Occluding one eye followed by other
 Disappearance of peripheral image
 Affected ...
Hess or Lees chart :
 A dissociation test
 Reproducible pictorial record of ocular movements
of eye in all gaze
 Distin...
Cont :
 Screen divided into squares
Inner field - 9 dots ( cardinal positions of gaze )
Outer field - 16 dots
 Chart plo...
Interpretation :
 Position of central dot - deviation
 Smaller field - affected eye
Constriction - limitation, enlargeme...
Cont :

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Others :

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Diplopia :
 When non corresponding points stimulated in
two eyes by same object
 Minor degree - compensation - overactio...
Binocular diplopia :
 False image projected in same direction which
ineffective muscle normally moves eye
 Horizontal di...
Diplopia following trauma :
 Not due to paresis of prime mover
 Inability of antagonist to “pay out rope’
 Fibrosis bet...
Cont :
 Elevation associated with posterior movement
of pole
 Deepening of supra tarsal crease
“RETRACTION SIGN”

www.i...
Binocular fixation test :
 Demonstrate over which conjugate movement
possible
 Displays areas of binocular vision & dipl...
Interpretation:
 Field displaced away from direction of maximum
limitation
 Greater limitation - smaller field
 Narrow ...
Soft tissue injuries - Eyelid :
 Most common is bruise
 Deep bruising - demarcation line, eye of panda
 Direct ocular i...
Steps in eyelid closure :
 First

- suture to cut ends of tarsal plate

 Second - close posterior lamella of lid
 Third...
Corneal injury :
 5 layered
 Epithelial damage - painful & irritable eye
 Stromal & endothelial damage - edema
 Diagno...
Torsorrhaphy :
 To protect cornea
 For ectropion & paralytic drooping of lower eyelid
 Incise 6-8mm inter marginal tiss...
Hyphema :
 Bleeding into anterior chamber
 Blood gravitates to lower segment
 Advised rest - major 2* haemorrhage
 Aqu...
Iris :
 Iridiolysis - tear - D shaped pupil
 Common sequel following blunt trauma - hyphema
 Traumatic mydriasis - smoo...
Lens :
 Subluxation - common sequel
 Principal clinical sign - wobbling of iris
 Dislocation into anterior chamber - em...
Retina :
 Retinal dialysis - peripheral retinal tear
 Vitreous fluid lifts retina - retinal detachment
 10% - immediate...
Berlins edema :
 Traumatic retinal edema
 Whitening of eye
 Blurring of vision
 Opthalmoscopy - milk-white against red...
Classification :
 Associated zygomatic complex #
1. # stable after elevation
2. # unstable after elevation
 Isolated # o...
# - clinical features :
 Circumorbital ecchymosis , subconjunctiva haemorrhage
 Proptosis - blood posterior to septum ,t...
Emphysema :

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Access to orbital # :
 Lateral & medial eyebrow
 Crows feet , existing laceration
 Subciliary or blepheroplasty
 Infra...
Orbital rim & wall # :
 Inferior orbital rim - most common
 Supra orbital margin - highest resistance to impact
 Isolat...
Treatment :
 Supra orbital margin - no treatment
 Closed reduction - digital manipulation , bone hooks
 Open reduction ...
Cont :

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Orbital floor # :
 Most common - thinnest - 0.27mm
 Hydraulic force - sudden application of pressure
 2 types - Direct ...
Indirect :
 Classical blow-out # by Converse & Smith - 1957
 Object of greater diameter than rim - blow out #
 # of bon...
Direct :
 # of orbital floor through extension of force
 Trauma to rim
 # of rim - also called as “pure #”
 Herniation...
Blow-out – C/F :
 Diplopia
 Enophthalmos , supratarsal fold deepening
 Narrowing of palpebral fissure
 Paresthesia, al...
Investigations :
 OM view - “hanging-drop” appearance , antral opacity
 Coronal view - floor & medial wall
 Saggital vi...
Traction test :
 Forced duction test
 Performed bilaterally in conscious patient
 Tendon of inferior rectus grasped - L...
Others :
 Electromyography - Bjork - Diagnosis of combined lesion
inferior rectus incarceration & superior rectus weaknes...
Blow-in # :
 Dingmann & Natvig - 1964
 Elevation of fragments of floor or roof , intact rim
 Upward herniation of floor...
Surgical intervention :
 Defect <1cm,>5mm, positive clinical & x-ray ,duction test
 Defect >1cm
 Emert et al - diplopia...
Access – Blow-out :
 Antral approach
 Trans conjunctival
 Infra orbital
1. Subciliary
2.Subpalpebral
 Pre existing sca...
Antral approach :
 Cald well luc, inspect floor - fibroptic source
 Trap- door #, fragments attached to periosteum - sup...
Cont :
 Inspect ocular level - avoid overpacking
 Pack - free of infection - iodoform
 Pack removal - 3wks
 Antral bal...
Trans conjunctival :
 Bourguet - 1928 - cosmetic procedure
 Traction suture - eyelids, fixation suture - fornix
 Incisi...
Cont :
 Conjunctiva & septum freed from orbicularis oculi
 Dissection upto rim

 Incise periosteum 5mm below,rim - peri...
Cont :

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Subciliary - stepped incision :
 Blephroplasty type of incision
 Excellent access - floor,medial & lateral wall
 Parall...
Cont :

