1. Department of oral and maxillofacial surgery
Orbital fracture
Done By
AMRITHA JAMES
2. Anatomy
Anatomically the orbit resembles a
four sided pyramid.
The orbital roof formed from
Orbital plate of the frontal bone
Lesser wing of the sphenoid bone.
The floor of the orbit is formed from
three bones:
Maxillary bone
Palatine bone
Orbital plate of the zygomatic
bone
3. Then medial wall of the orbit is
formed from four bones:
Frontal process of the maxilla
Lacrimal bone
Orbital plate of the ethmoidal
bone
Lesser wing of the sphenoid
The Lateral wall is formed from two
bones:
Zygomatic bone
Greater wing of the sphenoid
4.
5. EXTRAOCULAR MUSCLES
The four recti and two oblique
muscles:
Superior rectus
Inferior rectus
Lateral rectus
Medial rectus
Superior oblique
Inferior oblique
All are supplied by oculomotor nerve
III except superior oblique (Trochlear
N) and lateral rectus (Abducens)
6. BLOOD SUPPLY AND NERVE SUPPLY
The arterial supply to the orbit is
from ophthalmic artery.
The venous drainage is through the
superior and inferior ophthalmic
veins.
The innervation of the orbit is
through
Oculomotor nerve
Trochlear nerve
Abducens nerve
Opthalmic nerve
7. Classification
Fractures involving orbit may be classified according to the pattern
of involvement of walls of the orbit as
1. Fractures limited to internal orbital skeleton (Blow out and Blow in
fractures). Orbital floor, medial wall, or roof can be involved.
8. 2. Fractures involving orbital rim /along
with internal orbital skeleton.
These fractures may be sub
classified into:
Inferior rim fracture
Superior rim fracture
Lateral rim fracture
Rim fracture in association with
fractures involving internal orbital
skeleton
9. 3. Fractures of orbit associated with other fractures of facial skeleton. These
include:
2. Naso-orbito-ethmoid fracture
1. Zygomatico maxillary fracture
11. 4. Orbital apex fractures :
These fractures should be identified early because of potential threat to
neurovascular structures at superior orbital fissure and optic canal. Optic
canal injuries can lead to traumatic optic neuropathy.
12. Blow out fractures of orbit
An orbital blowout fracture is a
traumatic deformity of the orbital
floor or medial wall, typically
resulting from impact of a blunt
object larger than the orbital
aperture.
Bone is displaced away from the
orbit
13. There are two broad categories of
blowout fractures:
OPEN DOOR : large, displaced and
comminuted
TRAPDOOR : linear, hinged, and
minimally displaced.
Blowout fractures can also be classified
as
PURE BLOWOUT FRACTURES
– not involving orbital rim
IMPURE FRACTURE – fracture
line extends to orbital rim
Trapdoor
15. Two theories have been proposed to account for blow out fracture:
Hydraulic theory and Buckling theory.
1. Hydraulic theory:
This theory suggests
that sudden increase in
intraorbital pressure
causes decompressing
fracture into the
adjacent sinus.
16. 2. Buckling theory: It states
that the orbital rim buckles and
transmits forces to the orbital
walls, resulting in an orbital
floor fracture.
17. White-eyed Blow-out Fracture
The greenstick fracture is a pediatric response to external
deforming forces.
Here, intra-orbital soft tissue (fat and muscle) may become
entrapped within the fracture as the elastic bones snap back
into place, resulting in severe restrictive external
ophthalmoplegia.
There is lack of external periocular signs of trauma in many
pediatric cases and hence known as the white-eyed blow-out
fracture.
Surgery must be performed within 48-72 hours, as there is a
high risk of necrosis of the entrapped ocular muscle
18. Effects of blow out fracture
Muscle entrapment Damage to infra orbital nerve Herniation of orbital
contents into the sinus.
19. Blow in fracture
Bone is displaced into the orbit.
May involve the roof, floor, medial or lateral wall.
If orbital rim is intact, then it is termed as pure orbital rim fractures.
Exophthalmos present.
Oblique 3-D Reformatted Spiral CT Images
21. Clinical features
EARLY FEATURES:
Periocular Edema
Paresthesia of infra orbital
nerve
Subconjuctival hemorrhage
Circumorbital ecchymosis
Ptosis
Limitation of ocular movement
Unilateral epistaxis
22. LATE FEATURES:
Diplopia (due to muscle entrapment)
Enopthalmos (due to retraction of
extraoccular muscles and escape of
orbital fat)
Lowering of ocular level
Narrowing of palpebral fissure
23. Diagnosis
FORCED DUCTION TEST: The limbus is gripped with forceps, and the
globe is moved in multiple position to stretch the rectus muscles and superior
oblique muscle and tendons, evaluating for any restriction in movement.
