Management of Orbital Fractures

Management of
Orbital Fractures
Risto Kontio, MD, DDS, PhDa,*, Christian Lindqvist, MD, DDS, PhDa,b
KEYWORDS
Blow-out Orbital surgery Orbital reconstruction
Fracture of orbit Resorbable Bone graft
Trauma to the orbital region can result in consider- INDICATIONS FOR ORBITAL FRACTURE SURGERY
able facial deformity and can affect vision and the
nervous system of the face. Rehabilitation of the Several factors need to be considered in deter-
patient requires an understanding of the alteration mining whether surgical intervention is indicated
in form and function of the orbit, including the in- in a patient with an orbital fracture. A careful
traorbital and intraocular tissues, and the materials history and thorough physical examination are
and methods available for repair. integral components in making decisions
The indications for surgery on orbital floor frac- regarding the subsequent management of these
tures are controversial. Strong indications include patients.
enophthalmos greater than 2 mm, significant hy- There is general agreement that lack of ocular
poglobus, or diplopia. Certain consensus also motility is an important consideration. Motility limi-
prevails regarding the need for surgery when there tation can be graded on a scale from 0 to 4, where
is an increase of orbital volume more than 1 cm3. 0 equals no limitation (normal) and 4 equals no
When there are lesser degrees of trauma, movement in the field of gaze. Each limited field
disagreement remains regarding the best method of gaze represents a 25% reduction in motility.
of treatment. The most commonly accepted cause for limited
The timing of surgery for orbital fractures has motility is entrapment of the extraocular muscles
also been a controversial issue. Orbital fractures (inferior rectus muscle) or their fascia into a fracture
differ from all other facial fractures in that surgery gap in the orbital floor.
does not typically attempt to achieve bone healing. Diplopia is another consideration. Although it
Rather, the goal of surgery is simply to reconstruct may be a consequence of muscle entrapment, it
the defect area of the fractured wall. As such, de- can also result from muscle edema, hemorrhage
laying the operation for varying periods of time is in the orbital cavity, and motor nerve palsy.
feasible. Rarely can it be considered an emer- Another plausible cause is direct injury to the ex-
gency operation. traocular muscles or nerves. Diplopia correlates
The material of choice for wall reconstruction better with the severity of orbital injury than with
has also been under continued debate. There is the change of orbital volume.1 Surgery may
general agreement that the ideal material for re- increase the risk of diplopia, at least temporarily.
pairing the orbital floor should be rigid enough to Enophthalmos is another factor to consider and
support the orbital contents and should restore is usually a sign of a large orbital wall defect
the original orbital form and volume. It should be (Fig. 1A, B). Most practitioners define this as
safe and user friendly so that even inexperienced greater than 1 cm3. The underlying cause of
surgeons can handle it. It is the responsibility of enophthalmos is a discrepancy between the
oralmaxsurgery.theclinics.com
the surgeon to recognize the diversity of the volume of the orbital soft tissues and the bony
materials available and to apply them selectively orbital cavity. Enophthalmos greater than 2.0 mm
in clinical use. typically indicates the need for surgical
a
Department of Oral and Maxillofacial Surgery, Helsinki University Hospital, 00029 HUS, Helsinki, Finland
b
Institute of Dentistry, University of Helsinki, POB 41, FIN-00014, Helsinki, Finland
* Corresponding author.
E-mail address: risto.kontio@hus.fi (R. Kontio).
Oral Maxillofacial Surg Clin N Am 21 (2009) 209–220