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Inferior marginotomy:
 WOLFE - 1982
 Access to herniated fat at posterior limit of floor

 Rim intact , elective osteot...
Reconstruction :
 To seal off antral cavity
 Physiologically acceptable smooth surface - adhesions
 Restore dimension &...
Key points :
 Medial canthal ligament left undisturbed
 2 steps - Orbital frame ,Internal orbit
 Orbital frame - reduce...
Autografts :
 Large defects - key, defects > 1-1.5cm
 Kaye - antral wall
 Rowe - iliac crest
 Hotte - mastoid , contra...
Cont :
 Graft greater in size , edges bevelled
 Stable medial & lateral margins - hole - rim to 3mm inner
 Posterior ma...
Cont :
 Infra orbital nerve free - graft above - adhesions
 Children >11yrs - 8,9,10 rib cartilage
 Release of internal...
Pre–op :

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Calvarial bone graft :

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Cont :

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Cont :

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Homograft :
 Defect less than 1cm
 Lyodura since 1970
 Absorbed & replaced with fibrous tissue - indistinguishable
 In...
Allelograft :
 Encapsulated by fibrous tissue - not replaced
 Function - seal off communication until encapsulation
 Po...
MEDPOR channel implant :

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Cont :

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Reconstruction of orbital floor fracture with polyglactin
910/polydioxanon 2005 May;63(5):646-50.retrospective study.
patc...
DOI : 10.2240/azojomo0106

Bioceramic Orbital Plate Implant
Jocelyn P. Reyes, Josefina R. Celorico, Lina C. dela Cuesta, J...
Complications :
 Retrobulbar haemorrhage
 Superior orbital fissure syndrome
 Orbital apex syndrome
 Carotico - caverno...
Decompression :
 Measurement - Hertel exophthalmometer
 Normal - 16-21mm beyond rim , > 21mm - diagnostic
 Remove any o...
Retrobulbar haemorrhage :
 Less than 1% - mid face trauma
 Injury within intraconal space - short ciliary artery
 Compr...
Cont :
 Central retinal vessels - obstruction
 Infarction - end result
 Irreversible retinal cell damage - 15 – 20 min
...
Mechanisms – Hertley et al :
 Two mechanisms
 Direct pressure

- Increased volume of contents

 Forward pressure - upon...
Clinical features :
 Pain, Decreasing visual acuity
 Diplopia , opthalmoplegia & severe ptosis
 Marked subconjunctival ...
Medical treatment :
 Intraocular pressure reduction - dehydration
 Mannitol(200ml of 20%) - shrinks vitreous
 Acetazola...
Surgical intervention :
 Explore intraconal space
 Post op - through intramuscular septum uniting inferior
& lateral rec...
Drainage – Extraconal space :
Septum incised at lateral aspect above or below
canthal ligaments
 Medial incision - damag...
Decompression of optic
 Unless clear evidence of compression
 Perineural & interstitial edema - delayed blindness - bene...
Adjunct :
 Spasmolytic agent - papaverine - cannula in
supraorbital artery
 Paracentesis of anterior chamber
 Incision ...
Superior orbital fissure syndrome:
 Following impact from lateral aspect
 Gross periorbital edema , proptosis
 Subconju...
Cont :
 Specific sign - altered sensation - forehead to
vertex - frontal branch of trigeminal
 Dilated pupil - loss of c...
Orbital apex syndrome :
 Extension of superior orbital fissure syndrome
 Injury to optic nerve - hallmark
“Loss of cons...
Carotico-cavernous fistula :
 Orbital trauma extending to basal fracture
 Tears carotid artery within cavernous sinus
“...
Treatment :
 Diagnosis - arteriography
 Surgical closure - transcranial
 Embolization

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Enopthalmos :
 Late consequence of orbital trauma
 Soft tissue manifestation of bony defect
 4 types
1.Simple enopthalm...
Treatment :
 Correction of zygomatic position & orbital floor
 Augmentation of retrobulbar bulge
 Bone behind equator -...
Hypoglobus :
 Linked to ball in foam
 Equator from lateral orbital plane to lacrimal crest
 Bone 1cm at inferior orbita...
Canalicular injuries :
 Penetrating injuries - between punctum & lacrimal sac
 Insert lacrimal probe - punctum into prox...
Cont :

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Orbital trauma /certified fixed orthodontic courses by Indian dental academy

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The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and offering a wide range of dental certified courses in different formats.

Indian dental academy provides dental crown & Bridge,rotary endodontics,fixed orthodontics,
Dental implants courses.for details pls visit www.indiandentalacademy.com ,or call
0091-9248678078

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Orbital trauma /certified fixed orthodontic courses by Indian dental academy