25. Radiological Findings
Floor disruption
Sinus opacification
Prolapsed soft tissue classically
gives rise to the ‘tear drop’ sign.
Orbital emphysema
Asymmetry
Soft tissue swelling
26. Initial Management
Ice affected area
Elevation of head
Use of nasal decongestants
Broad spectrum antibiotics like Augmentin
Oral steroids to prevent fibrosis
No nose blowing
27. Indications for Repair
Diplopia that persists beyond 7 to 10 days.
Obvious signs of entrapment.
Relative enophthalmos greater than 2mm.
Fracture that involves greater than 50% of the orbital floor.
Entrapment that causes an oculocardiac reflex with resultant
bradycardia and cardiovascular instability.
Progressive infra orbital nerve numbness.
28. Immediate repair
Non resolving oculocardiac reflex with
entrapment
Bradycardia, heart block, nausea, vomiting,
syncope
Early enophthalmos or hypoglobus
causing facial asymmetry
“White-eyed” floor fracture with
entrapment
29. Delayed repair
The majority of orbital fractures are managed initially
with observation, then surgical intervention, if
indicated, within 14 days of injury.
1.Symptomatic diplopia with positive forced duction test
2. Large fracture causing enophthalmos
3. Significant hypoglobus
4. Progressive infraorbital hypoanesthesia.
30. Preoperative
Orbital fracture repair generally requires general anesthesia.
The patient requires a general medical assessment.
Diagnostic imaging studies should be made available in the
operating room for intraoperative guidance.
31. Surgical approach
Surgical repair of orbital fractures typically involves the following
steps:
1. Exposure with degloving the facial skeleton
2. Reduction
3. Rigid fixation with replacement of lost or comminuted bone
4. Soft-tissue resuspension
5. Closure
33. ADVANTAGES:
o Excellent aesthetics results.
o Quick to do.
o No skin, muscle disssection
o Low incidence of ectropian.
o Scar can be seen only by of lateral extension which heals
rapidly.
DISADVANTAGES:
o Limitation of access
o Medial extent can be limited.
36. Subciliary &Subtarsal Incision
ADVANTAGES:
o Easy &quick to do in case of edema
o Estimation of giving incision can easily be made
o Scar inversion is greatly diminished.
DISADVANTAGES:
o Vertical lid shortening
o Increased incidence of impairments with subciliary incision.
37. Transmaxillary Endoscopic Approach
Offers excellent visualization of the entire orbital floor and is safe and
efficacious and eliminates any postoperative eyelid complications.
Trapdoor and medial blow-out fractures are the best candidates for an
endoscopic approach.
Endoscopic view of the orbital floor from the maxillary sinus
38. With all approaches, dissection is carried down to the periosteum of
the orbital rim.
Flap is reflected.
A subperiosteal dissection is done to exposes the limits of the fracture.
Herniated and entrapped orbital soft tissue is reduced.
Once the orbital soft tissues are repositioned, an orbital implant is
placed to completely cover the orbital bony defect
A forced duction test is performed at this point to confirm adequate
relief of entrapment.
Closure of periosteum may help prevent implant migration.
Conjunctiva or skin may be closed with a 6-0 absorbable suture.
40. Bone graft
Donor sites include the split calvarial
bone graft, rib, maxillary wall,
mandibular symphysis, iliac crest,
antral bone and coronoid process.
INDICATION:
o Fractures in children <7 years of
age.
ADVANTAGES:
o Low material costs
o Smooth surface
o Variability in thickness
o Radiopacity
o Maximal biocompatibility
41. DISADVANTAGES:
o Additional donor site needed
(necessitating additional surgery
time for harvest, pain, scar, and
possible surgical complications)
o Possible contour and dimensional
changes due to remodeling
o Difficult to shape according to
patients anatomy
o Less drainage from the orbit than
with titanium mesh
42. cartilage
Septal and auricular cartilage have
been used for reconstruction of orbital.
ADVANTAGES
Most biocompatible
No sharp edges
Minimal donor site morbidity
DISADVANTAGES
Poor structural support
Not radio-opaque
INDICATIONS
Small fractures
43. Titanium meshes
INDICATION: Large orbital floor defects
ADVANTAGES:
o Stability
o Biocompatible
o Ease in Contouring
o Adequate in large three-wall fractures
o Radiopacity
o Spaces within the mesh to allow dissipation of
fluids
o No donor site needed
o Tissue incorporation may occur
45. An artificial model is used intraoperatively to contour the
plate in order to fit the shape of the orbit.