doi:10.1016/j.coms.2008.12.012
1042-3699/08/$ – see front matter ª 2009 Elsevier Inc. All rights reserved.
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210 Kontio & Lindqvist
Fig. 1. (A) Patient with severe right enophthalmos and hypophthalmos after an injury in a basketball game.
(B) Coronal CT scan showing the difference in orbital volume between the two sides.
intervention; however, factors such as globe teth- allowing the requisite orbital swelling to resolve,
ering by entrapment, fat necrosis, and posterior facilitating accurate diagnosis and strengthening
soft tissue necrosis also may lead to enophthal- the indications for surgery.
mos. Furthermore, an orbital floor defect alone Rarely can orbital fracture repair be considered
will not necessarily cause enophthalmos if the urgent; however, the ideal time to intervene after
integrity of the fascial sling supporting the eye is fracture occurrence cannot be precisely defined.
intact.2 Clinical judgment aided by CT imaging is Surgical timing differs in each case depending on
crucial if operation is considered in patients with the patient’s age, fracture type (size, location,
enophthalmos. Post injury edema and hemorrhage displacement, and comminution), functional
can cause the false illusion of proptosis and mask impairment, esthetic deformities, and other clinical
a true enophthalmos. and radiographic findings. These factors should be
The ability to recognize enophthalmos is crucial weighed and individualized in each case. A classi-
for the surgeon. Ahn and coworkers recently pub- fication system with treatment algorithms and
lished a study related to orbital volume change and timing of surgery exists for numerous other forms
late enophthalmos assessed by CT scanning.3 of maxillofacial trauma but not for orbital trauma.
There seems to be a direct relationship between Koorneef and Zonneveld4 has suggested
the increase of orbital volume and measured a conservative approach to blow-out fractures. In
enophthalmos. In cases with an orbital volume 1983, Hawes and Dortzbach,5 and later Leitch
increase of less than 1 mL, the extent of enoph- and coworkers,6 advocated surgery for orbital
thalmos is around 0.9 mm, whereas at a volume floor fractures within 14 and 21 days after trauma.
of 2.3 mL the enophthalmos is 2 mm. For every On the other hand, Cole and coworkers2 have sug-
1 mL increase of volume there is approximately gested that urgent treatment should be consid-
a 0.9 mm increase in enophthalmos;3 however, in ered in the case of traumatic optic neuropathy.
normal orbits, there can be a natural volume differ- Visual acuity and color desaturation testing must
ence of up to 8% between the left and right sides.3 be performed if such an injury is suspected. The
use of steroids and decompression has been sug-
TIMING OF ORBITAL SURGERY gested. Corticosteroids can be used as the only
treatment if the visual acuity is better than 20/400.
The timing for orbital fracture repair is controver- Another indication for urgent surgery is an
sial. Proper surgical timing for an orbital fracture orbital fracture combined with an oculocardiac
is paramount for producing good results. It has reflex.7 The symptoms include a vagal tone
been suggested that there is an increase in response with bradycardia, heart block, nausea,
complications such as adhesions and fibrosis vomiting and syncope. The change in vagal tone
with late or delayed surgery, which can lead to is presumable related to soft-tissue entrapment.
unsatisfactory outcomes; however, orbital frac- The condition may be fatal; therefore, it should
tures differ from all other facial fractures in that be managed with urgent surgical intervention.
surgery does not typically attempt to achieve Urgent surgery is also indicated for orbital wall
bone healing. The goal of surgery is simply to fractures in children associated with ocular motility
restore the preinjured form of the orbital walls. As limitations. The soft and flexible bones of children
such, delaying the operation for varying periods can result in a trap door fracture leading to entrap-
is often recommended. This delay is beneficial in ment of the soft tissues. A defect opens in the
Management of Orbital Fractures 211
orbital floor and, because of the greenstick nature about which is preferable; however, there is general
of the fracture, it subsequently closes leading to consensus that the ideal material for orbital floor
the entrapment. This phenomenon is sometimes repair should be strong enough to support the
called a ‘‘white-eyed appearance.’’ Limitation of orbital contents, inexpensive, readily available,
ocular motility should always lead to suspicion of easy to contour, resorbable, and, most importantly,
possible muscle incarceration.8 biocompatible. One factor that has had a direct
Early surgery is inevitably required for pene- impact on the evolution of surgical management
trating craniocerebral injuries such as missile or of internal orbital fractures is the increased avail-
nonmissile injuries associated with possible shock ability of numerous biomaterials for reconstructing
waves. Early surgery is also necessary when orbital the bony contours and restoration of the proper
wounds are caused by needles, scissors, knife orbital volume (Tables 1 and 2) (Box 1).
blades, or other sharp objects. Presumed trivial
orbital wounds may actually involve severe trauma,
Autogenous Grafts
and these injuries should lead to a high index of
suspicion related to penetrating craniocerebral Autogenous tissues were among the first materials
injuries. CT scans with a bone window setting used to reconstruct the internal orbit and are still in
should be performed in all suspected cases not frequent use today.12–15 They involve a second
only to rule out the presence of a retained foreign operative site, which increases morbidity, and
body but also to define the site and extent of injury. require a longer operative time to harvest. Some
High energy trauma with shock waves and cavity of these tissues are limited in quantity and are
formation can result in severe complications plagued by variable amounts of resorption over
including vascular injuries. In these patients, angi- time.16 Unpredictable resorption and the potential
ography should be considered. Early surgical inter- for late enophthalmos are the most critical argu-
vention might decrease, among others things, the ments against the use of autogenous materials,
chance of formation of intracranial scar tissue and particularly regarding autogenous bone grafts
an epileptic focus. This possibility was suggested and, to a lesser degree, cartilage. Autogenous
by Chibbaro and Tacconi,9 who noticed that none cartilage grafts are also too flexible to provide
of the patients who had early surgery developed adequate support for the orbital contents when
epilepsy. The longest follow-up was 13 years. there are large defects.17 Ilankovan and Jackson
De Man and coworkers10 have suggested that report that cartilage in its fresh state has
young patients with severely restricted eyeball a tendency to warp and is unsatisfactory for recon-
motility, an unequivocally positive forced duction struction of bony orbital walls.18
test, and CT findings indicating a blow-out fracture Autogenous bone grafting (Fig. 2A, B) has been
of the orbital floor should undergo operative treat- the gold standard in providing a framework for
ment as soon as possible after injury, whereas repair of the injured facial skeleton and orbital
a wait and see policy, keeping the patient under walls.12,14,19 The advantages of autogenous bone
observation, seems to be appropriate for blow- are its relatively good resistance to infection, its
out fractures in adults. Matteini and coworkers replacement by host bone through creeping
and Grant and coworkers7,11 found that in pedi- substitution, the lack of a host response against
atric patients with diplopia, early repair resulted the graft, and the lack of risk for late extrusion.
in more rapid improvement of symptoms than Nevertheless, resorption and reduction of graft
late treatment; they suggested that a symptomatic volume is a concern for long-term success.16
trap door fracture in young patients should be Basically there are two forms of nonvascularized
considered an indication for urgent treatment. In autogenous bone grafts—cortical and cancellous.
these studies, the timing of surgery for orbital frac- Cancellous grafts are revascularized more rapidly
ture was strongly related to a combination of the and more completely than are cortical grafts;
following parameters: (1) the anatomic location of however, cancellous bone imparts little mechan-
the fracture, (2) the presence of open or pene- ical strength. When cancellous bone is used to
trating wounds, (3) the presence of cerebrospinal reconstruct large continuity defects, additional
fluid leakage, (4) the patient’s age, (5) functional stabilization and rigid fixation, such as a titanium
impairment or muscle entrapment, and (6) serious mesh system, are required.20 A corticocancellous
forms of compression or ischemia. graft usually produces the best results by
combining the attributes of both forms.20
MATERIALS FOR RECONSTRUCTION Different sources such as calvarium, iliac crest,
mandible, maxilla, and rib have been used.12,21–24
Several different materials are available for restora- Currently, calvarial bone seems to be the best
tion of the orbital walls, and there is no consensus choice for orbital wall reconstruction;12,23
Table 1
Advantages and disadvantages of autogenous, allogeneic, and xenograft materials for orbital
wall reconstruction
Autogenous Grafts Allogeneic Grafts Xenografts

