Abstract
Purpose
This paper aims to update current knowledge on orbital roof fractures and their reconstruction techniques through a multicenter experience, a literature review and detailing two cases involving autologous and heterologous bone grafts.
Methods
A Medline search from 2018 to 2023 was conducted, alongside a retrospective review of similar cases treated across four Italian hospitals. Inclusion criteria required all clinical and radiological data to be available, with a minimal follow-up of 6 months.
Results
Coronal incision was most common in the 16 studies analyzed, with titanium mesh or plates as primary reconstruction materials. Only four cases utilized autogenous bone, and dislocated bone fragment removal occurred in four patients. Early treatment was prioritized for emergencies, with 70 % of cases undergoing coronal incision. Most cases required defect reconstruction, primarily with titanium mesh. One patient experienced late rhinoliquorrhea, and only one required revision surgery.
Conclusion
Conservative approaches were mostly favored, with early intervention reserved for enophthalmos and ocular movement impairment. Upper eyelid blepharoplasty approach was considered safe for cases without intracranial injuries or frontal bone fractures. Heterologous bone grafts emerged as a potential alternative to titanium mesh, while autogenous bone harvested from the frontal box reduced operative time and complications in delayed treatments. VSP custom-made prosthesis can be utilized in complex fractures.
1
Introduction
Even if infrequent (1–5%), orbital roof fractures represent a challenge for the maxillo-facial surgeon, due to concomitant trauma and risks to the eye and orbital contents [ ]. Obviously, their management is secondary to stabilization of life-threatening injuries, but in presence of visus impairment (9.1 % of cases) as consequence of optic nerve compression early treatment is advocated. In addition, in order to prevent potentially fatal complications such as meningitis, brain abscess formation and encephalocele, surgical intervention shouldn’t be delayed, as reported by a recent systematic review [ , ]. Orbital roof fractures are most frequent in young males (mean age: 25,5yrs), and main causes are motor vehicle accidents. Where indicated, most of these patients undergo surgical repair through coronal approach, and titanium mesh and bone grafts are mostly used for reconstruction. An ideal grafting material has to be simple and ready to use, has to guarantee aesthetical and functional results and should not be reabsorbed, infected or extruded. Obviously, autogenous bone represents the best choice from this point of view [ ], but replacement of dislocated fragment, eventually rotated, is not always possible, and bone (or cartilage) grafting leads to an increased surgical time and eventually to further complications. Reviewing most recent literature about this topic, the aim of this paper is to update these data with a multicenter experience over the last years, also describing one case of reconstruction using heterologous bone graft, routinely used for orbital floor reconstruction [ ], that can be considered as a possible alternative to titanium mesh, and one case in which autogenous bone graft was harvested directly from frontal box.
2
Material and methods
Medline search on Pubmed searching for “orbital roof fracture” was performed. Inclusion criteria were articles discussing management of orbital roof fractures in adult patients in order to update the data reported by Lucas et al., in 2020 [ ]. Titles and abstracts of all initial studies collected from 2018 to 2024 in English literature were screened for inclusion and the full texts were evaluated by three independent reviewers. All studies were allocated a quality score for level of evidence using the Grades of Recommendation, Assessment, Development and Evaluation criteria.
In addition, retrospective review of adult patients (>18 yrs) affected by orbital roof fractures that underwent surgery at S.M. Goretti Hospital, Latina (2020–2023), Policlinico Umberto I, Rome (2011–2023), Policlinico Le Scotte, Siena (2021–2023) and San Salvatore Hospital, L’Aquila (2021–2023) were identified. All patients were managed by maxillofacial surgeons, eventually in association with neurosurgeons for those cases having neurosurgical symptoms or requiring a transcranial approach. To be included, for all patients all clinical and radiological data had to be available, and a minimal follow-up of 6 months was required.
The study is HIPAA compliant and adheres to the ethical principles as outlined in the Declaration of Helsinki as amended in 2013. Informed consent was not obtained as most of these subjects would likely not be locatable or contactable following their discharge, and data was de-identified during the collection process.
3
Results
In total, 15 studies were deemed to meet inclusion criteria. Main findings are illustrated in Table A and B [ ].
