Classification and Management of

Infra-orbital Rim Fractures

Anantanarayanan Parameswaran, MDS, DNB,* Elavenil Panneerselvam, MDS, MBA,y
Mrunalini Ramanathan, MDS,z
Milen Mathew Kottackal, BDS,x and Bipasha Mukherjee, MSk
Purpose: Fractures of the infraorbital rim (IOR) are often undertreated with a resultant compromise of
facial esthetics and function. The purpose of this research was to identify types of IOR fractures related
clinical findings and assess post-treatment outcomes.
Methods: A retrospective cohort study was implemented involving all patients treated for IOR fractures
during an 18-month period. Data consisted of treatment records, pretreatment and post-treatment photo-
graphs, and computed tomographic (CT) scans. The types of fractures were matched to the treatment
instituted. The type of fracture was the independent variable, while the dependent variables were (i) clin-
ical findings such as lid and globe malposition, tethering of facial skin, diplopia, and infraorbital nerve
paresthesia, and (ii) treatment outcome assessed by surgeon and patient. Data were analyzed statistically
to study frequencies, proportions, and associations using SPSS (v26, IBM, Armonk, NY).
Results: Forty-three patients (41 males and 2 females) with IOR fractures were treated between July
2019 and January 2021. The age range was 18 to 50 years. The etiology for trauma in all patients was a
motor vehicle accident. Fifty-one fractures were classified into 6 types based on CT presentation. The sin-
gle line fracture (concomitant with other bones) was the most prevalent (58.8%), while globe malposition
was the most common clinical finding (35.8%). Lid malposition, globe malposition, and tethering of facial
skin were associated with the type of IOR fracture (P = .04, P = .02, and P = .01, respectively). Excellent
outcomes were scored in 32 and 25 fractures by the surgeon and patients, respectively, (P = .015 and
P = .003). The inter-rater agreement between the surgeon and patient was significant (Kappa = 0.680;
P < .001).
Conclusions: Clinical findings in IOR fractures are dependent on the fracture type. Treatment of frac-
tures based on their CT presentation produces effective management of signs/symptoms and improved
treatment outcomes.
Ó 2022 American Association of Oral and Maxillofacial Surgeons
J Oral Maxillofac Surg 80:1053-1061, 2022

Trauma to the midface frequently results in as well as functional problems. Zingg et al1
derangement of the infraorbital rim (IOR). Clini- described IOR fracture as one of the subtypes of
cally, fractures of the IOR present with cosmetic zygomaticomaxillary complex (ZMC) fractures

*Professor, Department of Oral and Maxillofacial Surgery, Conflict of interest: None.

Meenakshi Ammal Dental College and Hospital, Maduravoyal,
Chennai, Tamil Nadu, India.
yProfessor, Department of Oral and Maxillofacial Surgery, SRM
Dental College and Hospital, Chennai, Tamil Nadu, India.
zGraduate student, Department of Oral and Maxillofacial Surgery,
Graduate School of Medical Sciences, Shimane University, Izumo,
Japan.
xResident, Department of Oral and Maxillofacial Surgery,
Meenakshi Ammal Dental College and Hospital, Maduravoyal,
Chennai, Tamil Nadu, India.
kDirector, Department of Orbit Oculoplasty, Reconstructive and
Aesthetic Services, Shankara Nethralaya, Chennai, India.
Address correspondence and reprint requests to Dr Panneerselvam:
Department of oral and maxillofacial Surgery, SRM Dental college and
Hospital, Ramapuram campus, Ramapuram, Chennai 600089, Tamil
Nadu, India; e-mail: elavenilomfs@gmail.com
Received May 31 2021
Accepted January 2 2022
Ó 2022 American Association of Oral and Maxillofacial Surgeons
0278-2391/22/00003-9
https://doi.org/10.1016/j.joms.2022.01.002

