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

www.indiandental...
INTRODUCTION



The importance of orbit is to protect vital
structures by allowing fractures to occur.
Because the globe ...
AIM





To manage trauma or any injury to the
orbital region both functionally and
esthetically.
To correct diplopia a...
CLASSIFICATION OF ORBITAL
FRACTURES
I. ISOLATED FRACTURES OF ORBIATL RIM:

SUPERIOR
 INFERIOR
 LATERAL
 MEDIAL
II. ISOL...
III. ORBITAL WALL FRACTURES:
1. BLOW OUT FRACTURE:
 pure blow out fracture
 impure blow out fracture
2. BLOW IN FRACTURE...
PATHOPHYSIOLOGY
Bone conduction theory “buckling
“
 Less energy
 Small fractures limited anterior
floor
Hydraulic theory...
CLINICAL DIAGNOSIS
BASED ON AREA INVOLVED

:

PERIORBITAL TISSUES:

OEDEMA

SUBCONJUNCTIVAL HEMORRHAGE

CIRCUMORBITAL E...
BASED ON TIMING:
Early features:
 Limitation of elevation of eye.
 Paresthesia of infra orbital nerve.
 Alteration of o...
INVESTIGATIONS
RADIOGRAPHIC FINDINGS:

PLAIN RADIOGRAPHY.

WATERS PROJECTION.
C.T SCAN &MRI:

Coronal scanning

Axial ...
SPECIAL
TESTS
FORCED
DUCTION
TEST
/TRACTION
TEST
ELECTROMY
OGRAPHYdone by
opthalmologist.
ORBITOGRAP www.indiandentalacade...
OPTHALMOLOGIC
EVALUATION







Periorbital examination
Visual acuity
Pupillary size and shape
Ocular motility
Fundo...
DIPLOPIA
Two images of same object
Monocular diplopia
Binocular diplopia
CAUSES:
EDEMA/HEMATOMA
RESTRICTED

MOTILITY
NE...
MANAGEMENT
TWO APPRACHES:

CONSERVATIVE APPROACH

SURGICAL APPROACH

www.indiandentalacademy.com
MANAGEMENT
CONSERVATIVE APPRACH:
 Several authors have put forward there
concepts whether to observe or to do
some early ...
MANAGEMENT
OBSERVATION:

minimal diplopia

good ocular motility

no signs of enopthalmos
EARLY INTERVENTION:(WITHIN TWO...
Orbital Floor


When to explore? (Shumrick study)








Persistent diplopia with positive forced duction
Obvious...
PUTTERMANS REVISED INDICATION:

7 days of systemic corticosteroids for the
resolution of the diplopia within first 3 week...
CONTRAVERSIES:
 Oedema
 Diplopia may resolve rapidly after injury
has settled.
 Motility problems if not treated
immedi...
TRAP DOOR FRACTURES:(mechanical
incarceration of the extra ocular muscle):
 This can be diagnosed by CT & by forced
ducti...
SURGICAL MANAGEMENT:
 Crikelair & co workers said….in case of
persistent diplopia or enopthalmos after 2
weeks –surgical ...
Depending on the area & extent &also
aesthetic consideration the following
incisions are given for the particular area..
O...
www.indiandentalacademy.com
SUBCILIARY APPROACH

www.indiandentalacademy.com
SUBTARSAL APPROACH

www.indiandentalacademy.com
SUBCILIARY &SUBTARSAL INCISION:
ADVANTAGES:
 Easy &quick to do
 In case of edema also estimation of giving incision
can ...
TRANSCONJUCTIVAL
APPROACH

www.indiandentalacademy.com
TRANSCONJUCTIVAL
APPROACH

www.indiandentalacademy.com
TRANSCONJUNCTIVAL
INCISION
:

Advantages:

Excellent aesthetics results.
 Quick to do.
 No skin muscle disssection
 Low...
ORBITAL ROOF & LATERAL WALL:

EYE BROW INCISION

UPPER BLEPHAROPLASTY INCISION

BI CORONAL INCISION

LATERAL CANTHOTOM...
EYEBROW INCISION

www.indiandentalacademy.com
UPPER BHLEPHAROPLASTY
INCISION

www.indiandentalacademy.com
BICORONAL INCISION

www.indiandentalacademy.com
BICORONAL INCISION

www.indiandentalacademy.com
LATERAL
CANTHOTOMY&CANTHOLYSI
S

www.indiandentalacademy.com
MEDIAL ORBITAL APPROACH:

