This document discusses orbital fractures, including: - The surgical anatomy of the orbit and boundaries like the lateral wall and medial wall. - Biomechanics, etiology, fracture patterns, and classification of orbital fractures. - Clinical presentation, diagnosis using imaging like CT, and management including complications. - Recent trends involve use of stereolithography models and computer-assisted reconstruction based on cone beam tomography for complex orbital fractures.

2. ORBITAL FRACTURES

3.  INTODUCTION
 SURGICAL ANATOMY
 BIOMECHANICS OF ORBITAL FRACTURE
 ETIOLOGY AND EPIDEMIOLOGY
 FACTURE PATTERN
 CLASSIFICATION
 CLINICAL PRESENTATION
 DIAGNOSIS & IMAGING
 MANAGEMENT
 COMPLICATIONS
 RECENT TRENDS

4.  Its is a four sided pyramid
with its apex at the optic
foramina
 Paired bony cavities, housing
and protecting globe.
 Orbital Growth
By 5 yrs - 85% by
Puberty - 100%

7.  BOUNDARIES OF ORBIT
 LATERAL WALL –
formed by :
a) Anterior surface of greater
wing of sphenoid
posteriorly.
b) Orbital surface of
zygomatic bone anteriorly.

8.  Frontal and zygomatic
bone
 FZ suture - Narrowest
and weakest
 The lateral wall is almost
devoid of foramina, so its
anterior portion can be
broached without serious
haemorrhage

9. MEDIAL WALL –
a) Orbital plate of the
ethmoid bone.
b) Anteriorly - continues as
the lacrimal bone which is
weakened by the
nasolacrimal canal passing
through the fossa.
c)Posteriorly – optic foramen
in sphenoid bone

10.  Poorly defined and merges
posteriorly with lacrimal
bone.
 Displacement in this
region results in deformity
of naso orbital valley and
displacement of canthal
ligament.

11.  ROOF :
 Orbital part of frontal bone.
 Posteriorly - lesser wing of
sphenoid
 The junction of the roof with
the medial wall is in close
proximity to the cribriform
plate of the ethmoid.
 Penetration of the
duramater will allow
cerebrospinal fluid to
escape into either the orbit
or the nose, or both cavities.

12.  Infraorbital foramen to midpoint
of inferior orbital fissure : 24mm
 Anterior lacrimal crest to medial
aspect of optic canal :42mm
 FZ suture to superior orbital
fissure : 35mm
 Supraorbital notch to superior
orbital fissure : 40mm
 Supra orbital notch to superior
aspect of optic canal : 45mm

13.  The lamina papyracea (or orbital lamina) is a
smooth, oblong bone plate which forms the lateral
surface of the labyrinth of theethmoid bone in the
skull.
 The plate covers in the middle and posterior
ethmoidal cells and forms a large part of the medial
wall of the orbit.

14.  It articulates above with the orbital plate of the
frontal bone, below with the maxilla and the
orbital process of palatine bone, in front with the
lacrimal, and behind with the sphenoid.
 Its name lamina papyracea is a literal description, as
this part of the ethmoid bone is paper-thin and
fractures easily. A fracture here could cause
entrapment of the medial rectus muscle.

17. SUPERIOR OBLIQUE

18. INFERIOR OBLIQUE
INFERIOR OBLIQUE

22.  Fractures produced by the  limited to the anterior
part of
Buckling mechanism the orbital floor
 Hydraulic-type fractures  Involving Anterior &
Posterior were much larger parts of the
Floor as well as
the Medial Wall of the Orbit
 The Average Energy required to fracture the orbital floor
BUCKLING MECHANISM - 1.54 J
HYDRAULIC MECHANISM - 1.22 J
Ahmad, Fateh; et al..
Journal of Craniofacial Surgery. 17(3):438-441, May 2006.
2006 Muntaz B. Habal, MD

27. Pure and impure
A 3-mm downward
displacement of the entire
floor
Orbital volume that is
increased by 1.5 cm3
a 5%
increase
Producing 1-1.5 mm of
Enophthalmos
1957 by Smith & Regan

28.  A blow-in fracture is an inwardly displaced
fracture of the orbital rim or wall resulting in
decreased orbital volume.
 Described by dingman and natvig in 1964.
 Antonyshyn et al noted proptosis because of
decrease orbital volume in 41 cases.

