Dr. Bhavik Miyani, Resident Doctor in Department of Oral and Maxillofacial Surgery, Narsinhbhai Patel Dental College and Hospital, Visnagar.

1. PRESENTED BY,
DR. BHAVIK MIYANI,
OMFS PG- II
NPDCH, VISNAGAR.
GUIDED BY,
DR. ANIL MANAGUTTI,
DR. SHAILESH MENAT,
DR. RUSHIT PATEL,
DR. JIGAR PATEL.

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

3.  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%
 Volume - 30ML

8. IO Tendon

9. SUPERIOR OBLIQUEINFERIOR OBLIQUE

12. ACTION OF VARIOUS MUSCLE
Muscl
e
Primar
y
Action
Secondary
Action
Tertiary
Action
LR
Abductio
n
None None
MR Adduction None None
SR
Elevatio
n
Intortion Adduction
IR Depressio
n Extortion Adduction
IO
Extortio
n
Elevation Abduction

13. IO
SO IR
SR
MRLR
MEDIALLATERAL

18. Pfeiffer, Smith & Regan

19. Le Fort Smith and Converse

21. Erling, 1999

23.  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

24. Tomohisa Nagasao, M.D. et. Al
Department of Plastic and Reconstructive Surgery,
TOKYO
PRS• June 2006

25. The Journal of Cranio-Maxillofacial Trauma
1999;5(l):41-46
Mark S. Brown, MD, Willy Ky, MDf, Richard D. Lisman, MD|

32. ZYGOMATIC PROCESS
OF FRONTAL BONE
GREATER WING
OF SPHENOID
ORBITAL PART
OF ZYGOMATIC BONE

33. ANT & POST ETHMOIDAL
FORAMINA
ORBITAL PART
OF FRONTAL BONE
LACRIMAL BONE
ETHMOID BONE
ORBITAL PART
OF MAXILLARY BONE
LESSER WING
OF SPHENOID

34.  Floor is concave
and then convex
 Floor slopes into
medial wall.
 Maximum vertical
dimension 1.5 cm
behind rim

35. 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

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

37. CHILDREN BEFORE
PUBERTY
Risk of muscle or soft
tissue entrapment
Immature bone
greater elasticity of
the orbital bone
Kyung-Chul Yoon, Man-Seong Seo,
Dept. Ophthalmology, Chonnam National
University Hospital, KOREA
J Korean Med Sci 2003; 18: 881-5
TRAPDOOR
FRACTURE

38. Minor eye injuries :
 Subconjunctival hemorrhage

39.  Corneal abrasion
 Injury to the eyelids

40. Nonperforating eye injuries :
Conjunctiva and cornea
Anterior chamber
- Hymphema
- Traumaic iritis

41. Injury to iris and pupil
Injury to lens
Injury to ciliary body
Retinal and choroidal injury
Perforating eye injuries

43.  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

44.  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

45. CLASSIFICATION OF ORBITAL WALL DEFECTSCLASSIFICATION OF ORBITAL WALL DEFECTS
C. Jaquiery et al.,C. Jaquiery et al.,
Maxillofacial unit , University Hospital, Basel, SwitzerlandMaxillofacial unit , University Hospital, Basel, Switzerland
IJOMS ‘07 :36;193-199IJOMS ‘07 :36;193-199

46. Category I

47. Category II

48. Category III

49. Category IV

50. Category V

51. 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
6. Late restoration of contour by onlay grafts

53. Circumorbital
Ecchymosis
Subconjunctival
Haemorrhage
Orbital
Emphysema
Diplopia

54. Proptosis
Ptosis, Pseudoptosis)

55. Increased
inter-canthal distance
TELECANTHUS
Ocular Level
Canthal Level

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

59. Floor Fracture Trap Door Fracture

60. Medial Wall Fracture Lateral Wall Fracture

61. Pneumo- Orbitum Roof Fracture

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

64. Pupilary reflexes
Visual acuity
Ocular movements
Presence of Diplopia,
Exopthalmos or
Enopthalmos
Opthalmic injuries
Ligaments
Inter pupilary distance
Oedema
Circumorbital Ecchymosis
Subconjunctival
Haemorrhage
Orbital Emphysema
The Periorbital tissues.Ey
e

65. Hess test
Snells test
Fundoscopy
Jones test to assess the patency
of the nasolacrimal duct

66. 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.

67. d

68. 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.  Persistent Diplopia.
 Cosmetically significant and clinically apparent
Enophthalmos.
 Physical and radiographic signs of exophthalmus
 Radiological evidence of significant comminution of
orbital rim, the floor or the zygoma.
 Combination of the floor and the medial wall defects
with soft tissue displacement.
Arch otolaryngology head and neck surgery
1997;123:378-84.

74.  Defect < 1cm2
 Localized anteriorly to the
equator of the eye ball can
be surgically exposed &
revised but not repaired.
 Defects of the  Resorbable membranes like
orbital floor and PDS sheeting
the medial wall of
limited size

75. Larger defects requires a stable material in order
to support the orbital content and to prevent
the risk of secondary Enopthalmos & Diplopia
(JOMS ‘04 : 62 :1280-1297)

76. Complex orbital fractures required more than one
material for reconstruction.
PDS sheeting, or Ti meshes or larger autologous
bone grafts can be used to provide stability,
additional bone chips can be introduced to fill up
the gaps and to tune projection by comparing the
reconstruction with unaffected orbit.

77. As demonstrated by Ellis and
Tan.
 With correct use of the materials,
complications of the orbital reconstruction are
not material related
( JOMS ‘03 : 61 :442-453)

78. In terms of anatomic accuracy , Ti meshes are
preferred –over autologous bones grafts, but in
terms of functional autologous bones grafts are
preffered
 In case of larger defects (IV, V) is often restricted by
limited access to the internal orbit and bears the
risk of iatrogenic damage to the periorbital tissue.
 CAS may be a helpful tool in the context of orbital
reconstruction.

80.  Retrobulbar Haemorrhage
 Superior orbital fissure syndrome
 Orbital apex syndrome
 Carotico cavernous fistula
 Canalicular injuries

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

82.  Proptosis
 Subconjunctival edema
& ecchymosis
 Dialating pupil
 Loss of direct light reflex
 Preservation of
consentual reflex
 Opthalmoplegia
 Increased intraoccular
pressure
 Constriction of retinal
arterioles
 Pallor of the optic disc
 Cherry red macular spot
 Globe hard on palpation

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

84. 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….

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.  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 7 the
Ophthalmic Surgeons, will contribute to the
progression of orbital reconstruction techniques.