1053
1054
(Type A3-isolated IOR fracture) and laid emphasis
on its treatment.
IOR constitutes one of the horizontal buttresses of
the facial skeleton,2 and hence, its restoration plays a
very important role in maintaining the skeletal integrity
and soft tissue balance of the mid-face.3,4 Many sur-
geons advocate exposure of the IOR to assess the preci-
sion of reduction in ZMC fractures. However, fixation at
the IOR is considered less reliable5 and performed only
in unstable fractures,6 as the third point of fixation.7
Often, when the rim demonstrates a continuity defect,
they are underestimated, and less emphasis is given to
their exploration and reconstruction. This has been
attributed to their potential for complications associ-
ated with surgical exposure, such as loss of lid support
and unfavorable scarring. But neglected or improperly
treated IOR fractures may also result in secondary defor-
mities that are unesthetic and challenging to correct.3,4
Reconstruction of the IOR is also an important prereq-
uisite for the restoration of the orbital floor,8,9 and for
maintaining the support of the lower eyelids and soft
tissues of the mid-face.
Contemporary literature lacks a description of
symptoms specific to the type of IOR fractures and
their management. The purpose of this research was
to identify types of IOR fractures and determine if
the presentation of clinical findings (signs/symptoms)
and treatment outcomes were dependent on the types
of fractures. The investigators hypothesize that
tailoring the treatment according to the fracture type
could enhance the resolution of signs/symptoms and
improve clinical outcomes.
Patients and Methods
To address the research purpose, the authors imple-
mented a retrospective cohort study. The study was
exempted from approval by the Institutional Ethics
Committee. The sample was comprised of all patients
Table 1. TYPES OF IOR FRACTURES MATCHED TO TREATMENT INSTITUTED
Type of
IOR Fracture Definition
A1 Single line fracture of the IOR (Isolated)
A2 Single line fracture of the IOR (concomitant with
other facial bones)
B1 Multiple line fracture of the IOR (Isolated)
B1d B1 type fracture with continuity defect
B2 Multiple line fracture of the IOR (concomitant with
other facial bones)
B2d B2 type fracture with continuity defect
Parameswaran et al. Management of Infraorbital Rim Fracture. J Oral Maxillofac Surg 2022.
MANAGEMENT OF INFRAORBITAL RIM FRACTURE
who had undergone treatment for fractures involving
the IOR between July 2019 and January 2021. Inclu-
sion criteria consisted of patients aged between 18
and 50 years with fractures involving the IOR and
who consented to be part of the study. Pediatric/geri-
atric patients and patients unwilling to participate in
the study were excluded.
DATA COLLECTION
Data was collected from pretreatment and posttreat-
ment documents, namely clinical records, computed
tomography (CT) scans, and photographs, and were
evaluated by Investigator 1 (experienced maxillofacial
surgeon), who was not part of the surgical team. Pho-
tographs and clinical records were used to tabulate
clinical findings before and after surgery, and the treat-
ment instituted. The clinical findings studied included
(1) lid malposition–abnormal position of the lower
eyelid in the vertical direction, (2) globe
malposition–which denoted hypo/hyper globus, (3)
tethering of facial skin–cicatricial scarring of the in-
fraorbital skin with adherence to the underlying
bone/fragments (4) diplopia and (5) infraorbital nerve
(ION) paresthesia.
TYPES OF IOR FRACTURES AND TREATMENT
Six types of IOR fractures were identified based on
CT presentations. Treatment instituted was matched
to the type of fracture (Table 1 & Fig 1). A1 type frac-
tures received no surgical treatment. Type A2 fractures
were primarily managed by reduction and fixation of
concomitant fractures followed by fixation at the
IOR when additional stability was required. Type B1
fractures were fixed with a spanning plate to fix the
multiple fractured fragments. The presence of conti-
nuity defect (B1-d) was managed with bone grafting.
Type B2 fractures were managed in 2 steps: (1) reduc-
tion and fixation of the concomitant fractures (2)
assessment of the IOR, and management similar to
Treatment Instituted
No intervention
ORIF of concomitant fractures followed by fixation
at the IOR when additional stability was required
ORIF with spanning plate
ORIF with spanning plate + bone graft for defect
bridging
ORIF of concomitant fractures followed by ORIF of
IOR with spanning plate
ORIF of concomitant fractures followed by ORIF of
IOR with spanning plate + bone graft
PARAMESWARAN ET AL 1055

FIGURE 1. Classification of IOR fractures matched to defect-based treatment.