29. CHILDREN UP TO
AGE 7
ORBITAL ROOF FRACTURE
- larger cranium
- lack of frontal sinus
pneumatization
ORBITAL FLOOR FRACTURE
Occurs primarily in older
Children

30.  Children are particularly
susceptible to pure orbital
fractures of the trapdoor variety .
Trapdoor fracture, which first
described by Soll and Poley .
 Occurs when a segment of the
bony orbit fractures and becomes
displaced, but remains attached
on one side.
 It makes orbitral contents
herniated through the fracture
sites, which results in entrapment
of these herniated contents
• Immature bone
greater elasticity of the orbital bone

32.  Superior rim
 Lateral 3rd
( lacrimal
recess)
 Central 3rd
(supraorbital
nerve)
 Medial 3rd
(frontal sinus)
 Inferior rim
 Central 3rd
(infraorbital
nerve)
 Medial 3rd
(inferior oblique
origin)
Rowe and Wiliams
Medial rim
Medial canthal ligament
Lacrimal passage
Lateral rim
Lateral canthal ligament
Suspensory ligament

33.  Roof
 Anterior cranial fossa, superior rectus, frontal sinus.
 Floor
 Antrum, inferior rectus/inferior oblque, infraorbital
nerves and vessels.
 Medial wall
 Ethmoidal sinus, medial rectus, suspensory ligament.
 Lateral wall
 Superior orbital fissure and associated structures

34. 1. No treatment
2. Indirect reduction with
a. no fixation
b. temporary support
3. Direct reduction and fixation
4. Immediate reconstruction by grafting
5. Delayed reconstruction by osteotomy or grafting.

36. Circumorbital
Ecchymosis
Subconjunctival
Haemorrhageorbital emphysema

37.  Lang (1888) – Expanded orbit
 Bite et al (1985), Manson et al (1986), Whitehouse et al
(1994) – Orbital expansion was the primary reason for
enophthalmos & not the fat atrophy..
 It has been shown that a 0.8–1 ml increase of bony
orbital volume corresponds to 1 mm on the Hertel
exopthalmometer (Lee & Chiu 1993; Ploder et al.
2002).
37

38.  Is defined as a retro position
of the globe in its three-
dimensional relationship in
the orbit and should be
assessed in relation to the
contra lateral eye and facial
structures
 Hertels
exophthalmometer is
used to determine the
degree of enophthalmos
 more than 3mm is
indicative of surgery.

39.  The effusion of blood into and around extra-ocular
muscles interferes with their delicate action required to
maintain co-ordination of the eye movement.
 Binocular – neurogenic injury or restricted motility.
 Monocular-one eye – detached lens
 Traumatic diplopia can result by –
 Physical interference:
1. Extravasation of blood into and around the muscles
and oedema
2. Impingement of bony spicules
3. Displacement of the inferior oblique muscle

40.  Koornneef & Zonneveld found that
entrapment of IR ms is not the major cause
of diplopia. They found that impaired globe
motility is caused by connective tissue
derangement inside the orbit
 Tessier – oculomotor imbalance
40

41. Proptosis
Ptosis

42. Increased
inter-canthal distance
TELECANTHUS
Ocular Level

45.  If fracture occurs above
whitnall’s tubercle
 Bone displaced downwards
along with upper eyelid
 Physical sign - hooding of globe

46.  Epiphora is an overflow of tears onto the face. A
clinical sign or condition that constitutes insufficient
tear film drainage from the eyesin that tears will drain
down the face rather than through the nasolacrimal
system.
 Causes of epiphora include ocular irritation and
inflammation (including trichiasis and entropion) or
an obstructed tear outflow tract which is divided
according to its anatomical location .

47.  Another cause could be poor reconstruction of the
nasolacrimal duct system after trauma to the area.
Cause of trauma could be facial fractures (including
nasoethmoid fractures or maxillary Le Fort fractures),
and soft tissue trauma involving the nose and/or the
eyelid. This condition is often frustrating or irritating

48. 48

49. 49

50. 50

52.  Plain radiography.
PNS
AP skull and PA skull view.
 Computed Tomography.
 MRI

54. Floor Fracture Trap Door Fracture

55. Roof Fracture

57.  History
 Complete General Physical Examination
 Palpation of the Bony walls of the orbit
and other associated structures

58. Visual acuity
Ocular movements
Presence of
Diplopia,Exopthalm
os or Enopthalmos
Ligaments
Inter pupilary
distance
Oedema
Circumorbital Ecchymosis
Subconjunctival
Haemorrhage
Orbital Emphysema
The Periorbital tissues.Ey
e

60. Surgery should be performed within 2 weeks after
the edema around the eye has decreased.
In children, callus is formed on the bone
fracture in 7 days, which makes it difficult to
reduce fractures accurately.
Hence, facial bone fractures should be operated
on earlier in children than in adults.

61.  1957 : Converse & Smith – should be corrected ..within 1st
three weeks.
 1974 : Puttermann – proposed conservative management – if
diplopia persists for >4 months do contralateral eye muscle
surgery.
 Dulley & Fells criteria – 2 wks of observation for diplopia with
corticosteroids and physiotherapy. Surgical Intervene if
enophtholmous >3mm, Diplopia persists, large herniation
 Dortzbeck - >2mm enopthalmous, Persistent diplopia for
>2wks.

63. d

65.  Ectropion is a medical condition in which the
lower eyelid turns outwards. It is one of the
notable aspects of newborns exhibiting
congenital Harlequin-type ichthyosis .
 can occur due to any weakening of tissue of
the lower eyelid. The condition can be
repaired surgically.