  1. 1. ORBITALTRAUMA INDIAN DENTAL ACADEMY Leader in continuing dental education www.indiandentalacademy.com www.indiandentalacademy.com
  2. 2. www.indiandentalacademy.com
  3. 3. www.indiandentalacademy.com
  4. 4. Introduction : Anatomical region of clinical and surgical interest “Cross roads” , signposts - complex injuries needs additional expertise Often underestimated and undertreated Interesting & difficult areas in facial trauma www.indiandentalacademy.com
  5. 5. Orbit :  Bony vault houses eyeball  Quadrangular based pyramid  Average volume - 30cc,globe - 7cc (1/4)  Growth completed by 83% by 5yrs  Seven bones form orbit www.indiandentalacademy.com
  6. 6. Orbital injuries :  Alone or associated with others  Low impact force - floor,NOE  High impact force - roof,supraorbital rim  Complicated by their proximity www.indiandentalacademy.com
  7. 7. Principles of ATLS :  Airway  Breathing  Circulation  Disability management & drainage  Exposure & examine www.indiandentalacademy.com
  8. 8. Examination :  Inspect ocular damage  Lacerations - eyelid,lacrimal,cornea  Oedema & circumorbital ecchymosis  Subconjunctival - “Flame shaped”  Bright red ecchymosis - Oxygen diffusion www.indiandentalacademy.com
  9. 9. Cont :  Posterior limit defined - conjunctival  Posterior limit ill-defined - orbital wall #  Medial wall - ecchymosis over sclera  Fundus inspected with opthalmoscope  Pupillary and occular levels on both sides www.indiandentalacademy.com
  10. 10. Scoring system - BADACT :  Blow out  Acuity  Diplopia  Amnesia  Comminuted Trauma www.indiandentalacademy.com
  11. 11. Pupils :  Effort made to record size  Reaction to illumination  Swollen lids difficult to perform  Fixed dilated pupils - occulomotor www.indiandentalacademy.com
  12. 12. Light reflex : www.indiandentalacademy.com
  13. 13. Surgical anatomy : Lateral wall  By zygoma & greater wing sphenoid  Inclined 45* - orbital apex,90*- each other  FZ suture - line of relative weakness  Orbital tubercle - 1cm below FZ suture www.indiandentalacademy.com
  14. 14. Medial wall :  By very thin plate of ethmoid  Anterior & posterior ethmoidal foramen  Weakened by nasolacrimal apparatus  Splaying apart 1. Walls - Traumatic hypertelorism 2. Ligament - Traumatic telecanthus www.indiandentalacademy.com
  15. 15. Roof :  Reinforced by greater wing of sphenoid  Mainly of frontal bone - anterior cranial fossa  Rim thick becomes thin posterior from edge  Elderly - roof resorbed in selected areas  Dura confluent with peri orbita - careful dissection www.indiandentalacademy.com
  16. 16. Floor :  Orbital portion of maxilla & zygoma  Posteriorly by small piece of palatine bone  Triangular -“Guitar plectrum”  Inferior orbital groove - 2.5cm from rim  Inferior orbital canal - 5mm below rim  Thin 0.5mm, weakest portion medial to groove www.indiandentalacademy.com
  17. 17. Cont :  Not horizontal slopes upwards & medially 45* ascends posteriorly at 30*  Weakened by presence of groove  Blow-out fracture occur medial to it  Sagging of contents into maxillary sinus www.indiandentalacademy.com
  18. 18. Orbital rims :  Supero lateral & inferior - thicker  Part posterior to it and medial - thinner  Floor & medial - common site #  Inward displacement - increased intraocular pressure herniation  Paranasal & ethmoidal sinuses - air bags  Globe perforation - uncommon www.indiandentalacademy.com
  19. 19. Inferior orbital rim :  Unable to withstand force  Depression - origin of inferior oblique  # often leads to diplopia  Greatest diameter lies within and not at periphery  Direction of instrument changed - periosteal elevation www.indiandentalacademy.com
  20. 20. Soft tissues : Eyelids  Skin is thin - very lax areolar tissue  Careless dissection -“Button-holing”  Rich arterial & venous supply  Trauma - circum orbital ecchymosis,”black eye”  Delayed onset - # roof or anterior cranial fossa www.indiandentalacademy.com
  21. 21. Nerve injury :  Anastomosis between sensory & motor  Opening principally by levator  Innervation - occulomotor - ptosis  Closing principally by orbicularis oris  Innervater by facial - lower eyelid drooping www.indiandentalacademy.com
  22. 22. Orbicularis oculi :  3 parts  Orbital ,palpebral , lacrimal  Lateral eyebrow incision - parallel to palpebral  In line of hair follicles,long axis of eyebrow  Crows feet wrinkles - skin right angle to fibres  FZ suture 1cm above outer canthus www.indiandentalacademy.com
  23. 23. Levator palpebrae superioris :  From under surface of lesser wing  Divides into 2 lamella  Upper attached to tarsal plate & skin of eyelid  Lower attached to upper margin of tarsal plate  Mullers muscle - nonstriated,sympathetic  Trauma - Ptosis,pseudo-enopthalmos,miosis www.indiandentalacademy.com
  24. 24. Orbital septum :  Skeletal framework of eyelids  Membraneous sheet attached to lacrimal crest & orbital rims  Thickened to form upper & lower tarsal plates  Inferomedial aspect - incomplete - air escape to preseptal space - periorbital swelling www.indiandentalacademy.com
  25. 25. Palpebral ligaments :  By fibrous extensions of tarsal plates  Lateral canthus - Y shaped Superficial bundle - frontal process of zygoma Deep bundle - whitnalls tubercle  Medial canthus - Y shaped Anterior fibres - frontal process of maxilla Posterior fibres - lacrimal fossa  Maintain level & shape of orbiral fissure www.indiandentalacademy.com