Parameswaran et al. Management of Infraorbital Rim Fracture. J Oral Maxillofac Surg 2022.

B1/B1-d fractures. All recruited patients were operated
on by the primary author (AP).
OUTCOME EVALUATION
A postoperative audit was performed by investigator
1. All patients were assessed for presence/absence of
individual clinical findings, with absence indicating
resolution. A score of 0 was marked when signs/symp-
toms were nonresolved and 1, when resolved. Clinical
features such as lid and globe malposition and teth-
ering of skin were audited by the investigator using
clinical photographs by comparing the affected side
with the unaffected side, while diplopia and ION

FIGURE 2. Workflow for the study.

Parameswaran et al. Management of Infraorbital Rim Fracture. J Oral Maxillofac Surg 2022.
1056 MANAGEMENT OF INFRAORBITAL RIM FRACTURE

paresthesia were audited from clinical records. A Table 2. SUMMARY OF STUDY VARIABLES FOR THE
scoring of treatment outcome was also derived from ENTIRE SAMPLE
patients by Investigator 2, using a questionnaire vali-
dated by 3 specialists. A resolution percentage (RP%) Variable Descriptive Statistics
was then calculated by using the formula; (Number
of resolved findings/Number of presenting findings) Sample
 100. The treatment outcomes were then graded Patients 43
Total facial fractures 83
into 4 categories based on the resolution percentage:
IOR fractures assessed 51
no improvement (<20%), improved outcome Symptoms assessed 95
(20-40%), good outcome (41-74%), and excellent Gender
outcome (75-100%). Figure 2 demonstrates the work- Male 41
flow for data collection and outcome assessment. Female 2
Age (years)
VARIABLES AND OUTCOME MEASURES Mean 29.8
St Dev 9.5
The type of IOR fracture was the independent vari- Range 18 to 50
able, while treatment outcome and clinical findings Etiology
were the dependent variables. Determining the associ- Motor vehicle accident 43
ation between the type of fracture and treatment out- Type of IOR fracture (N = 51) Distribution (%)
comes was considered as the primary outcome
measure, and the association of the fracture type to A1 1 (1.96)
clinical findings was the secondary outcome measure. A2 30 (58.82)
B1 0 (0)
STATISTICAL TESTS B1d 1 (1.96)
B2 9 (17.65)
Data obtained were compiled on an MS Office Excel B2d 10 (19.61)
Sheet (v 2019, Microsoft Redmond Campus, Red- Type of treatment instituted
mond, Washington, United States). Data were sub- (N = 51) Distribution (%)
jected to statistical analysis using a statistical package
for social sciences (SPSS v 26.0, IBM, Armonk, NY). No intervention 2 (3.92)
Descriptive statistics were performed for frequencies, ORIF 29 (56.86)
percentages and mean and standard deviation. Com- ORIF with spanning plate 9 (17.65)
parison of proportions and test for independence ORIF with bone graft 11 (21.57)
was analyzed using Chi-square test and Fisher’s exact Symptoms assessed (N = 95) Distribution (%)
test when the expected cell frequency was less than
5. The Fleiss’ kappa test was performed to evaluate in- Lid malposition 31 (32.63)
terassessor reliability. For all the statistical tests, P < .05 Globe malposition 34 (35.78)
was statistically significant, keeping a error at 5%. Tethering of facial skin 9 (9.47)
Diplopia 8 (8.42)
ION paraesthesia 13 (13.68)
Results
Outcomes (N = 41) Surgeon Patient
A total of 43 patients were selected for the study,
which included 2 females and 41 males. The mean No improvement 0 1
age of the patients was 29.8 years, with a range of 18 Improved 2 3
to 50. The etiology for injury in all patients was motor Good 7 12
vehicle accidents (Table 2). Excellent 32 25
Parameswaran et al. Management of Infraorbital Rim Fracture. J
DISTRIBUTION OF FRACTURES AND SYMPTOMS Oral Maxillofac Surg 2022.