Characteristic Bone Cartilage Bone Dura Fascia/Cartilage Bone Dermis
Resistance to infection, FF FF F F F F U
long term
Facilitates bone growth FF — F F F F U
No foreign body FF FF F F F UU UU
reaction
Adequate mechanical FF U FF F U FF UU
properties
No second operative site UU UU FF FF FF FF FF
No donor site morbidity U U FF FF FF FF FF
Easy to harvest F F FF FF FF FF FF
Easy to mold U F U F F U F
Adequate in quantity FF F FF FF FF FF FF
Low resorption U F UU F F UU F
No risk of transmission FF FF U U U U U
of infectious agent
Abbreviations: FF, very favorable; F, favorable; U, unfavorable; UU, very unfavorable.
however, the anterior iliac crest is still the most exploration; however, an iliac crest bone graft is
common site.25 bulky unless trimmed, and it may resorb unpre-
An autogenous bone graft from the anterior iliac dictably. Bartkowski and Krzystkowa and de
crest is a favorable reconstruction material Visscher and van der Wal used corticocancellous
because enough bone is always available, and it iliac crest bone for orbital floor or medial wall
can be harvested simultaneously with the orbital reconstruction in their follow-up studies and
Table 2
Advantages and disadvantages of alloplastic implant materials for orbital wall reconstruction
Nonresorbable Alloplastic Resorbable Alloplastic

Materials Materials
Characteristic Tit Sil Tef HA BAG PDS PLLA PLDLA PGA PLA /PGA
Resistance to infection F U U U F U U U U U
Facilitates bone growth U U U F F U F F F F
No foreign body reaction F U U F F U U U U U
Adequate mechanical properties FF F F F FF U F F U F
No second operative site FF FF FF FF FF FF FF FF FF FF
No donor site morbidity FF FF FF FF FF FF FF FF FF FF
Easy to harvest FF FF FF FF FF FF FF FF FF FF
Easy to mold FF FF FF F U F F F F F
Adequate in quantity FF FF FF FF FF FF FF FF FF FF
Low resorption FF FF FF F FF UU F F UU U
No risk of transmission of infectious FF FF FF FF FF FF FF FF FF FF
agent
Abbreviations: BAG, bioactive glass; FF, very favorable; F, favorable; HA, hydroxyapatite; PDS, polydioxanone; PGA, poly-
glycolide; PLA/PGA, polylactide/polyglycolide; PLDLA, poly L/D lactide copolymer; PLLA, poly L lactide; Sil, silicone; Tef,
Teflon; Tit, titanium; U, unfavorable; UU, very unfavorable.
Box 1 bone is a rigid material, and the intraoperative

Different implant materials available for orbital three-dimensional assessment and accurate
wall reconstruction placement of such a bone graft is difficult.
Although the resorption rate is high, this can be
Tissue grafts compensated by a slight overcorrection to allow
Autogenous grafts (same individual) for some of the remodeling. The rate of enophthal-
mos and hypophthalmos is low (Fig. 4).
Bone
Possible donor site problems with autogenous
Cartilage iliac bone grafts include nerve and blood vessel
Dermis injuries, chronic pain, gait disturbances, and scar
Dura mater formation; however, considering the large number
of autogenous iliac crest grafts used, the donor
Fascia
site morbidity seems to be low.29,30 The results
Allogeneic grafts (same species but separate of a recent study are in accordance with these
genotype [allograft, homograft]) findings.1 The main complication was the skin
scar. It was recommended that the incision be
Bone
carefully planned, especially in female patients,
Cartilage because 20% of patients end up having a visible
Dermis scar in this area. Although the complication rate
Dura mater seems to be low, the donor site complications
should not be ignored.1
Fascia
Xenografts (another species) Allogeneic Grafts