  26. 26. Cont :  Small muscle from inferior orbital rim to posterior limb against lacrimal sac  Enables lower eyelid movement - empty sac  Transconjunctival incision - avoid damage  Trauma - FZ suture - antimongoloid slant  Medial aspect - traumatic telecanthus www.indiandentalacademy.com
  27. 27. Medial canthoplasty : www.indiandentalacademy.com
  28. 28. Tenons capsule :  Applied like bursa to eyeball  Thickened both sides - check ligaments “Suspensory ligament of lockhood” - inferior bulbi  Determinant of globe position - vertical  Other determinants - intact walls, fat ,muscles www.indiandentalacademy.com
  29. 29. Periorbital fat :  Cushion against which eye rotates  Balance of fat with others - AP position of globe  Many fibrous septa  Blow out # - mechanical entrapement  Interference with free rotation www.indiandentalacademy.com
  30. 30. Extraocular muscles :  4 recti - “annulus of zinn” at back of orbit  Superior oblique - lesser wing of sphenoid  Inferior oblique - inferior orbital floor  Medial & lateral recti - only horizontal movements  Superior & inferior recti - complex combinations www.indiandentalacademy.com
  31. 31. Cont : www.indiandentalacademy.com
  32. 32. Optic nerve :  Extension of brain - bathed with CSF  Considerable mobility within orbit - escape trauma  Dural sheath fused with canal - by Hotte  Optic portion of optic - 3cm long  Anterior 2/3 - central artery retina posterior 1/3 - opthalmic artery www.indiandentalacademy.com
  33. 33. Cont : www.indiandentalacademy.com
  34. 34. Blood vessels :  Retina - central artery of retina  Multiple posterior short ciliary branches encircle optic nerve  Enter choroid forming capillary plexus  Congestion - secondary effect on retina  Superior & inferior opthalmic vens - cavernous www.indiandentalacademy.com
  35. 35. Assessment :  Opthalmic assessment  Orthoptic test  Plain radiographs  Ultrasound  Sinuscopy  CT , MRI , Stereolithic models www.indiandentalacademy.com
  36. 36. Plain radiographs :  OM view - 10 , 30  Optic foramen - beam upwards & medially from PA  Waters view - roof & floor  Comparison of symmetry www.indiandentalacademy.com
  37. 37. Ultrasound :  Occasionally used  Orbital floor & medial wall  Disruption of lens & inner surface of globe  Opthalmic artery & vein investigated - contrast  Retinal blood flow - fluoroscopic means www.indiandentalacademy.com
  38. 38. CT :  Gold standard , investigation of choice  Both soft tissues & orbital wall  Volume assessment - biplanar CT - enopthalmos  3-5mm sections in both planes - walls  1.5mm axial cuts - optic canal # www.indiandentalacademy.com
  39. 39. Spiral 3D CT :  More accurate  Lacks definition - thin bones  Stereolithic models very useful  CT navigation device - reconstruction  Amount & position of graft www.indiandentalacademy.com
  40. 40. Cont : www.indiandentalacademy.com
  41. 41. MRI :  Soft tissue injury & entrapment  Radiolucent foreign body - wood  Unresolving orbital emphysema  Potential for displacement of metallic objects www.indiandentalacademy.com
  42. 42. Colour doppler :  Provides 2D image  Assessment of blood flow  For post traumatic high flow cavernous fistula  Angiography - confirmatory www.indiandentalacademy.com
  43. 43. Cover test :  Diplopia & hypoglobus  Occluding one eye followed by other  Disappearance of peripheral image  Affected eye & muscle involved www.indiandentalacademy.com
  44. 44. Hess or Lees chart :  A dissociation test  Reproducible pictorial record of ocular movements of eye in all gaze  Distinguish between entrapment & neurological impairment  Non injured eye will over react www.indiandentalacademy.com
  45. 45. Cont :  Screen divided into squares Inner field - 9 dots ( cardinal positions of gaze ) Outer field - 16 dots  Chart plotted - showing limitation & overaction  Patient 0.5m from screen , red & green glasses  Examiner - red torch, patient - green torch  Glasses reversed, also with normal eye www.indiandentalacademy.com
  46. 46. Interpretation :  Position of central dot - deviation  Smaller field - affected eye Constriction - limitation, enlargement - overaction  Larger field - unaffected eye  Narrow field - restricted in opposite direction mechanical restriction www.indiandentalacademy.com
  47. 47. Cont : www.indiandentalacademy.com
  48. 48. Others : www.indiandentalacademy.com
  49. 49. Diplopia :  When non corresponding points stimulated in two eyes by same object  Minor degree - compensation - overaction of synergistic muscle in unaffected eye  Monocular - dislocated lens,macula lesion,retinal detachment  Binocular - following trauma www.indiandentalacademy.com
  50. 50. Binocular diplopia :  False image projected in same direction which ineffective muscle normally moves eye  Horizontal diplopia - false image on right of true direction of lateral rectus  Vertical diplopia - false image above true direction of superior rectus  Identification - Cover test www.indiandentalacademy.com
  51. 51. Diplopia following trauma :  Not due to paresis of prime mover  Inability of antagonist to “pay out rope’  Fibrosis between sheath & periosteum  Inferior rectus entrapement - superior rectus mechanically ineffective  Axis of rotation shifted posteriorly www.indiandentalacademy.com