 Facial fractures: 43 patients accounted for 83

facial fractures in total. The most common facial
fracture concomitant with IOR fractures were
orbital fractures (36.1%), followed by ZMC frac-
tures at 34.9% (Table 2).
 Fractures of the IOR: An analysis of fractures of
the infraorbital rim revealed 51 fractures, with
8 patients demonstrating bilateral fractures.
Isolated fractures of the IOR were rare, account-
ing for 3.9%, while fractures of the IOR, concom-
itant with other facial bones, accounted for the
remaining 96%. Of these, the single line fracture
(A2) was the most frequent (58.8%), followed by
multiple fracture lines with continuity defect
(B2-d) that was seen in 19.6% (Table 2)
PARAMESWARAN ET AL 1057

 Clinical findings: A total of 95 signs/symptoms Discussion

were recorded in 41 fractures, with 10 fractures
being asymptomatic. Malposition of the globe
was the most frequently noted finding (35.78%),
followed by lid malposition (32.63%). Diplopia
was the least recorded, accounting for 8.42%.
(Table 2).
ASSOCIATION BETWEEN THE TYPE OF IOR
FRACTURE AND CLINICAL FINDINGS
Analysis of data demonstrated that there was a statis-
tically significant association between the occurrence
of lid malposition, globe malposition, and tethering of
facial skin, and the type of IOR fracture (P = .04,
P = .02 and P = .01 respectively) (Table 3).
ANALYSIS OF TREATMENT OUTCOMES
Resolution of clinical findings was scored by both
surgeon and patient, which were further graded to
obtain treatment outcomes. The grading revealed
excellent for 32 fractures, good in 7, and improved sta-
tus in 2, according to the surgeon’s audit. In contrast,
grading by the patients revealed excellent outcomes in
25 fractures, good in 12, improved results in 3, and no
improvement in 1 fracture. The association between
the fracture types and treatment outcomes is provided
in Table 4.
EVALUATING INTERASSESSOR RELIABILITY
The Fleiss’ kappa test demonstrated substantial
agreement between the 2 assessors (surgeon and pa-
tient) in the assessment of treatment outcomes (Kappa
value = 0.680, P < .001).
Disruption of the IOR is seen in fractures of the
Orbit, ZMC, NOE, and Lefort II fractures10 (Boyette
et al., 2015), resulting in structural as well as func-
tional problems. Despite its common occurrence,
the number of IOR fractures managed by ORIF is low
due to a lack of awareness regarding the potential com-
plications and improper guidelines for management.
Poorly treated IOR fractures frequently lead to hard tis-
sue deformities, as well as deficits of overlying soft tis-
sue; compromised support to lower eyelid and facial
soft tissues resulting in clinical conditions such as ec-
tropion, increased scleral exposure and tethering of
the infralid soft tissues. Displaced orbital rims also
lead to functional problems related to the eyeball7,9
and infraorbital nerve.11 Further, increased scleral
show7 may result in complications such as corneal
exposure, infection, or ulceration.12,13 Smaller conti-
nuity defects at the IOR are the most frequently ne-
glected. When not reconstructed, even these small
defects, in due course, lead to unfavorable sequel
due to the thin skin overlying the IOR. The purpose
of this study was to investigate the utility of a treatment
algorithm for the management of IOR fractures and
report outcomes in a cohort of patients. Customizing
treatment based on our algorithm demonstrated signif-
icantly enhanced post-treatment outcomes, as well as
improvement in the resolution of symptoms.
SIGNS/SYMPTOMS AND RATIONALE FOR
TREATMENT BASED ON TYPE OF FRACTURE
Our results demonstrate that the presentation of
signs/symptoms such as lid and globe malposition, as
well as increased scarring in the infraorbital region,
are associated with the type of fracture. And hence

Table 3. TABLE DEMONSTRATING THE ASSOCIATION BETWEEN THE TYPE OF IOR FRACTURES AND CLINICAL FIND-
INGS

Tethering
Lid Globe of Facial ION
Malposition Malposition Skin Diplopia Paraesthesia
Type of
IOR Fracture N P A P A P A P A P A

A1 1 0 1 0 1 0 1 0 1 0 1
A2 30 15 15 17 13 1 29 6 24 7 23
B1d 1 1 0 0 1 0 1 0 1 0 1
B2 9 7 2 8 1 4 5 1 8 3 6
B2d 10 9 1 9 1 4 6 1 9 3 7
Total 51 32 19 34 17 9 42 8 43 13 38
P value .004 .006 0.001 0.27 0.28

Abbreviations: P, present; A, absent.