Biocoral Allogeneic materials have been used successfully
Bone for orbital wall reconstruction; however, their use
is decreasing because of concern over the antige-
Dermis nicity of the material and the potential transmission
Alloplastic materials of infectious disease.31
Nonresorbable nonmetal
Xenografts
Bioactive glass
Hydroxyapatite Xenogeneic bone was popular in the 1960s but fell
into disfavor due to reports of patients developing
Polyethylene
autoimmune diseases following bovine bone
Silicone transplants.32 In theory, the transmission of infec-
Teflon tious disease is possible when xenografts are
used, although no such reports are available in
Nonresorbable metal the literature.
Titanium Xenografts are rarely used for the repair of
internal orbital fractures. Only a few case reports
Vitallium
are available regarding their application within
Resorbable the orbit. A severe inflammatory reaction with
a granulomatous component has been reported
Polydioxanone
after the use of porcine dermis in orbital wall
Polyglycolides reconstruction.33–35
Polylactides
Alloplastic Materials
Alloplasts have gained popularity for reconstruc-
concluded that it was well tolerated and an tion of the internal orbit because of their ease of
adequate material for such repair.26,27 Their results use and the fact that there is no donor site
are similar to those of many other morbidity. Other benefits of alloplasts include
researchers.12,16,23,28 shorter operation times, the large variety of sizes
Kontio and coworkers1 also found that recon- and shapes available, and their seemingly endless
struction of the orbital walls with iliac bone was supply. The alloplasts can be classified into those
reliable, restoring the volume and the shape of that are nonresorbable and those that are resorb-
the orbit well (Fig. 3A, B). Nevertheless, iliac able (see Table 2).
Fig. 2. Autogenous bone graft for reconstruction of the orbital floor. (A) Free iliac crest bone graft shaped to
match the orbital floor. (B) CT three-dimensional view showing a free iliac bone graft in place to reconstruct frac-
tured orbital floor.
Nonresorbable alloplasts to be reliable, and bone graft positioning is more

Nonresorbable alloplastic materials include tita- secure. The infection rate has been reported to
nium, silicone, polytetrafluoroethylene, polyeth- be 5%.40 It was not until the reports by Sargent
ylene, hydroxyapatite, and bioactive glass. and Fulks and Sugar and coworkers that metals
Titanium plates are thin, stiff, and easy to contour. alone were routinely used for orbital reconstruction
They are easily stabilized, maintain their shape, without an intervening bone graft or alloplast
and have the unique ability to compensate for between the metal and the orbital soft tissues.41,42
volume without the potential for resorption. When Many researchers have concluded that titanium
titanium plates were introduced, it was generally mesh implants are a simple and reliable option
believed that they did not need to be removed for routine orbital floor repair.12,42,43 Several types
because titanium is a highly biocompatible of titanium mesh plates are available (Fig. 5A, B).
material;36 however, it has been shown that both Rubin and coworkers compared the use of
titanium and aluminum are released from commer- custom-shaped orbital floor titanium plates with
cially pure titanium into adjacent areas and even vitallium mesh and autogenous bone grafts.44
into regional lymph nodes.37,38 The clinical rele- They reported no significant complications related
vance of this release is not yet known. It has to the orbital implants. Metal implants were easier
been suggested that in pediatric surgery, in areas to use than autogenous bone grafts.
of bony resorption and deposition, metallic plates Silicones (polyorganosiloxanes) are synthetic
should be removed due to plate displacement polymers of silicon and oxygen (known as
and restriction of growth.39 siloxane) modified with various organic groups
Further disadvantages of titanium implants in attached to the silicon atoms. Silicone rubber is
orbital wall reconstruction include extrusion due a chemically inert material available in block and
to dehiscence of the covering soft tissue and the sheet forms.
risk of infection. There is also a theoretical risk of Polytetrafluoroethylene (Teflon) is a long-chain
injury to the tissues of the orbital apex from halogenated carbon polymer made by the poly-
a subsequent blow to the orbit. Because of the merization of tetrafluoroethylene gas at high
mesh structure, the orbital implant is difficult to temperature and pressure. Both materials evoke
remove. a mild fibroblastic or inflammatory reaction.45,46
Titanium implants have been used to span large Both have been used for orbital wall reconstruc-
defects in the internal orbit and provide a platform tion even though they are not osteogenic, osteo-
for bone graft support. This technique has proved conductive, or osteoinductive. Widely varying
Fig. 3. (A) Coronal view of orbital floor after reconstruction with an iliac crest bone graft. (B) Sagittal view of
patient. Note the good position of the graft.
complications have arisen from the use of these in the reconstruction of large traumatic orbital floor
alloplastic implants, such as inferior eyelid defects.52,53
swelling, pain, ocular dystopia, maxillary sinusitis, Bioactive glasses are silicates containing sodium,
extrusion, and local infection.47,48 calcium, and phosphate as their main network modi-
Porous polyethylene is a highly inert material. fier components. The chemical bonding of BAGs
Its porous character allows for rapid fibrovascular and bone has been demonstrated, and the materials
and soft tissue ingrowth and eventual incorpora- have proved to be biocompatible and nontoxic.54–56
tion by bone. High-density porous polyethylene Bioactive glass is osteoconductive in humans.57
implants have been used successfully for correc- Studies have demonstrated that bioactive glass
tion of mild-to-moderate posttraumatic enoph- particles of a small size (300–355 mm [Biogran])
thalmos.49 In a series of 140 patients, there was have the capacity to stimulate bone formation
just one instance of implant infection requiring without contact with pre-existing bone.58
removal and no implant migration or exposure.50 Good results have been achieved with this
Other investigators also have concluded that material in frontal sinus surgery.59 However, only
porous polyethylene sheets offer advantages a few studies are available on the use of bioactive
when used for orbital reconstruction.51 They glass in orbital wall reconstruction. In a prospective
seem to permit predictable, stable results with study, Kinnunen and coworkers60 compared the
few complications. use of bioactive glass with conventional autoge-
Hydroxyapatite has been used for both primary nous grafts (cartilage with or without lyophilized
and secondary reconstruction of the orbital walls. dura) for the repair of orbital floor defects after
Both hydroxyapatite block scaffolding and trauma. They concluded that bioactive glass was
computer-aided machined hydroxyapatite ceramic well tolerated and showed adequate maintenance
implants have proved to be useful alternatives to of orbital and maxillary sinus volume without any
metallic floor implants and autogenous bone grafts evidence of resorption.
Fig. 4. Total number of patients