  52. 52. Cont :  Elevation associated with posterior movement of pole  Deepening of supra tarsal crease “RETRACTION SIGN” www.indiandentalacademy.com
  53. 53. Binocular fixation test :  Demonstrate over which conjugate movement possible  Displays areas of binocular vision & diplopia  Plotted on perimeter,white target used for fixation  Patient follows target from centre to periphery  Appreciated diplopia recorded www.indiandentalacademy.com
  54. 54. Interpretation:  Field displaced away from direction of maximum limitation  Greater limitation - smaller field  Narrow field - mechanical limitation www.indiandentalacademy.com
  55. 55. Soft tissue injuries - Eyelid :  Most common is bruise  Deep bruising - demarcation line, eye of panda  Direct ocular injury - posterior limit seen  Massive swelling of eyelid - sign of retrobulbar  Laceration on medial side - lacrimal apparatus www.indiandentalacademy.com
  56. 56. Steps in eyelid closure :  First - suture to cut ends of tarsal plate  Second - close posterior lamella of lid  Third - suture grey line to opposite side  Fourth - suture 0rbicularis oculi within wound  Fifth - suture skin www.indiandentalacademy.com
  57. 57. Corneal injury :  5 layered  Epithelial damage - painful & irritable eye  Stromal & endothelial damage - edema  Diagnosis - light reflection & fluorescein stain  Topical anaesthetic & cyclopentolate www.indiandentalacademy.com
  58. 58. Torsorrhaphy :  To protect cornea  For ectropion & paralytic drooping of lower eyelid  Incise 6-8mm inter marginal tissues  Incise base of bare area to open wounds  Closure www.indiandentalacademy.com
  59. 59. Hyphema :  Bleeding into anterior chamber  Blood gravitates to lower segment  Advised rest - major 2* haemorrhage  Aqueous drainage obstruction - 2* glaucoma  Steroid & acetazolamide www.indiandentalacademy.com
  60. 60. Iris :  Iridiolysis - tear - D shaped pupil  Common sequel following blunt trauma - hyphema  Traumatic mydriasis - smooth muscle paralysis  Angle recession occurs - gonioscopy , slit lamp  Both reflexes absent www.indiandentalacademy.com
  61. 61. Lens :  Subluxation - common sequel  Principal clinical sign - wobbling of iris  Dislocation into anterior chamber - emergency  Changes in refraction  Rupture of lens capsule - aqueous fluid entry traumatic catract, opacification www.indiandentalacademy.com
  62. 62. Retina :  Retinal dialysis - peripheral retinal tear  Vitreous fluid lifts retina - retinal detachment  10% - immediate , 70% - 2yrs , 20% - > 2yrs  Prevention by treating dialysis  Treatment - photocoagulation,cryotherapy www.indiandentalacademy.com
  63. 63. Berlins edema :  Traumatic retinal edema  Whitening of eye  Blurring of vision  Opthalmoscopy - milk-white against red fundus  Edema at macula - eclipse blindness www.indiandentalacademy.com
  64. 64. Classification :  Associated zygomatic complex # 1. # stable after elevation 2. # unstable after elevation  Isolated # of orbital rims  Isolated # of orbital floor  Complex comminuted # www.indiandentalacademy.com
  65. 65. # - clinical features :  Circumorbital ecchymosis , subconjunctiva haemorrhage  Proptosis - blood posterior to septum ,tenderness  Surgical emphysema - crackling sensation,nasal communication - attempt to blow nose  Pneumogram in x-ray, through antral wall or roof  Paraesthesia over infra orbital distribution - #  Diplopia,telecanthus,ocular cant,epiphora,CSF leak www.indiandentalacademy.com
  66. 66. Emphysema : www.indiandentalacademy.com
  67. 67. Access to orbital # :  Lateral & medial eyebrow  Crows feet , existing laceration  Subciliary or blepheroplasty  Infraorbital , medial canthal  Transconjunctival, bicoronal  Transnasal , antral , buccal sulcus www.indiandentalacademy.com
  68. 68. Orbital rim & wall # :  Inferior orbital rim - most common  Supra orbital margin - highest resistance to impact  Isolated # - kinetic energy absorbed over small area  Early ages - lack of frontal sinus - anterior cranial fossa #  Medial - NOE complex #  Lateral - zygomatic complex # www.indiandentalacademy.com
  69. 69. Treatment :  Supra orbital margin - no treatment  Closed reduction - digital manipulation , bone hooks  Open reduction FZ suture - lateral eyebrow Base of frontal process of zygoma - Subciliary,lateral part  Trans osseous wires, bone plates,K wire,external pins www.indiandentalacademy.com
  70. 70. Cont : www.indiandentalacademy.com
  71. 71. Orbital floor # :  Most common - thinnest - 0.27mm  Hydraulic force - sudden application of pressure  2 types - Direct , Indirect  Inclination of walls - medial & downward direction of force www.indiandentalacademy.com
  72. 72. Indirect :  Classical blow-out # by Converse & Smith - 1957  Object of greater diameter than rim - blow out #  # of bony floor anterior to inferior orbital fissure  Blunt trauma to globe - increased intra orbital pressure  Herniation of orbital fat , inferior rectus & oblique - antrum  Rim intact , also called as “impure #” www.indiandentalacademy.com
  73. 73. Direct :  # of orbital floor through extension of force  Trauma to rim  # of rim - also called as “pure #”  Herniation may or may not be present www.indiandentalacademy.com
  74. 74. Blow-out – C/F :  Diplopia  Enophthalmos , supratarsal fold deepening  Narrowing of palpebral fissure  Paresthesia, alteration of occular level  Restricted movement of eye - full vertical www.indiandentalacademy.com