67. Placement of anterior
maxillary wall graft
Placement of
Ballon Catheter

71.  Titanium
 Silicone
 Polyethylene
 Teflon
 Bioactive glass implants

72.  Polydioxanone
 Polylactide
 Polyglycolic acid
 Vicrylmesh - polyglactin-910

73. Complex orbital fractures required more than one
material for reconstruction.
additional bone chips can be introduced to fill up
the gaps and to tune projection by comparing the
reconstruction with unaffected orbit.

74. In terms of anatomic accuracy , Ti meshes are
preferred –over autologous bones grafts, but in
terms of function autologous bones grafts are
preffered
 In case of larger defects is often restricted by
limited access to the internal orbit and bears the
risk of iatrogenic damage to the periorbital tissue.

76.  Retrobulbar Hemorrhage
 Superior orbital fissure syndrome
 Orbital apex syndrome

77. Loss of vision as a complication
of Maxillo- facial trauma
occurs in  3-12%
The blindness due to
Retrobulbar Haemorrhage
 48- 50%

78.  Proptosis
 Subconjunctival edema
& ecchymosis
 Dialating pupil
 Loss of direct light reflex
 Opthalmoplegia
 Increased intraoccular
pressure
 Constriction of retinal
arterioles
 Cherry red macular spot
 Globe hard on palpation

79. Diagnosis and treatment of Retrobulbar Haematomas following blunt orbit
trauma
Int J Oral Maxillofac Surg 2005
Mar;34(2):127-31

80. Immediate action
Remove any sutures in the area, for pressure relief
Surgical decompression….
Medication
Mannitol 1g/Kg as 20% infusion
Osmotic diuretic
Contra-indicated in congestive
cardiac Failure.
Acetazolamide 500mg IV
Dexamethasone 8mg
Papaverine 40mg smooth muscle relaxant
Dextran 40 500mls IV improves perfusion
IF NO RESPONSE TILL 48 HRS STEROIDS TO BE DISCONTINUED…
Consider Surgical decompression….

81.  Objective – decompression of orbit.
 If retro bulbar hemorrhage arises after surgery which
involved access to orbital floor, same incisions may be
used for evacuation of blood from extra conal space.
 If this approach is unsuccessful antrum is approached
,any pack on balloon is defected, and roof is inspected
for any spicules free of periosteum and it is picked up .
After creation of adequate space, suction may be
applied.

82.  For intraconal space: Incision in placed
above and below lateral canthal ligament,
dividing the orbital septum – provides access
to inter muscular septum between inferior and
lateral rectus muscle

83.  By banks in 1967
 An instructive example of precise anatomic
localization of a lesion by neurologic sign.
SIGN AND SYPTOMS
 Gross and persistent oedema
 Proptosis and subconjuctival ecchymosis.
 Dilation of pupil, ptosis
 Radiological evidence of reduction in the
dimensions of the superior orbital fissure.

84.  Combination of superior orbital fissure syndrome
and optic nerve injury
 Etiology: bony compression of optic nerve and
superior orbital fissure
 Symptoms: loss of direct light reflex
 maintenance of consensual reflex

86. Fracture types can be evaluated and repaired
endoscopically without the need for an extensive
eyelid incision.
It offers improved visualization, anatomic fracture
repair, no risk of postoperative eyelid complications,
and good clinical results.
Facial Plast Surg 2004;

87. STEREOLITHOGRAPHY
Stereolithography is an
industrial process
which uses data
generated from
computer-assisted
design (CAD) to
generate three-
dimensional models.
Journal of Oral and Maxillofacial Surgery
Volume 63, Issue 2, February 2005, Pages 200-208

88. Computer-assisted
reconstruction of
orbital floor based on
cone beam
tomography
bjoms.2005.06.031
Christoph Zizelmann et al..
BJOMS Jan 2007 (Vol. 45, Issue 1, Pages 79-80)

89. A straight titanium plate size 1.0mm to 1.3mm is cut lengthwise to be
inserted into one of the channels.

90. The implant is sized and cut with heavy scissors to fit the defect. The straight plate is inserted into one of the
channels.

91. The MEDPOR Channel Implant and straight plate are shaped to conform to the
size and configuration of the orbital floor.

92. The implant is positioned on solid bone (if available). It is advanced carefully so as
not to pinch or incarcerate orbital soft tissue.

93. Once positioned, the plate is cut to the appropriate length so it can be secured
to solid bone with a 4, 5, or 6mm screw.

94. The screw secures the plate and the MEDPOR Channel Implant in position.

95.  Accuracy of reconstruction is a prerequisite for
anatomical positioning of the eye ball in order to
prevent functional disorders.
 The management of orbital fractures and their
complications will be benefited from a
multidisciplinary approach.
 Hence the continued relationship between Cranio
-Maxillofacial Surgeons, Plastic Surgeons & the
Ophthalmic Surgeons, will contribute to the
progression of orbital reconstruction techniques.

96.  Fonseca – Trauma vol 2
 Trauma and Esthetic reconstuction – Peter Ward Booth
 Surgical approaches to facial skeleton – Ellis .
 Rowe and William’s Maxillofacial Injuries – Vol 1 and 2 -1994
 Oral & Maxillofacial Surgery Clinics of North America – Orbital Trauma

97. THANK YOU
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