with enophthalmos and proptosis
of 2 mm or more during each clin-
ical follow-up after iliac crest graft
reconstruction. N 5 24, prospec-
tive study. (Adapted from Kontio
RK, Laine P, Salo A, et al. Recon-
struction of internal orbital wall
fracture with iliac crest free bone
graft: clinical, computed tomog-
raphy, and magnetic resonance
imaging follow-up study. Plast
Reconstr Surg 2006;118:1365–74;
with permission.)
Fig. 5. (A) View of orbital titanium mesh plate 0.4 mm in thickness (Synthes) on a plastic skull model. (B) View of
this type of plate being used for reconstruction of a large orbital wall defect.
Resorbable alloplasts good enough for orbital reconstruction, and the

Biodegradable polymers (Fig. 6) have been used overall results seem to be acceptable;67 however,
for biomedical applications for many years. Poly- some studies have shown less favorable
glycolide, polylactide, and polydioxanone (PDS) outcomes. The lack of osteoconductive properties
all degrade in vitro and in vivo by hydrolysis.61 was documented by Baumann and coworkers.68
PDS has been mainly used for sutures, cords, These investigators concluded that large defects
pins, and screws in experimental and clinical in the orbital floor (more than 2.5 cm2) cannot be
orthopedic surgery.62,63 It is usable in soft tissue, reconstructed with a PDS sheet, which should be
tendon, and ligament surgery because of its flexi- used only in cases without massive orbital fat
bility.64 PDS has been reported to be well tolerated herniation. These observations were similar to
by the body and does not give rise to clinically those in a study by Kontio and coworkers.69 PDS
detectable inflammatory reactions.62 did not act as an osteoconductive material, but
New bone formation has been noted when PDS bone healing took place in areas of displaced
is used for orbital wall reconstruction.65 It is easy remnants of periosteum and bone fragments. In
to cut to suitable sizes, can be shaped and general, the fractured floor on the last postopera-
adjusted, and retains its structural integrity long tive CT scan was similar to that seen on the CT
enough for a sufficiently rigid scar to be scan before operation.69 It was concluded that
formed.65,66 Resorption occurs within 1 year. floor reconstruction using PDS implants alone is
Because of resorption, overcorrection was inadequate. Merten and Luhr70,71 and later de
thought to be necessary.66 PDS is mechanically Roche and coworkers agreed with these results
and further showed that PDS provokes adverse
foreign body reactions. This phenomenon was
confirmed in the study by Kontio and coworkers.
MRI revealed adverse reactions in 63% of
patients, thick scar formation in 38%, fibrotic
sinuses filled with air or gas in 19%, and a fibrotic
sinus with fluid formed around a PDS implant in
6% (Fig. 7). When the implants were removed,
several small fragments of PDS were found inside
a dense connective tissue capsule.69
Polylactide implants have been used for orbital
floor reconstruction since 1972, when Cutright
and Hunsuck published an experimental study
on rhesus monkeys using 1.5-mm thick poly L lac-
tide (PLLA) sheets.72 They reported normal healing
of the fracture and normal globe movements. The
PLLA sheets were resorbed by phagocytes and
Fig. 6. Resorbable implant (Synthes Polymax) for giant cells with villous projections. Residual PLLA
orbital wall reconstruction. was detectable after 38 weeks, but no
ratio. Reconstruction of the orbital walls with an