  75. 75. Investigations :  OM view - “hanging-drop” appearance , antral opacity  Coronal view - floor & medial wall  Saggital view - kind of implant  MRI - soft tissue incarceration  Sinuscopy - herniation of fat , floor defect www.indiandentalacademy.com
  76. 76. Traction test :  Forced duction test  Performed bilaterally in conscious patient  Tendon of inferior rectus grasped - LA  Rotate eye upwards  Restriction - muscle entrapment, fibrous adhesions  No restriction - does not exclude floor defect www.indiandentalacademy.com
  77. 77. Others :  Electromyography - Bjork - Diagnosis of combined lesion inferior rectus incarceration & superior rectus weakness  Orbitography - radio opaque contrast medium - Milauskas Communication between orbit & antrum www.indiandentalacademy.com
  78. 78. Blow-in # :  Dingmann & Natvig - 1964  Elevation of fragments of floor or roof , intact rim  Upward herniation of floor  Compression of air within antrum  Linear shock wave with negative pressure from rebound of orbital contents  Rarely demands surgical correction www.indiandentalacademy.com
  79. 79. Surgical intervention :  Defect <1cm,>5mm, positive clinical & x-ray ,duction test  Defect >1cm  Emert et al - diplopia with positive duction - delay 2wks  Putterman et al - all blow out # waited for 4-6 months  Most clinicians - waiting period 2 wks  Diplopia & enopthalmos - surgical intervention www.indiandentalacademy.com “Sooner the better”
  80. 80. Access – Blow-out :  Antral approach  Trans conjunctival  Infra orbital 1. Subciliary 2.Subpalpebral  Pre existing scar www.indiandentalacademy.com
  81. 81. Antral approach :  Cald well luc, inspect floor - fibroptic source  Trap- door #, fragments attached to periosteum - support  Antral pack - material of choice  Exert controlled force upon specific area of antral roof  3-6m of gauze soaked in whitehead varnish, aural forceps  Build up in layers ,avoid force in postero superior corner www.indiandentalacademy.com
  82. 82. Cont :  Inspect ocular level - avoid overpacking  Pack - free of infection - iodoform  Pack removal - 3wks  Antral balloon - 30ml Foley catheter - Jackson et al (1965)  Through intranasal antrostomy - No 16 -18 catheter  Disadvantage - no selective pressure  Removal - after 14www.indiandentalacademy.com days
  83. 83. Trans conjunctival :  Bourguet - 1928 - cosmetic procedure  Traction suture - eyelids, fixation suture - fornix  Incision between conjunctiva & tarsal plate  Incise palpebral portion of oculi superficial to septum  Small incision 3mm below tarsal plate www.indiandentalacademy.com
  84. 84. Cont :  Conjunctiva & septum freed from orbicularis oculi  Dissection upto rim  Incise periosteum 5mm below,rim - periorbital fat herniation  Sub periosteal dissection - retraction with copper strip  Dissection upto inferior orbital fissure  Excellent access - floor . Inferior orbital rim  Invisible scar , restricted access www.indiandentalacademy.com
  85. 85. Cont : www.indiandentalacademy.com
  86. 86. Subciliary - stepped incision :  Blephroplasty type of incision  Excellent access - floor,medial & lateral wall  Parallel & 2-3mm below margin of lower eyelid only skin  Undermining of skin,do not incise muscle fibres  Palpate rim - incise muscle fibres  5mm below rim - incise periosteum www.indiandentalacademy.com
  87. 87. Cont : www.indiandentalacademy.com
  88. 88. Inferior marginotomy:  WOLFE - 1982  Access to herniated fat at posterior limit of floor  Rim intact , elective osteotomy - 1.5cm each side of foramen  From rim to level of infraorbital nerve  Vertical cuts joined horizontally,convergent cuts along floor  Segment mobilised - excellent access to affected area www.indiandentalacademy.com  Wired back in position
  89. 89. Reconstruction :  To seal off antral cavity  Physiologically acceptable smooth surface - adhesions  Restore dimension & contour of orbit  Indirect support for globe “Key area” - posterior part of medial wall 1.Main support for anterior projection of globe 2.Paper thin structure - damaged in orbital injuries 3.Technically difficult to repair www.indiandentalacademy.com
  90. 90. Key points :  Medial canthal ligament left undisturbed  2 steps - Orbital frame ,Internal orbit  Orbital frame - reduce zygoma ,arch,lateral orbital wall - key  Internal orbit - key area - platform for further grafts  Globe protrude 2mm - compensate for volume loss - swelling  End of reconstruction - forced duction test www.indiandentalacademy.com
  91. 91. Autografts :  Large defects - key, defects > 1-1.5cm  Kaye - antral wall  Rowe - iliac crest  Hotte - mastoid , contralateral side  Bell & Weisenbaugh - nasal septal cartilage “Calvarial graft” - graft of choice www.indiandentalacademy.com
  92. 92. Cont :  Graft greater in size , edges bevelled  Stable medial & lateral margins - hole - rim to 3mm inner  Posterior margin - adequately supported  Cortical surface - facing globe  Compare pupillary levels on both sides www.indiandentalacademy.com
  93. 93. Cont :  Infra orbital nerve free - graft above - adhesions  Children >11yrs - 8,9,10 rib cartilage  Release of internal stresses - graft curl - floor contour  Graft resorption - 25%  Less risk of extrusion & infection www.indiandentalacademy.com