| Authors | Study year | LOE | Study design | Conclusions |
|---|---|---|---|---|
| Shah et al. [ ] | 2018 | 4 | CR | Access to the orbital roof can make accurate edge-to-edge alignment of the fragments difficult and they can slip. Our simple simple three-pronged technique was easy to do and there was little morbidity |
| Klančnik et al. [ ] | 2018 | 4 | CR | Penetrating orbitocranial wound is a life-threatening condition that demands interdisciplinary approach and treatment. |
| Liu et al. [ ] | 2020 | 4 | CR | In this case, early diagnosis and proper globe repositioning with reconstruction of the orbital roof could allow recovery of vision, as well as prevention of intracranial infection. |
| Hwang et al. [ ] | 2020 | 4 | CR | Through this case of blowout fracture of the orbital roof with an intact orbital rim, found after craniotomy, we should be aware of the possibility that an orbital roof fracture can be missed on conventional brain computed tomography. |
| Caras et al. [ ] | 2020 | 4 | CR | Rapid reconstruction following massive cranial trauma in the presence of multiple ICHs can be effectively managed with good gross neurological outcome. The role and specific characteristics of orbital reconstruction to minimize focal neurological deficits in similarly complex trauma remain to be elucidated. |
| Pereira et al. [ ] | 2020 | 4 | CR | It is preferable, and in most cases extremely necessary, that the surgical decompression and rigid internal fixation and/or surgical reconstruction could be performed first for later ophthalmic follow-up. |
| Pereira et al. [ ] | 2020 | 4 | CR | Evan the meshes being easier to handle, it is important to evidence the possibilities of futures complications and the requirement to remove the biomaterial which can cause damage to brain tissue. Although, the autogenous bone graft it is the most predictable for orbital reconstruction as well as being the gold standard due to its osteogenic, osteoinductive and osteoconductive properties. |
| Lofrese et al. [ ] | 2020 | 4 | CR | A wait-and- see approach could represent a reasonable safe and effective option, but at the condition of an aggressive clinical and radiological follow- up. A conservative strategy could help in avoiding precocious and sometimes unnecessary procedures, presumably granting time for the development of an advantageous intraorbital/intracranial pressure gradient to trigger a spontaneous realignment of the displaced fragment. |
| Baviskar et al. [ ] | 2021 | 4 | POS | The use of VSP in orbital fractures is feasible. The surgical jig facilitates precise, near‐normal OV restoration as an inexpensive adjunct to routine ORIF. To achieve optimum results, tailor‐made implants should be focused upon to enable structural OV reconstruction. |
| Gebran et al. [ ] | 2021 | 4 | RCS | Most orbital roof fractures can be managed conservatively. Early fracture treatment is safe and may be beneficial in patients with vertical dysmotility, globe malposition, and/or a defect surface area larger than 4 cm [ ]. Ophthalmologic prognosis is generally favorable; however, traumatic optic neuropathy is major cause of worse visual outcome in this population. |
| Dubey et al. [ ] | 2022 | 4 | CR | Unique presentation of orbital roof fracture resulting in both superior oblique palsy and acquired Brown syndrome. |
| Mukit et al. [ ] | 2023 | 4 | CR | This is the first reported penetrating globe injury from a vape pen explosion. |
| Park et al. [ ] | 2023 | 4 | RCS | Globe indentation from blow-in fractures are rare. Clinicians should be suspicious in cases of high-velocity trauma to the superolateral orbit with hypoglobus, motility limitation, and indentation of the globe upon dilated exam. Prompt diagnosis and early surgical removal of the compressive orbital bone fragments in a multidisciplinary fashion can lead to good visual, functional, and cosmetic outcomes. |
| Jamali et al. [ ] | 2023 | 4 | POS | Early definite management of displaced orbital roof fractures secures reliable functional and cosmetic results and reduces the incidences of intracranial and ocular complications. |
| Park et al. [ ] | 2023 | 4 | CR | Conservative treatment can acquire the best outcome regarding cosmesis and function unless the patient requires an emergent operation for other medical conditions. This is key for successfully returning the patient’s form and function. |
Considering only 13 papers that describes 26 surgical cases ( Table B ), coronal incision was the most used approach (16 pts, 61,5 %), and in most cases reconstruction was achieved using titanium mesh or plates (respectively 8 and 3 pts, 42,3 %), while in 4 cases bone autogenous graft harvesting was performed. In 4 patients only dislocated bone fragment removal was performed [ ]. Only one case of combined transnasal transorbital approach was described, and reconstruction was performed using fascia lata [ ]. Conclusions were similar to those previously described ( Table A ) [ ].
| Authors | N° pts | Ethiology | Surgical approach | Recontruction |
|---|---|---|---|---|
| Callahan et al. [ ] | 1 | Gunshot | Upper blepharoplasty incision | Titanium mesh |
| Hwang et al. [ ] | 1 | Precipitation | Coronal incision | Titanium mesh |
| Liu et al. [ ] | 1 | Blunt body trauma | Coronal incision | Bone fragment reposition |
| Caras et al. [ ] | 1 | assault | Coronal incision | Titanium plates |
| Pereira et al. [ ] | 1 | Road accident | Coronal incision | Titanium mesh |
| Vedhapoodi et al. [ ] | 1 | Road accident | Transorbital transnasal endoscopic approach | Fascia lata |
| Pereira et al. [ ] | 1 | Road accident | Coronal approach | Bone graft |
| Mukit et al. [ ] | 1 | Penetrating injury | Coronal approach | Bone graft |
| Park et al. [ ] | 3 | 1 Train 1 sport accident 1 assault |
1 extended eyelid incision 1 brow laceration 1 brow laceration |
Bone fragment removal (no reconstruction) |
| Gebran et al. [ ] | 8 | 4 road accident 2 fall 1 assault 1 gunshot |
7 coronal approach 1 orbital, brow incision |
4 titanium mesh 1 titanium plates 1 bone graft 1 temporalis muscle/fascia 1 no reconstruction |
| Klančnik et al. [ ] | 1 | Penetrating injury | Coronal approach | Titanium plates |
| Shah et al. [ ] | 1 | Falling masonry | Coronal approach | Bone graft |
| Jamali et al. [ ] | 5 | Road accident | Coronal approach | Titanium mesh |
Regarding our experience, a total of 20 adult patients affected by orbital roof fractures were identified according to inclusion criteria (17 males and 3 females). Median age was 44,5 yrs (range:20–71) and main cause was road accident (65 % of cases). Details are reported in Table C .