iliac bone graft is a reliable procedure that restores
the volume and shape of the orbit well; however,
iliac bone is a rigid material, and the intraoperative
three-dimensional assessment and accurate
placement of the bone graft are difficult. The
resorption rate is high, but most of it seems to be
advantageous remodeling. Slight overcorrection
is probably beneficial. No single factor can explain
enophthalmos or hypophthalmos alone.
Secondary operations seem to lead to a poor
outcome. The question of which alloplastic mate-
Fig. 7. CT scan at 4 month follow-up showing sinus rial is most appropriate for reconstruction of the
involvement with a PDS orbital floor implant. orbital walls remains unanswered.
REFERENCES
inflammatory reactions were seen. Similar findings
were reported later by Rozema and coworkers.73 1. Kontio RK, Laine P, Salo A, et al. Reconstruction of
In a study by Cordewener and coworkers,74 the internal orbital wall fracture with iliac crest free
long-term outcome was evaluated after the repair bone graft: clinical, computed tomography, and
of orbital floor defects with resorbable as-polymer- magnetic resonance imaging follow-up study. Plast
ized PLLA implants to determine whether these Reconstr Surg 2006;118:1365–74.
patients showed symptoms that could be indica- 2. Cole P, Boyd V, Banerji S, et al. Comprehensive
tive of the presence of a late tissue response. In management of orbital fractures. Plast Reconstr
the preceding years none of the patients had Surg 2007;120:57–61.
experienced any problems such as infection, 3. Ahn HB, Ryu WY, Yoo KW, et al. Prediction of enoph-
migration, or extrusion of the implants, all of which thalmos by computer-based volume measurement
might have indicated complications. The main of orbital fractures in a Korean population. Ophthal
drawback of PLLA implants is the low degradation Plast Reconstr Surg 2008;1:36–9.
rate and slow resorption in clinical use.75 4. Koorneef L, Zonneveld FW. The role of direct multi-
The use of polyglycolide implants to treat 20 planar high resolution CT in the assessment and
blow-out fractures has been reported.76 Two management of orbital trauma. Radiol Clin North
patients complained of continuous infraorbital Am 1987;4:753–9.
edema which, according to the investigators, 5. Hawes MJ, Dortzbach RK. Surgery on orbital floor
was caused by poor residual drainage. The fractures: influence of time of repair and fracture
problem was resolved by regular massage of the size. Ophthalmology 1983;90(9):1066–70.
region. Copolymers of biodegradable polyglyco- 6. Leitch RJ, Burke JP, Strachan IM. Orbital blowout
lide and polylactide acids have also been used fractures: the influence of age on surgical outcome.
for fracture treatment. Experimental studies have Acta Ophthalmol 1990;68:118–24.
shown that this copolymer has a more rapid rate 7. Grant JH, Patrinely JR, Weiss AH, et al. Trapdoor
of degradation (9 to 15 months) than PLLA; there- fracture of the orbit in a pediatric population. Plast
fore, it might be more suitable as an orbital implant Reconstr Surg 2002;109:482–9.
material.77 Clinical studies have shown good 8. Brannan PA, Kersten RC, Kulwin DR. Isolated medial
results with Lactosorb throughout the craniofacial orbital wall fractures with medial rectus muscle
skeleton.78,79 incarceration. Ophthal Plast Reconstr Surg 2006;3:
178–83.
SUMMARY 9. Chibbaro S, Tacconi L. Orbito-cranial injuries
caused by penetrating non-missile foreign bodies.
Orbital surgery is not risk free. Complications Acta Neurochir (Wien) 2006;148:937–42.
include persistent pain and paresthesias, diplopia, 10. de Man K, Wijngaarde R, Hes J, et al. Influence of
and visual loss. The surgeon must always consider age on the management of blow-out fractures of
the potential complications against the possible the orbital floor. Int J Oral Maxillofac Surg 1991;20:
benefits gained from the reconstruction proce- 330–6.
dure. Surgery is not always necessary. When there 11. Matteini C, Renzi G, Becelli R, et al. Surgical timing
is small fracture, good ocular motility, and no in orbital fracture treatment: experience with 108
significant enophthalmos or hypophthalmos, the consecutive cases. J Craniofac Surg 2004;15:
surgeon should critically consider the risk/benefit 145–50.
12. Ellis E III, Tan Y. Assessment of internal orbital recon- 29. Banwart JC, Asher MA, Hassanein RS. Iliac crest
struction for pure blowout fractures: cranial bone bone graft harvest donor site morbidity: a statistical
grafts versus titanium mesh. J Oral Maxillofac Surg evaluation. Spine 1995;20:1055–60.
2003;61:442–53. 30. Ahlmann E, Patzakis M, Roidis N, et al. Compar-
13. Converse JM, Smith B. Enophthalmos and diplopia ison of anterior and posterior iliac crest bone
in fractures of the orbital floor. Br J Plast Surg grafts in terms of harvest-site morbidity and func-
1957;9:265–74. tional outcomes. J Bone Joint Surg Am 2002;84:
14. Kaye BL. Orbital floor repair with antral wall bone 716–20.
grafts. Plast Reconstr Surg 1966;37:62–5. 31. Thadani V, Penar PL, Partington J, et al. Creutzfeldt-
15. Lai A, Gliklich RE, Rubin PA. Repair of orbital blow- Jakob disease probably acquired from a cadaver
out fractures with nasoseptal cartilage. Laryngo- dura mater graft: case report. J Neurosurg 1988;