  94. 94. Pre–op : www.indiandentalacademy.com
  95. 95. Calvarial bone graft : www.indiandentalacademy.com
  96. 96. Cont : www.indiandentalacademy.com
  97. 97. Cont : www.indiandentalacademy.com
  98. 98. Homograft :  Defect less than 1cm  Lyodura since 1970  Absorbed & replaced with fibrous tissue - indistinguishable  Inert , non allergic , sterile  Subperiosteal location  Pre sterilized packs - rehydrated with saline www.indiandentalacademy.com
  99. 99. Allelograft :  Encapsulated by fibrous tissue - not replaced  Function - seal off communication until encapsulation  Polyglactin & tricalcium phosphate,polydiaxone - resorption  Teflon (tetrafluoro ethylene ), silicone  Dacron reinfoced silastic - better retention  Extent - 3mm behind rim to tnferior orbital fissure www.indiandentalacademy.com  Passive , no pressure
  100. 100. MEDPOR channel implant : www.indiandentalacademy.com
  101. 101. Cont : www.indiandentalacademy.com
  102. 102. Reconstruction of orbital floor fracture with polyglactin 910/polydioxanon 2005 May;63(5):646-50.retrospective study. patch (ethisorb): a J Oral Maxillofac Surg. Buchel P, Rahal A, Seto I, Iizuka T. Department of Cranio-Maxillofacial, Skull Base, Facial Plastic and Reconstructive Surgery, Inselspital University of Berne, Switzerland. PURPOSE: We sought to evaluate the effectiveness and the complications related to the use of Ethisorb (resorbable alloplastic material) in the reconstruction of orbital floor fractures. PATIENTS AND METHODS: We retrospectively reviewed the charts of all patients who underwent orbital floor fracture reconstruction with Ethisorb since 2001. We only included patients with a minimum follow-up of 3 months. The following data were recorded for every patient: age, gender, cause of trauma, time from trauma to surgery, signs and symptoms, concomitant ocular injuries, radiographic analysis, pertinent intraoperative findings (including the type of approach), follow-up time, and postoperative complications. RESULTS: Eighty-seven patients were included in the study. Twenty-one patients (24.1%) experienced postoperative complications. Of these, only 3 patients (3.4%) had permanent complications directly related to the Ethisorb membrane (diplopia, enophthalmos). Two of these patients required revision surgery and are discussed in the article. CONCLUSIONS: The results of our study demonstrate the effectiveness of Ethisorb in the repair of small-to-moderate orbital floor fracture defects (up to a maximum size of 2 x 2 cm). www.indiandentalacademy.com
  103. 103. DOI : 10.2240/azojomo0106 Bioceramic Orbital Plate Implant Jocelyn P. Reyes, Josefina R. Celorico, Lina C. dela Cuesta, James M. Filio, Leonilo G Daan, Severino T. Bernardo and Jessica Marie Abano Porous biphasic calcium phosphate bioceramic orbital plate implant consisting of about 77% βTCP and 23% HAp was developed as a low cost alternative to commercially available orbital plate implant. The pore size of the material, which is 198 microns, contributed to the early fibrovascular ingrowth into the pores of the plate implant. 12 orbits of 6 adult domestic cats underwent orbital plate implantation. Results of biocompatibility tests show the excellent potential of the developed bioceramic orbital plate implant for orbital floor fracture reconstruction. It is biocompatible, allows vascularization, resistant to resorption, and has proven to have physiological bone induction as well as bone conduction properties. Conclusion Bioceramics orbital plate implant was successfully developed using calcium phosphate dihydrate and calcium carbonate as the starting materials. The processing conditions for the fabrication of this material include the calcination of the starting materials at 800°C, the addition of clay as binder and sintering at 1280°C for 3 hours. These contribute to the formation of a biphasic calcium phosphate ceramic consisting of 77% beta-tricalcium phosphate and 23% hydroxyapatite. The pore size of the material, which is 198 microns, promotes early fibrovascular ingrowth into the pores of the plate implant. Moreover, post –operative examinations showed that the developed orbital plate implants were biocompatible and did not exhibit any kind of adverse effects to the surrounding tissues. Results of biocompatibility tests on adult cats demonstrated the promising potential of the developed orbital plate implant as an attractive and affordable option for orbital floor fracture reconstruction. www.indiandentalacademy.com
  104. 104. Complications :  Retrobulbar haemorrhage  Superior orbital fissure syndrome  Orbital apex syndrome  Carotico - cavernous fistula  Enophthalmos www.indiandentalacademy.com
  105. 105. Decompression :  Measurement - Hertel exophthalmometer  Normal - 16-21mm beyond rim , > 21mm - diagnostic  Remove any of walls  Through caldwell-luc - ethmoidectomy  Remove lamina papyracea,ethmoidal arteries intact  Remove roof of antrum , later incise periosteum , support www.indiandentalacademy.com
  106. 106. Retrobulbar haemorrhage :  Less than 1% - mid face trauma  Injury within intraconal space - short ciliary artery  Compression of other arteries  Changes in perfusion pressure gradient  Venous congestion & edema around optic www.indiandentalacademy.com