CORONAL INCISION

LATERAL NASAL INCISION

TRANSCONJUNCTIVAL APPROACH

SUB CILIARY INCISION

...
MATERIALS FOR
RECOSTRUCTION
FUNCTIONS:
 To seal off antral cavity from orbit
 To provide a physiologically acceptable &p...
MATERIALS FOR
RECOSTRUCTION
GRAFTS
 AUTOGRAFTS(BONE OR CARTILAGE)
 HOMOGRAFTS(LYOPHILISED
DURAMATER)
 ALLELOGRAFTS(TEFL...
Orbital Floor
Bone Grafting


Need to
support
floor full 4
cm

www.indiandentalacademy.com
AUTOGRAFTS:













antral wall
septal cartilage
cancellous bone from mastoid
calvarial bone
inner plate ...








HOMOGRAFTS:
disadvantages :
greater susseptibility to infection
increased rate of resorption.
Lyophilised hu...
IMPLANTS:
RESORBABLE
NON RESORBABLE IMPLANTS.
resorbable implants:
polydiaxane
polylactides
non resorbable implants:
titan...
COMPLICATIONS
HEMORRHAGE /ORBITAL HEMATOMA
RETROBULBAR HEMMORHAGE
BLINDNESS
DIPLOPIA
SUPERIOR ORBITAL FISSURE
SYNDROME
ORB...
ORBITAL HEMATOMA &ITS
TREATMENT

www.indiandentalacademy.com
RETROBULBAR
HEMORRHAGE

www.indiandentalacademy.com
Thank you
For more details please visit
www.indiandentalacademy.com

www.indiandentalacademy.com
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Orbital anatomy and 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 anatomy and trauma /certified fixed orthodontic courses by Indian dental academy