scope 1998;108:645–50. 69:766–9.
16. Sullivan PK, Rosenstein DA, Holmes RE, et al. Bone- 32. Pieron AP, Bigelow D, Hamonic M. Bone grafting
graft reconstruction of the monkey orbital floor with with Boplant: results in thirty-three cases. J Bone
iliac grafts and titanium mesh plates: a histometric Joint Surg Br 1968;50:364–8.
study. Plast Reconstr Surg 1993;91:769–75. 33. Converse JM, Smith B, Obear MF, et al. Orbital
17. Antonyshyn O, Gruss JS, Galbraith DJ, et al. blowout fractures: a ten year survey. Plast Reconstr
Complex orbital fractures: a critical analysis of Surg 1967;39:20–3.
immediate bone graft reconstruction. Ann Plast 34. Morax S, Hurbli T, Smida R. Bovine heterologous
Surg 1989;22:220–33. bone graft in orbital surgery. Ann Chir Plast Esthet
18. Ilankovan V, Jackson IT. Experience in the use of cal- 1993;38:445–50.
varial bone grafts in orbital reconstruction. Br J Oral 35. Cheung D, Brown L, Sampath R. Localized inferior
Maxillofac Surg 1992;30:92–4. orbital fibrosis associated with porcine dermal
19. Marx RE. Clinical application of bone biology to collagen xenograft orbital floor implant. Ophthal
mandibular and maxillary reconstruction. Clin Plast Plast Reconstr Surg 2004;20:257–9.
Surg 1994;21:377–92. 36. Breme J, Steinhäuser E, Paulus G. Commercially
20. Tideman H, Samman N, Cheung LK. Functional recon- pure titanium Steinhäuser plate screw system for
struction of the mandible: a modified titanium mesh maxillofacial surgery. Biomaterials 1988;9:310–3.
system. Int J Oral Maxillofac Surg 1998;27:339–45. 37. Moberg LE, Nordenram Å, Kjellman O. Metal release
21. Lee HH, Alcaraz N, Reino A, et al. Reconstruction of from plates used in jaw fracture treatment: a pilot
orbital floor fractures with maxillary bone. Arch Oto- study. Int J Oral Surg 1989;18:311–4.
laryngol Head Neck Surg 1998;124:56–9. 38. Onodera K, Ooya K, Kawamura H. Titanium lymph
22. Mintz SM, Ettinger A, Schmakel T, et al. Contralateral node pigmentation in the reconstruction plate
coronoid process bone grafts for orbital floor recon- system of a mandibular bone defect. Oral Surg
struction: an anatomic and clinical study. J Oral Oral Med Oral Pathol 1993;75:495–7.
Maxillofac Surg 1998;56:1140–4. 39. Fearon JA, Munro IR, Bruce DA. Observations on
23. Dempf R, Gockeln R, Schierle HP. Autogene Kno- the use of rigid fixation for craniofacial deformities
chentransplantate zur Versorgung der traumatisch in infants and young children. Plast Reconstr Surg
geschädigten orbita. Ophthalmologe 2001;98: 1995;954:634–7.
178–84. 40. Glassman RD, Manson PN, Vanderkolk CA, et al.
24. Siddique SA, Mathog RH. A comparison of parietal Rigid fixation of internal orbital fractures. Plast
and iliac crest bone grafts for orbital reconstruction. Reconstr Surg 1990;86:1103–9.
J Oral Maxillofac Surg 2002;60:44–50. 41. Sargent LA, Fulks KD. Reconstruction of internal
25. St John TA, Vaccaro AR, Sah AP, et al. Physical orbital fractures with vitallium mesh. Plast Reconstr
and monetary costs associated with autogenous Surg 1991;88:31–8.
bone graft harvesting. Am J Orthop 2003;32: 42. Sugar AW, Kuriakose M, Walshaw ND. Titanium
18–23. mesh in orbital wall reconstruction. Int J Oral Maxil-
26. de Visscher JG, van der Wal KG. Medial orbital wall lofac Surg 1992;21:140–4.
fracture with enophthalmos. J Craniomaxillofac Surg 43. Mackenzie DJ, Arora B, Hansen J. Orbital floor
1988;16:55–9. repair with titanium mesh screen. J Craniomaxillofac
27. Bartkowski SB, Krzystkowa KM. Blow-out fracture of Trauma 1999;5:9–16.
the orbit: diagnostic and therapeutic considerations, 44. Rubin PA, Shore JW, Yaremchuck MJ. Complex
and results in 90 patients treated. J Maxillofac Surg orbital fracture repair using rigid fixation of the internal
1982;10:155–64. orbital skeleton. Ophthalmology 1992;99:553–7.
28. Roncevic R, Malinger B. Experience with various 45. Lossing C, Hansson HA. Peptide growth factors and
procedures in the treatment of orbital floor fractures. myofibroblasts in capsules around human breast
J Maxillofac Surg 1981;9:81–4. implants. Plast Reconstr Surg 1993;91:1277–86.
46. Reno F, Lombardi F, Cannas M. UHMWPE oxidation (Maxon) and polydioxanone (PDS) sutures: an in
increases granulocytes activation: a role in tissue vitro study. Biomaterials 2002;23:2587–92.
response after prosthesis implant. Biomaterials 63. Plaga BR, Royster RM, Donigian AM, et al. Fixation
2003;24:2895–900. of osteochondral fractures in rabbit knees: a compar-
47. Pauzie F, Cheynet F, Chossegros C, et al. Long-term ison of Kirschner wires, fibrin sealant, and polydiox-
complications of silicone implants used in the repair anone pins. J Bone Joint Surg Br 1992;74:292–6.
of fractures of the orbital floor. Rev Stomatol Chir 64. Vainionpää S, Rokkanen P, Törmälä P. Surgical appli-
Maxillofac 1997;98:109–15. cations of biodegradable polymers in human
48. Rubin JP, Yaremchuk MJ. Complications and toxic- tissues. Progr Polym Sci 1989;14:679–716.
ities of implantable biomaterials used in facial recon- 65. Cantaloube D, Rives JM, Bauby F, et al. Use of
structive and aesthetic surgery: a comprehensive a cup-shaped implant of polydioxanone in orbital-
review of the literature. Plast Reconstr Surg 1997; malar fractures. Rev Stomatol Chir Maxillofac 1989;
100:1336–53. 90:48–51.