Parameswaran et al. Management of Infraorbital Rim Fracture. J Oral Maxillofac Surg 2022.
1058 MANAGEMENT OF INFRAORBITAL RIM FRACTURE

Table 4. ASSOCIATION BETWEEN TYPE OF IOR FRAC-

TURE AND TREATMENT OUTCOMES

Type Surgeon Patient

of IOR
Fracture N I G E NS NI I G E NS

A1 1 0 0 0 1 0 0 0 0 1
A2 30 1 3 18 8 1 0 5 16 8
B1d 1 0 0 1 0 0 0 0 1 0
B2 9 0 1 7 1 0 0 4 4 1
B2d 10 1 3 6 0 0 3 3 4 0
Total 51 2 7 32 10 1 3 12 25 10
P value .015 .003 FIGURE 4. Management of type B2 fracture (yellow arrow) by
ORIF with spanning plate.
Abbreviations: I, improved; G, good; E, excellent; Parameswaran et al. Management of Infraorbital Rim Fracture. J
NS, nonsymptomatic. Oral Maxillofac Surg 2022.
Parameswaran et al. Management of Infraorbital Rim Fracture. J
Oral Maxillofac Surg 2022.
plates and screws may be reduced and held in position
tailored recommendations are needed in managing in- using wires1,14 or absorbable sutures.1 In contrast, IOR
dividual patterns of IOR fractures. fractures with CD pose complex problems; (1) Lack of
Isolated fractures of the IOR, when present as a sin- lid support leading to inferior positioning of the lower
gle line (type A1), are usually undisplaced, and hence, eyelid and unesthetic exposure of sclera (2) Inade-
do not require treatment. The position of the eyelid or quate support to facial skin resulting in tethering to un-
the facial skin remains unaffected in such cases. How- derlying tissues/ectropion (3) absence of IOR
ever, when a single fracture line at the IOR occurs in precludes safe exploration of the orbital floor and
combination with other facial bones (Type A2), providing a proper base for fixation of orbital mesh
namely zygoma or maxilla, displacement is a frequent and (4) potential for implant failure when not bridged
clinical finding, and hence, mandates reduction. Fixa- by grafts.15 The above-mentioned complications
tion at the rim is dictated by the need for additional sta- mandate optimal reconstruction of the IOR anatomy.
bilization after the fixation of the other fractures Such situations with CD necessitate use of grafts (auto-
(Fig 3). grafts/allografts) (Figs 5-8). The use of plates alone to
When fracture lines are multiple, the management restore the rim, ‘without bone grafts’ may lead to
depends on the presence or absence of a continuity implant exposure and subsequent failure. This
defect (CD). The absence of CD after fracture reduc- occurs because of soft tissue contraction due to the
tion presents a clinical scenario that requires fixation dead space beneath the implant.16 Further, the use
with spanning plates alone (Fig 4). Comminuted frac- of bone grafts facilitates ideal fracture healing across
ture fragments that are not amenable to fixation with the defect.17