  1. 1. ORBITAL FRACTURE INDIAN DENTAL ACADEMY Leader in continuing dental education www.indiandentalacademy.com www.indiandentalacademy.com
  2. 2. INTRODUCTION  The importance of orbit is to protect vital structures by allowing fractures to occur. Because the globe is surrounded by fat and the medial wall and floor of the orbit are thin, force that is transmitted to the globe allows fracture of the orbit without significant globe injury. This accounts for the significantly higher incidence of fractures of the orbit as compared to open globe injuries. www.indiandentalacademy.com
  3. 3. AIM    To manage trauma or any injury to the orbital region both functionally and esthetically. To correct diplopia and enopthalmos. To know proper anatomy so that structures related to this area can be restored back to there anatomical position. www.indiandentalacademy.com
  4. 4. CLASSIFICATION OF ORBITAL FRACTURES I. ISOLATED FRACTURES OF ORBIATL RIM: SUPERIOR  INFERIOR  LATERAL  MEDIAL II. ISOLATED FRACTURE OF ORBITAL WALLS:  ROOF  FLOOR  MEDIAL  LATERAL  www.indiandentalacademy.com
  5. 5. III. ORBITAL WALL FRACTURES: 1. BLOW OUT FRACTURE:  pure blow out fracture  impure blow out fracture 2. BLOW IN FRACTURE www.indiandentalacademy.com
  6. 6. PATHOPHYSIOLOGY Bone conduction theory “buckling “  Less energy  Small fractures limited anterior floor Hydraulic theory  More energy  Larger fracture involving entire floor and medial wallentire wall  Should suspect more extensive orbit involvement with associated injuries (globe rupture)(rupture) www.indiandentalacademy.com
  7. 7. CLINICAL DIAGNOSIS BASED ON AREA INVOLVED : PERIORBITAL TISSUES:  OEDEMA  SUBCONJUNCTIVAL HEMORRHAGE  CIRCUMORBITAL ECCHYMOSIS  SURGICAL EMPHYSEMA EYELIDS:  ABNORMALITY OF PALPEBRAL FISSURE  PTOSIS  PSEUDOPTOSIS LIGAMENTS:  ANTIMONGOLOID SLANT  MONGOLOID SLANT  TELECANTHUS EYE:  PRESERVATION OF VISION  LIMITATION OF OCCULAR MOVEMENTS  DIPLOPIA  ENOPTHALMOS LACRIMAL APPARATUS:  EPIPHORA NEUROLOGICAL DEFICITS:  PARESTHESIA . www.indiandentalacademy.com
  8. 8. BASED ON TIMING: Early features:  Limitation of elevation of eye.  Paresthesia of infra orbital nerve.  Alteration of ocular level. Late features(after 7 to 10 days):  Diplopia  Lowering of ocular level  Enopthalmos  Deepening of supratarsal fold.  Narrowing of palpebral fissure www.indiandentalacademy.com
  9. 9. INVESTIGATIONS RADIOGRAPHIC FINDINGS:  PLAIN RADIOGRAPHY.  WATERS PROJECTION. C.T SCAN &MRI:  Coronal scanning  Axial scanning  Saggital scanning MRI used for assessment of soft tissue displacement www.indiandentalacademy.com
  10. 10. SPECIAL TESTS FORCED DUCTION TEST /TRACTION TEST ELECTROMY OGRAPHYdone by opthalmologist. ORBITOGRAP www.indiandentalacademy.com
  11. 11. OPTHALMOLOGIC EVALUATION       Periorbital examination Visual acuity Pupillary size and shape Ocular motility Fundoscopic examination Hyphema www.indiandentalacademy.com
  12. 12. DIPLOPIA Two images of same object Monocular diplopia Binocular diplopia CAUSES: EDEMA/HEMATOMA RESTRICTED MOTILITY NEUROGENIC INJURY EVALUATION: Testing ductions Forced duction test Electromyography Corneal light reflex www.indiandentalacademy.com
  13. 13. MANAGEMENT TWO APPRACHES:  CONSERVATIVE APPROACH  SURGICAL APPROACH www.indiandentalacademy.com
  14. 14. MANAGEMENT CONSERVATIVE APPRACH:  Several authors have put forward there concepts whether to observe or to do some early treatment or wait for some time to carry on some surgical procedure. www.indiandentalacademy.com
  15. 15. MANAGEMENT OBSERVATION:  minimal diplopia  good ocular motility  no signs of enopthalmos EARLY INTERVENTION:(WITHIN TWO WEEKS)  early enopthalmos causing facial asymmetry  white eyed floor fracture (children) LATE INTERVENTION:(AFTER TWO WEEKS)  symptomatic diplopia with positive forced duction test  late enopthalmos  progressive infra orbital hypoesthesia www.indiandentalacademy.com
  16. 16. Orbital Floor  When to explore? (Shumrick study)        Persistent diplopia with positive forced duction Obvious enophthalmos Comminuted orbital rim by CT >50% floor disruption by CT Combined floor/medial wall defects by CT Fracture of zygoma body by CT “Blow-in” fx with exophthalmos by PE or CT www.indiandentalacademy.com
  17. 17. PUTTERMANS REVISED INDICATION:  7 days of systemic corticosteroids for the resolution of the diplopia within first 3 weeks.  Hawer & Dartzbach evaluated size of orbital floor defects &felt that fracture involving more than half the floor should be reconstructed within first 2 weeks to avoid enopthalmos  Hertel exopthalmometry(enopthalmos):alignin the ruler through both the medial canthi &noting where the ruler bisects each eye. www.indiandentalacademy.com