Bending of mesh to form
Checking the proper contour
46. Porous polyethylene sheets (PPE)
ADVANTAGES:
o Availability
o Contouring (eased by the
artificial sterile skull)
o Smooth edges
o Allows tissue ingrowth
47. DISADVANTAGES:
o Not radiopaque (not visible on postoperative images)
o Lack of rigidity when a very thin wafer of PPE is used. When
a thicker rigid wafer is used there is a risk of causing a dystopia.
o Less drainage from the orbit than with titanium
48. Composite of porous polyethylene and titanium mesh
By combining titanium mesh with porous polyethylene the material becomes
radiopaque, and more rigid than porous polyethylene of a similar thickness.
49. ADVANTAGES:
o Availability
o Stability
o Contouring (eased by the artificial sterile skull)
o Adequate in large three-wall fractures (the pre-bent plate is
limited to medial wall and orbital wall fractures only).
o Radiopacity
o No donor site needed
o Tissue incorporation may occur
DISADVANTAGES:
o Less drainage from the orbit than with titanium mesh
50. Resorbable sheeting
Sheets made of polylactide, polyglactin, and polydioxanone have been
commercially made from resorbable materials for orbital reconstruction.
INDICATION :
Can be used in small gaps <2.5 cm2 with stable medial and lateral borders
ADVANTAGES:
Biocompatible
Pliable and can be contoured to the defect
Resorbable
DISADVANTAGES:
Cost
Concern for long-term stability and support
Not radio-opaque
51. Customized orbital implants
ADVANTAGES:
o Digitally designed by the
surgeon based on the
contralateral orbit
o Radiopaque
o Smooth surface
o Minimal or no contouring
necessary
DISADVANTAGES:
o Cost
o Time required to obtain the
implant
52. Reconstruction In Pediatric Patients
Small fractures may be treated with absorbable bioprosthetics, such
as polylactic and polyglycolic acid polymer implants.
These provide temporary support to the orbital floor and resorb over
a period of a year
They do not to restrict skeletal growth and provide rigid fixation in
pediatric patients
53. Implant fixation
Fixation of orbital reconstruction material
varies with the type and nature of the
fracture.
Fixation of most materials in the orbital
floor is achieved by the use of one or
more screws.
The diameter depends on anatomical
requirements but will normally vary
between 1.0, 1.3, or 1.5 mm.
54. Orbital Floor Fracture Transconjunctival Incision
And Exposure Of The
Fracture
Repositioning Of The
Fracture Fragment
Removal Of Displaced
Orbital Floor
Exposure Prior To Mesh
Insertion
Insertion Of Mesh.
Single Screw Fixation
Posterior To The Orbital
Rim
Postoperative CT
Case example
56. Complications
Intraoperative complications include the following:
Globe and optic nerve injury
Injury to the infraorbital nerve
Inadequate reduction of prolapsed tissue
Orbital hemorrhage
57. Postoperative complications include the following:
Blindness
Persistent diplopia
Globe malpositioning, particularly enophthalmos or
hypoglobus
Infection that presents as orbital cellulitis
Infraorbital nerve dysfunction in an orbital floor repair
Lid malpositioning, especially lower-lid retraction or
entropion
Implant infection, migration, or extrusion
Epistaxis or cerebrospinal fluid (CSF) leakage in medial
wall repairs
58. OTHER Recent advancements
Intraoperative computed tomography
• To verify that the orbit has been
properly reconstructed, a CT scan is
performed intraoperatively.
• The correct anatomic shape of the
titanium mesh used for orbital floor
reconstruction can be verified in the
intraoperative CT scan.
59. Computer-guided orbital reconstruction :mirror image overlay
guidance improves outcomes in complex orbital reconstruction
For virtual orbital reconstruction, auto
segmentation of the unaffected orbit is
performed first and then mirrored to the affected
side. 3-dimensional positioning of the mirrored
segment allows for anatomically correct virtual
orbital reconstruction.
60. 3D Printing (stereolithography)
• 3D printing helps visualize a patient's missing
orbital floor (left) versus original shape
before
• 3D printed prototypes help improve accuracy
and shorten the operation.
62. References
Management of orbital fractures: challenges and solutions Jennings R
Boyette,1 John D Pemberton,2 and Juliana Bonilla-Velez
Current Trauma Reports June 2016, Volume 2, Issue 2, pp 55–65
Management of Orbital Floor Fractures: An Oculoplastic Surgeon’s View 1 Surbhi
Arora, 2 Ashok Kumar Grover, 3 Shaloo Bageja
Orbital Floor Fractures (Blowout)Author: Adam J Cohen, MD
Midface Orbital floor fracture - Orbital reconstruction Authors: Carl-Peter
Cornelius, Nils Gellrich