FIGURE 3. Management of type A2 fracture (yellow arrow) by FIGURE 5. CT scan demonstrating type B2-d fracture. Yellow ar-
ORIF with miniplate. row demonstrating continuity defect.
Parameswaran et al. Management of Infraorbital Rim Fracture. J Parameswaran et al. Management of Infraorbital Rim Fracture. J
Oral Maxillofac Surg 2022. Oral Maxillofac Surg 2022.
PARAMESWARAN ET AL
FIGURE 6. Reconstruction of type B2-d fracture with ORIF using a
bone graft. Yellow arrow demonstrating bone graft.
Parameswaran et al. Management of Infraorbital Rim Fracture. J
Oral Maxillofac Surg 2022.
APPROACHES TO THE IOR
In the event of existing lacerations, we preferred us-
ing the same, to approach the IOR. When absent, the
choice of approach varied18; For single line, type A
fractures, a transconjunctival incision was used while
a subciliary incision was adopted for multifragmented
Type B1 and B2 fractures, where an extended expo-
sure was needed to facilitate fixation of a spanning
plate to the medial third of the IOR (the frontal process
of maxilla).
RECONSTRUCTION OPTIONS FOR IOR
The type of reconstruction is based on factors,
namely the size of the defect, availability of implants,
and involvement of the orbital floor. Three factors
need to be considered while choosing the ideal recon-
struction modality for the IOR; (1) presence of thin
periorbital soft tissues, which predispose to hardware
palpability, (2) absence of powerful muscle forces,
FIGURE 7. Pre-treatment clinical photograph of a patient with type B2-d fracture demonstrating globe. Malposition (blue arrow) and lid
malposition (yellow arrow).
Parameswaran et al. Management of Infraorbital Rim Fracture. J Oral Maxillofac Surg 2022.
1059
which may displace the fracture fragments, and (3)
curvature of the rim. Hence the ideal material for
IOR reconstruction must be thin but sturdy and well
contoured to restitute the arched rim.
The frequently used materials for IOR fixation consti-
tute metallic plates,19 and bioresorbable plates.20
Wires have also been used by many surgeons. Zingg
et al1 have used absorbable sutures to secure the frac-
tured rim. Among the various options, mini plates
deliver the right combination of adequate rigidity
with minimal thickness.21 However, palpability and
exposure are problems associated with metal plates.
The risk of plate exposure is more in IOR with CD,
necessitating a graft along with plate fixation.
Autografts,22-24 including Ilium, rib, calvarium, are
the commonly preferred options. Our study used
ramal graft for IOR with CD with good clinical
results. Although porous polyethylene has shown
good results as intraorbital implants, they are
associated with higher infection rates when placed in
areas with thin skin and minimal subcutaneous cover,
as in the current indications being discussed.25 In the
presence of a combined orbital floor and CD at the
IOR, a preformed titanium mesh may not be the ideal
choice as its fixation arms may not offer the necessary
spanning for the reconstruction of the rim. In contrast,
a universal titanium mesh may be used to reconstruct
the floor, as well as the rim, by adapting the anterior
end of the mesh to bridge the CD while reconstructing
the IOR and the entire defect on the facial side.
ANALYSIS OF TREATMENT OUTCOME
The study has analyzed the post-treatment out-
comes from both the surgeon and the patients’ per-
spectives to provide a more realistic assessment and
projection of the clinical results.26 This approach
1060
FIGURE 8. Post-treatment clinical photograph of a patient with type B2-d fracture demonstrating correction of globe and eyelid position.
Parameswaran et al. Management of Infraorbital Rim Fracture. J Oral Maxillofac Surg 2022.
also enhances the clinician’s understanding of the
areas of potential dissatisfaction from the patients’
perspective.27 The grading of treatment outcomes
was homogenous, with a high level of inter-rater agree-
ment. Minimal differences in grading between the sur-
geon and the patients may, however, be attributed to
the following factors28: (1) more critical outlook of pa-
tients regarding surgical outcome, (2) the outcomes
that influence a patients’ satisfaction may differ from
that of the surgeon, and (3) patients may report certain
complications, which are unexpected and not docu-
mented in the literature.
POSITIVES AND LIMITATIONS OF THE STUDY
The study data includes a large homogenous sample
operated by a single surgeon. It provides a simple and
reproducible classification with a treatment recom-
mendation for every type of fracture involving the
IOR with predictable outcomes. The study has also in-
tegrated results of the surgical audit and patient feed-
back in deriving a more meaningful assessment of
treatment outcomes. The retrospective study design
may be a limitation that adds scope for a randomized
controlled trial.
The infraorbital rim plays an important role in
defining the periorbital esthetics and function. The
study demonstrates that the classification provides a
good clinical basis for tailoring treatment to obtain
enhanced outcomes. The study also reveals that the
common clinical findings associated with IOR frac-
tures, such as malposition of the lower eyelid and
globe, and tethering of the infraorbital skin, are depen-
dent on the type of fracture.
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