| Sex | Age | Etiology | Associated fractures | Consciousness status at admission | symptoms | Time of surgery | Surgical approach | Reconstruction | Complications |
|---|---|---|---|---|---|---|---|---|---|
| F | 30 | Road accident | Le Fort II, fronto-temporo-parietal bone | unconscious | Rhinoliqorrea, exophtalmos | <48 h | Coronal approach | None, galea flap | None |
| M | 30 | Road accident | fronto-temporo-parietal bone | unconscious | Massive exophthalmos, Chemosis, Optic nerve compression | <12 h | Coronal approach | Heterologous bone, galea flap | None |
| M | 43 | Road accident | NOE, ACB (eye explosion), zygoma | conscious | Rinoliquorrea | <48 h | Coronal approach | None, galea flap | None |
| M | 20 | Road accident | NOE, frontal bone | conscious | Chemosis, diplopia | <48 h | Coronal approach | None, galea flap | None |
| M | 71 | Accidental fall | NOE, frontal bone | conscious | Periorbital hematoma | >48 h | Upper blepharoplasty incision | Titanium mesh | V1 deficit |
| M | 24 | Aggression | Frontal bone | conscious | Periorbital hematoma | >48 h | Coronal approach | None | None |
| M | 53 | Road accident | None | conscious | Periorbital hematoma, suspect CSF leack | <48 h | Combined endoscopic approach | None | None |
| M | 48 | Road accident | Frontal and malar bone | unconscious | Periorbital hematoma, CSF leack | <12 h | Coronal approach | Titanium mesh, galea flap | None |
| M | 44 | Road accident | Frontal bone, ACB | unconscious | Periorbital hematoma, CSF leack | <12 h | Coronal approach | Titanium mesh, galea flap | Rhinoliquorrea 3 months after surgery |
| M | 36 | Aggression | Frontal bone | conscious | Periorbital hematoma, diplopia | <48 h | Coronal approach | Titanium mesh, galea flap | None |
| M | 49 | Aggression | Fronto-orbital fracture, Fontal sinus, epidural hematoma | conscious | Periorbital hematoma, diplopia | <12 h | Coronal approach | Titanium mesh, galea flap | Diplopia |
| F | 67 | Accidental fall | Upper orbital margin | conscious | Periorbital hematoma | >48 h | Trans-laceration | Adsorbable dura substitute | None |
| M | 45 | Aggression | Frontal sinus, orbit | conscious | Diplopia | >48 h | Coronal approach | Autogenous bone | Minimal enophthalmos |
| M | 33 | Road accident | zygoma | conscious | Periorbital hematoma, diplopia | >48 h | Trans-laceration | Titanium mesh | None |
| M | 60 | Road accident | Upper orbital margin | conscious | Periorbital hematoma | >48 h | Trans-laceration | None | None |
| M | 34 | Aggression | Frontal bone, COMZ | conscious | Periorbital hematoma, III c.n. deficit | <12 h | Coronal approach | Bone repositioning, galea flap | Revision surgery (bone repositioning) |
| M | 54 | Road accident | fronto-temporo-parietal bone, Le Fort III, NOE, zigomatic arch, | unconscious | Rhinoliqorrea, esophtalmos, Periorbital hematoma | >48 h a | Coronal approach | Patient-Specific Titanium Mesh, galea flap | Endocranic Hypertension |
| F | 35 | Road accident | Le Fort II, frontal bone | conscious | Esophtalmos, Chemosis, Periorbital hematoma | <12 h | Coronal approach | Titanium Mesh, galea flap | None |
| M | 68 | Road accident | Frontal-temporal Bone, COMZ, Le Fort II | conscious | Chemosis, Periorbital hematoma | <48 h | Coronal approach | Galea flap | None |
| M | 45 | Road Accident | Frontal Bone | conscious | Chemosis, Periorbital hematoma | <24 h | Trans-laceration | Adsorbable dura substitute | None |
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