49. Karesh JW, Horswell BB. Correction of late enoph- 66. Iizuka T, Mikkonen P, Paukku P, et al. Reconstruction
thalmos with polyethylene implant. J Craniomaxillo- of orbital floor with polydioxanone plates. Int J Oral
fac Trauma 1996;2:18–23. Maxillofac Surg 1991;20:83–7.
50. Romano JJ, Iliff NT, Manson PN. Use of Medpor 67. Jank S, Emshoff R, Schuchter B, et al. Orbital floor
porous polyethylene implants in 140 patients with reconstruction with flexible Ethisorb patches:
facial fractures. J Craniofac Surg 1993;4:142–7. a retrospective long-term follow-up study. Oral
51. Rubin PA, Bilyk JR, Shore JW. Orbital reconstruction Surg Oral Med Oral Pathol Oral Radiol Endod
using porous polyethylene sheets. Ophthalmology 2003;95:16–22.
1994;101:1697–708. 68. Baumann A, Burggasser G, Gauss N, et al. Orbital
52. Ono I, Gunji H, Suda K, et al. Orbital reconstruction floor reconstruction with an alloplastic resorbable
with hydroxyapatite ceramic implants. Scand J Plast polydioxanone sheet. Int J Oral Maxillofac Surg
Reconstr Surg Hand Surg 1994;28:193–8. 2002;31:367–73.
53. Lemke BN, Kikkawa DO. Repair of orbital floor frac- 69. Kontio R, Suuronen R, Salonen O, et al. Effective-
tures with hydroxyapatite block scaffolding. Ophthal ness of operative treatment of internal orbital wall
Plast Reconstr Surg 1999;15:161–5. fracture with polydioxanone implants. Int J Oral Max-
54. Hench LL, Paschall HA. Direct chemical bond of illofac Surg 2001;30:278–85.
bioactive glass-ceramic materials to bone and 70. Merten HA, Luhr HG. Resorbable synthetics (PDS
muscle. J Biomed Mater Res 1973;7:25–42. foils) for bridging extensive orbital wall defects in
55. Gross U, Strunz V. The interface of various glasses an animal experiment comparison. Fortschr Kiefer
and glass ceramics with a bony implantation bed. Gesichtschir 1994;39:186–90.
J Biomed Mater Res 1985;19:251–71. 71. de Roche R, Adolphs N, Kuhn A, et al. Recon-
56. Aitasalo K, Kinnunen I, Palmgren J, et al. Repair of struction of the orbits with polylactate implants:
orbital floor fractures with bioactive glass implants. animal experimental results after 12 months and
J Oral Maxillofac Surg 2001;59:1390–5. clinical prospects. Mund Kiefer Gesichtschir
57. Tadjoedin ES, de Lange GL, Holzmann PJ, et al. 2001;5:49–56.
Histological observations on biopsies harvested 72. Cutright DE, Hunsuck EE. The repair of fractures of
following sinus floor elevation using a bioactive the orbital floor using biodegradable polylactic
glass material of narrow size range. Clin Oral acid. Oral Surg 1972;33:28–34.
Implants Res 2000;11:334–44. 73. Rozema FR, Bos RR, Pennings AJ, et al. Poly(L-lac-
58. Huygh A, Schepers EJ, Barbier L, et al. Microchem- tide) implants in repair of defects of the orbital floor:
ical transformation of bioactive glass particles of an animal study. J Oral Maxillofac Surg 1990;48:
narrow size range, a 0–24 months study. J Mater 1305–9.
Sci Mater Med 2002;13:315–20. 74. Cordewener FW, Bos RR, Rozema FR, et al. Poly
59. Peltola M, Suonpaa J, Aitasalo K, et al. Obliteration (L-lactide) implants for repair of human orbital floor
of the frontal sinus cavity with bioactive glass. defects: clinical and magnetic resonance imaging
Head Neck 1998;20:315–9. evaluation of long-term results. J Oral Maxillofac
60. Kinnunen I, Aitasalo K, Pöllönen M, et al. Recon- Surg 1996;54:9–13.
struction of orbital floor fractures using bioactive 75. Suuronen R, Pohjonen T, Hietanen J, et al. A 5-year
glass. J Craniomaxillofac Surg 2000;28:229–34. in vitro and in vivo study of the biodegradation of
61. Williams DF. Review: biodegradation of surgical polylactide plates. J Oral Maxillofac Surg 1998;56:
polymers. J Mater Sci 1982;17:1233–46. 604–14.
62. Mäkelä P, Pohjonen T, Törmälä P, et al. Strength 76. Sasserath C, Van Reck J, Gitani J. The use of a poly-
retention properties of self-reinforced poly L-lactide glycolic acid membrane in the reconstruction of the
(SR-PLLA) sutures compared with polyglyconate orbital floor and in loss of bone substance in the
maxillofacial region. Acta Stomatol Belg 1991;88: 78. Ahn DK, Sims CD, Randolph MA, et al. Craniofacial
5–11. skeletal fixation using biodegradable plates and cyano-
77. Wiltfang J, Merten HA, Becker HJ, et al. The resorb- acrylate glue. Plast Reconstr Surg 1997;99:1508–15.
able miniplate system Lactosorb in a growing cra- 79. Enislidis G, Pichorner S, Kainberger F, et al. Lacto-
nio-osteoplasty animal model. J Craniomaxillofac sorb panel and screws for repair of large orbital floor
Surg 1999;27:207–10. defects. J Craniomaxillofac Surg 1997;25:316–21.

Management of Orbital Fractures

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Management of

Oral Maxillofacial Surg Clin N Am 21 (2009) 209–220

Autogenous Grafts Allogeneic Grafts Xenografts

Abbreviations: FF, very favorable; F, favorable; U, unfavorable; UU, very unfavorable.

Nonresorbable Alloplastic Resorbable Alloplastic

Box 1 bone is a rigid material, and the intraoperative

Xenografts (another species) Allogeneic Grafts

Nonresorbable alloplasts to be reliable, and bone graft positioning is more

Fig. 4. Total number of patients

Resorbable alloplasts good enough for orbital reconstruction, and the

ratio. Reconstruction of the orbital walls with an

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