  107. 107. Cont :  Central retinal vessels - obstruction  Infarction - end result  Irreversible retinal cell damage - 15 – 20 min  Pressure gradient Normal - 2kPa(15mmHg) Retrobulbar haemorrhage - 13.3kPa(100mmHg) www.indiandentalacademy.com
  108. 108. Mechanisms – Hertley et al :  Two mechanisms  Direct pressure - Increased volume of contents  Forward pressure - upon iris - obstruction outflow aqueous humor  Through canal of schlemm www.indiandentalacademy.com
  109. 109. Clinical features :  Pain, Decreasing visual acuity  Diplopia , opthalmoplegia & severe ptosis  Marked subconjunctival edema & haemorrhage  Dilated pupils - loss of light reflex with intact consensual reflex  Ophthalmoscope - “Cherry red macular spots” constricted retinal arterioles www.indiandentalacademy.com
  110. 110. Medical treatment :  Intraocular pressure reduction - dehydration  Mannitol(200ml of 20%) - shrinks vitreous  Acetazolamide(500mg) - inhibits carbonic anhydrase - reduced aqueous production  Hydrocortisone(100mg) - intraorbital edema , spasm  Mega dose steroids - dexamethasone 3-4mg/kg 6 hourly - 24hrs,1mg/kg - 48hrs,continued 5 days www.indiandentalacademy.com
  111. 111. Surgical intervention :  Explore intraconal space  Post op - through intramuscular septum uniting inferior & lateral rectus  Open antrum - suction  Lateral canthotomy - dividing intramuscular septum  Direct access to intraconal spacee - by Moriarty (1982)  Globe in extreme adduction - conjunctival flap raised divide lateral rectus insertion  Point where fasciawww.indiandentalacademy.com bulbi around tendon is reflected
  112. 112. Drainage – Extraconal space : Septum incised at lateral aspect above or below canthal ligaments  Medial incision - damages - inferior oblique - trochlea - nasolacrimal sac & duct www.indiandentalacademy.com
  113. 113. Decompression of optic  Unless clear evidence of compression  Perineural & interstitial edema - delayed blindness - benefit from decompression  Electrophysiological testing - assessment of vision  Intra cranial approach - remove roof of canal  Niho et al - combined transantral & frontal sinus approach  Fukado - Transethmoidal approach www.indiandentalacademy.com
  114. 114. Adjunct :  Spasmolytic agent - papaverine - cannula in supraorbital artery  Paracentesis of anterior chamber  Incision parallel to iris anterior to canal of schlemm  Using catract knife  Iris return to normal position www.indiandentalacademy.com
  115. 115. Superior orbital fissure syndrome:  Following impact from lateral aspect  Gross periorbital edema , proptosis  Subconjunctival haemorrhage  Complex opthalmoplegia & ptosis - 3,4,6 nerves “Loss of direct light & consensual reflex” www.indiandentalacademy.com
  116. 116. Cont :  Specific sign - altered sensation - forehead to vertex - frontal branch of trigeminal  Dilated pupil - loss of corneal & accommodation  Wait for resolution - 3-6 months  Fixation of fracture with minimal manipulation  Operative intervention - deferred 10 - 14 days www.indiandentalacademy.com
  117. 117. Orbital apex syndrome :  Extension of superior orbital fissure syndrome  Injury to optic nerve - hallmark “Loss of consensual reflex in unaffected eye”  Ischemic optic neuropathy - common reason  Main area of impact - level of orbital roof  Lateral orbitotomy - procedure of choice www.indiandentalacademy.com
  118. 118. Carotico-cavernous fistula :  Orbital trauma extending to basal fracture  Tears carotid artery within cavernous sinus “Pulsating exophthalmos” , worse on bending  Relieved by occlusion of ipsilateral carotid “Bruit de debale” - associated murmur  Opthalmoplegia,diplopia,dilated pupil,decreased acuity www.indiandentalacademy.com
  119. 119. Treatment :  Diagnosis - arteriography  Surgical closure - transcranial  Embolization www.indiandentalacademy.com
  120. 120. Enopthalmos :  Late consequence of orbital trauma  Soft tissue manifestation of bony defect  4 types 1.Simple enopthalmos - related to abnormal bony position 2.With dystopia - related to bone & soft tissue injury 3.Cicatrical enopthalmos - restriction in movement - scarring 4.Enopthalmos secondary to fat atrophy www.indiandentalacademy.com
  121. 121. Treatment :  Correction of zygomatic position & orbital floor  Augmentation of retrobulbar bulge  Bone behind equator - push globe forward  Grafting - floor,medial,lateral,behind equator  Calvarial graft,iliac crest,rib,antral wall,auricular cartilage “Calvarial” - less resorption (20%), difficult shaping www.indiandentalacademy.com  Alloplastic - teflon, Homografts - lyodura & zenoderm
  122. 122. Hypoglobus :  Linked to ball in foam  Equator from lateral orbital plane to lacrimal crest  Bone 1cm at inferior orbital rim or under equator  Cantilevered from inferior orbital rim - deficient posteriorly  Correct position of zygoma www.indiandentalacademy.com
  123. 123. Canalicular injuries :  Penetrating injuries - between punctum & lacrimal sac  Insert lacrimal probe - punctum into proximal severed part  Cut end paler , dye through intact upper canaliculi  Pigtail , through upper canaliculus  Reconstruction - fine nylon plastic tubing  6-0 silk suture in grey line, tube after 2 wks www.indiandentalacademy.com
  124. 124. Cont : www.indiandentalacademy.com
  125. 125. THANK U www.indiandentalacademy.com

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