Management of Orbital Fractures

Key points

  • Orbital fractures are among the most common facial fractures sustained among adolescents and adults.

  • The surgical decision making in management of orbital fractures is largely dependent on patient-specific and surgeon-specific factors.

  • Although many approaches to the orbit have been described, the armamentarium of a surgeon should include at least 3 of those outlined in this article.

  • Postoperative complications in management of orbital fractures can be largely avoided with meticulous surgical technique.

Introduction: nature of the problem


Orbital fractures are exceedingly common, encompassing up to 16% of all facial fractures. These fractures are more common in adults, with a mean age of 32 years old, with the most common mechanism of injury being motor vehicle collision in adults and sport-related trauma in adolescents/children. The lower incidence in the adolescent population is likely because of the larger proportion of cancellous to cortical bone providing more elasticity and protective malar buccal fat pads. Although less common, orbital floor fractures in children are more likely to present with diplopia, extraocular muscle entrapment ,and nausea/emesis.

Orbital anatomy, pattern of injury

The orbit is composed of 7 bones and is quadrilateral pyramidal shaped with an average volume of 30 cm 3 . Important surgical landmarks to recognize are the optic canal, which is 40 to 45 mm from the medial wall, as well as the anterior and posterior ethmoidal foramen, which are 24 mm and 36 mm from the anterior lacrimal crest, respectively. Orbital injuries may be either blow-in or, more commonly, blowout patterns. The blow-in pattern results from high-velocity injuries to anterior cranial base and lead to decreased orbital volume with downward and forward displacement of the globe. The blowout pattern may lead to increased orbital volume and a posterior/inferior displacement of the globe, likely secondary to the compression forces buckling the orbital floor as force is transferred along the inferior orbital rim ( Fig. 1 ).

Fig. 1
Orbit bone anatomy.
( From Rougier J, Tessier P, Hervouet F, et al. Chirurgie plastique orbito-palpébrale. Paris: Elsevier Masson SAS; 1977. Copyright © Société Française d’Ophtalmologie. All rights reserved; with permission.)

Surgical technique

Preoperative planning

The history and physical examination are essential portions of preoperative planning. The findings from the clinical examination directly influence your surgical treatment planning and outcome. The complete assessment is beyond the scope of this text, but all patients with facial trauma should have a complete primary and secondary survey completed per advanced trauma life support (ATLS) guidelines to rule out any life-threatening trauma. Changes to visual acuity or pupillary reactivity and dysfunction of the extraocular muscles are first assessed to determine the severity of the orbital trauma and need for surgical intervention. Based on the findings, orbital trauma can be categorized into operative or nonoperative injuries and further defined based on urgency of repair as absolute (less than 24 hours), relative (within 24 hours, if possible), or delayed (within 2 weeks). Computed tomography (CT) without contrast is the standard imaging for orbital trauma evaluation ( Fig. 2 ).

Fig. 2
Patient with entrapment of inferior rectus muscle due to left orbital floor fracture. Note classic description of white eye blowout fracture. ( A ) No restriction in downward gaze. ( B ) No restriction on lateral gaze. ( C ) No restriction on medial gaze. ( D ) Restriction of upward gaze due to physical entrapment of inferior rectus muscle. ( E ) Coronal CT demonstrating left orbital floor “trap-door” fracture with entrapment of inferior rectus muscle.

Indications and contraindications

See Table 1 .

Table 1
Indications and contraindications in the surgical management of orbital fractures
Data from Boyette JR, Pemberton JD, Bonilla-Velez J. Management of orbital fractures: challenges and solutions. Clin Ophthalmol. 2015;9:2127-37; and Vega, L, Svoboda L, Tiwana, PS, et al. Orbital fractures. In: Kademani D, Tiwana PS, editors. Atlas of oral and maxillofacial surgery. St. Louis: Elsevier Saunders; 2016. p. 773-85.
Operative Management Indications
Absolute indication for immediate repair (<24 h)
  • Muscle entrapment

  • Occulocardiac reflex activation

Relative indication for immediate repair (within 24 h, if possible)
  • Disruption of 50% or more of the orbital floor

Indication warranting delayed repair (within 2 wk)
  • Diplopia in lateral gaze

  • Enophthalmos (>2 mm)

  • Orbital dystopia (>2 mm)

  • Occular motility dysfunction with eurologic etiology ruled out

Nonoperative Management Contraindications
  • Ocular injuries (hyphema, globe rupture, retinal tear)

  • Recent ophthalmologic surgery

  • Only eye with vision is involved with fracture

Reconstruction and implant selection

See Table 2 .

Table 2
Advantages, disadvantages, and indications for common orbital implants
Data from Meara DJ, Jones LC. Controversies in maxillofacial trauma. Oral Maxillofac Surg Clin North Am. 2017;29(4):391-399; and Boyette JR, Pemberton JD, Bonilla-Velez J. Management of orbital fractures: challenges and solutions. Clin Ophthalmol. 2015;9:2127-37.
Advantages Disadvantages Indications
  • Biocompatible

  • Malleable, able to contour and fit to adjacent bone

  • Easily sterilized

  • Good strength

  • Easy placement of fixation screws

  • Radiopaque

  • Sharp and unrefined edges

  • Gaps allow tissue ingrowth

  • Questionable restriction

  • Possible nidus for infection

  • Large defects

Titanium-reinforced porous polyethylene
  • Biocompatible

  • Malleable, able to contour

  • Good strength and long-term stability

  • Radiopaque

  • Can easily be removed

  • Easy placement of fixation screws

  • Low infection rate

  • Decreased porosity for drainage

  • Large defects

Patient specific
  • Anatomically ideal

  • Reduced operating room time

  • Risk of impurities and rejection

  • Requires intact surrounding orbit

  • Time for implant fabrication

  • Stiff implant does not provide intraoperative corrections

  • High cost

  • Complex orbital reconstructions

  • Involvement of adjacent structure, such as zygoma, orbital rim

Resorbable polymerized poly l -lactide (PLLA)
  • Pliable

  • Low infection rate

  • Degrades slowly

  • Questionable long-term stability of reconstruction

  • Late inflammatory reaction

  • Not radiopaque

  • Defects <2.5 cm 2

  • Fractures in children

Resorbable poly l -lactide-co-glycolide
  • Pliable

  • Low infection rate

  • Degrades slowly

  • Not radiopaque

  • Defects <2.5 cm 2

  • Fractures in children

Calvarial bone
  • Most biocompatible

  • Good strength

  • No sharp edges

  • Radiopaque

  • Donor site morbidity

  • Increases operative time

  • Long-term bone resorption

  • Difficult to adjust

  • Fractures in patient <7 y old

  • Patient preference

  • Prior failed/rejected implant

  • Biocompatible

  • No sharp edges

  • Donor site morbidity

  • Poor structural support

  • Difficult to adjust

  • Not radiopaque

  • Small fractures

Only gold members can continue reading. Log In or Register to continue

Stay updated, free dental videos. Join our Telegram channel

Jan 19, 2020 | Posted by in Oral and Maxillofacial Surgery | Comments Off on Management of Orbital Fractures

VIDEdental - Online dental courses

Get VIDEdental app for watching clinical videos