  18. 18. CONTRAVERSIES:  Oedema  Diplopia may resolve rapidly after injury has settled.  Motility problems if not treated immediately.  Asymptomatic patient may develop diplopia or enopthalmos if not treated www.indiandentalacademy.com
  19. 19. TRAP DOOR FRACTURES:(mechanical incarceration of the extra ocular muscle):  This can be diagnosed by CT & by forced duction test. Timing of repair:  children: within 5 days produces better results  adults: no specific time period. But treated after 14 days has good long period results. www.indiandentalacademy.com
  20. 20. SURGICAL MANAGEMENT:  Crikelair & co workers said….in case of persistent diplopia or enopthalmos after 2 weeks –surgical repairing of orbital fractures is needed.  Persistent diplopia for 4 months following trauma-contralateral eye muscle surgery or contralateral fat resection to mask enopthalmos. www.indiandentalacademy.com
  21. 21. Depending on the area & extent &also aesthetic consideration the following incisions are given for the particular area.. ORBITAL FLOOR:  SUBCILIARY INCISION.  TRANSCONJUNCTIVAL INCISION  SUB TARSAL INCISION  www.indiandentalacademy.com
  22. 22. www.indiandentalacademy.com
  23. 23. SUBCILIARY APPROACH www.indiandentalacademy.com
  24. 24. SUBTARSAL APPROACH www.indiandentalacademy.com
  25. 25. SUBCILIARY &SUBTARSAL INCISION: ADVANTAGES:  Easy &quick to do  In case of edema also estimation of giving incision can easily be made  Scar inversion is greatly diminished. DISADVANTAGES:  Vertical lid shortening  Increased incidence of impairments with subciliary incision. www.indiandentalacademy.com
  26. 26. TRANSCONJUCTIVAL APPROACH www.indiandentalacademy.com
  27. 27. TRANSCONJUCTIVAL APPROACH www.indiandentalacademy.com
  28. 28. TRANSCONJUNCTIVAL INCISION : Advantages: Excellent aesthetics results.  Quick to do.  No skin muscle disssection  Low incidence of ectropian.  Scar can be seen only b cos of lateral extension which heals rapidly. Disadvantages:  Limitation of access  Medial extent can be limited.  www.indiandentalacademy.com
  29. 29. ORBITAL ROOF & LATERAL WALL:  EYE BROW INCISION  UPPER BLEPHAROPLASTY INCISION  BI CORONAL INCISION  LATERAL CANTHOTOMY INCISION. www.indiandentalacademy.com
  30. 30. EYEBROW INCISION www.indiandentalacademy.com
  31. 31. UPPER BHLEPHAROPLASTY INCISION www.indiandentalacademy.com
  32. 32. BICORONAL INCISION www.indiandentalacademy.com
  33. 33. BICORONAL INCISION www.indiandentalacademy.com
  34. 34. LATERAL CANTHOTOMY&CANTHOLYSI S www.indiandentalacademy.com
  35. 35. MEDIAL ORBITAL APPROACH:  CORONAL INCISION  LATERAL NASAL INCISION  TRANSCONJUNCTIVAL APPROACH  SUB CILIARY INCISION www.indiandentalacademy.com
  36. 36. MATERIALS FOR RECOSTRUCTION FUNCTIONS:  To seal off antral cavity from orbit  To provide a physiologically acceptable &physically inert smooth surface.  Restore the contour &dimension of the orbit  To provide some indirect support for the globe IDEAL REQUISITES:  Easy to mould  Easy to fixate  Biocompatible  Strong & readily available. www.indiandentalacademy.com
  37. 37. MATERIALS FOR RECOSTRUCTION GRAFTS  AUTOGRAFTS(BONE OR CARTILAGE)  HOMOGRAFTS(LYOPHILISED DURAMATER)  ALLELOGRAFTS(TEFLON OR SILASTIC) www.indiandentalacademy.com
  38. 38. Orbital Floor Bone Grafting  Need to support floor full 4 cm www.indiandentalacademy.com
  39. 39. AUTOGRAFTS:             antral wall septal cartilage cancellous bone from mastoid calvarial bone inner plate of ileum. 8 ,9,&10 ribs at costosternal junction (children) TO SECURE THE GRAFT: soft stainless steel wire microplate or miniplate titanium mesh ADVANTAGE: high tissue compatibility DISADVANTAGE: second surgical procedure. www.indiandentalacademy.com
  40. 40.       HOMOGRAFTS: disadvantages : greater susseptibility to infection increased rate of resorption. Lyophilised human dura-commonly used,gets absorbed &replaced by fibrous tissue available in pre sterilised packets. www.indiandentalacademy.com
  41. 41. IMPLANTS: RESORBABLE NON RESORBABLE IMPLANTS. resorbable implants: polydiaxane polylactides non resorbable implants: titanium silicone polyethylene teflon ADVANTAGES: second operation to harvest bone is not necessary DISADVANTAGES: materials become fibrotically encapsulated causing infection www.indiandentalacademy.com
  42. 42. COMPLICATIONS HEMORRHAGE /ORBITAL HEMATOMA RETROBULBAR HEMMORHAGE BLINDNESS DIPLOPIA SUPERIOR ORBITAL FISSURE SYNDROME ORBITAL APEX SYNDROME CARATICO CAVERNOUS FISTULA www.indiandentalacademy.com
  43. 43. ORBITAL HEMATOMA &ITS TREATMENT www.indiandentalacademy.com
  44. 44. RETROBULBAR HEMORRHAGE www.indiandentalacademy.com
  45. 45. Thank you For more details please visit www.indiandentalacademy.com www.indiandentalacademy.com

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