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The purpose of this article is to introduce simple, minimally invasive, more effective, and more comfortable method using a customized balloon with contrast agent for orbital floor fracture. The customized balloon was fabricated to compensate for its shortcomings, based on the experiences from four patients who underwent the surgery of orbital floor fracture using a Foley catheter.In a 33-year-old female patient with only orbital floor fracture, the reduction was performed using a transmaxillary approach with a customized balloon. The customized balloon was made using latex glove and 6 French gavage tube, and the contrast agent was injected within the balloon. A micro saw was used to form a window on the anterior wall of the maxillary sinus. Compared to the round bur, a micro saw can create an internal bevel along with minimal bone removal, which makes it possible to insert the bone fragment tightly without falling into the maxillary sinus when the fragment is repositioned. The use of contrast agent makes it more visible to determine the position of the balloon instantly during surgery by take portable radiograph. The balloon has removed after 3 weeks and no diplopia or no enophthalmos was observed. There remained very small defect on the anterior sinus wall about the size of gavage tube.The transmaxillary approach, along with a conjunctival or subciliary approach, can be a good choice for the treatment of orbital fractures. Compared to the conventional Foley catheter, the application of a customized balloon and contrast agent supports the entire orbital floor evenly and wide, and fills the maxillary sinus without an empty space. It is easy to check the location of the balloon through x-ray photography during surgery, and has a very little discomfort for the patient.

The most effective treatment for orbital fractures is still under debate and different strategies are proposed in the literature. All such strategies focus on reconstruction of the orbital structure, neglecting the main function of the medial and inferior walls, these latter being constructed so as to break during high energy trauma. The aim of the authors is to highlight the difference between different reconstructive techniques in an orbital fracture restoration, being inclined to favor repair over reconstruction of the orbital floor, assuming that a second trauma could happen and reconstructive material left in the orbit may damage the visual apparatus in such a scenario. Following this theme, the authors propose a reconstruction strategy using a custom made stereolithographic model and resorbable plate made of polylactic acid mesh molded onto it. The mesh is used alone or in combination with bone graft, to obtain a better reparative result. At present, this approach is best suited to sports people and the young. Even if a deeper evaluation of the method would be useful, the series of case studies presented could be of stimulus for future discussion.

The reconstruction of the orbit has been carried out throughout history using different techniques. However, the persistence of high rates of complications mainly associated with the position of the eyeball and the migration of reconstruction implants have generated the need and importance of continuing to study new techniques, including with the help of technology. Virtual planning combined with endoscopic access and 3D models could decrease the number of complications associated with the aforementioned problems. For this, the aim of this observational retrospective study is to show the authors’ experience of 19 cases in different orbital fractures using endoscopic support and virtual planning as great alternative in orbital reconstruction. Within maxillofacial trauma, one of the greatest functional and aesthetic challenges for the surgeon is the orbital reconstruction, which in the event of not obtaining adequate results, can lead to aesthetic, functional and even occupational problems.1 The walls and orbital floor are commonly involved in maxillofacial trauma generated sensory problems, eye movement limitations, or changes in the position of the eyeball. The reason why one of the objectives of the treatment is the recovery of the anatomy in a matter of volume and position.2 The endoscopic approach has become important in maxillofacial reconstruction due to the direct visualization of fractures, which consequently results in a reduction in the complications associated with the surgical accesses made due to the extension.3 The loss of important anatomical references at the time of the reconstruction has hindered the processes and that is why the use of technology through the creation of software that obtains information to create images through computed tomography that imitate the contralateral orbit are also very useful.4 The main problem to be faced in orbital reconstruction surgery corresponds to recovering the orbital volume.5 Also, due to having complex, narrow anatomy and with important structures, the next problem is the proper visualization of anatomical structures and bone defects and their manipulation at the same time.6 This is why the objective of this study is to show our experience with 19 cases using endoscopic support and virtual planning for the management of traumatic injuries.

A subciliary incision has been widely used not only for blepharoplasty but also for facial fracture surgery. However, lower eyelid malpositioning is one of the most common complications after fracture surgery. A limited number of studies have been conducted on the relationships among evaluation of the canthal area, orbital vector analysis, and lower eyelid malpositioning following the subciliary approach for surgical repair of fractures. The primary goal of this study was to identify and analyze the possible risk factors, including incidence of lower eyelid malpositioning and orbital vector after surgical correction of the orbital fracture. A total of 241 cases of orbital fracture surgery was retrospectively reviewed. Data related to the patient and surgery were collected. Orbital vector and angle that reflects the vector, distance between soft tissue and bone in the lateral canthal area were measured for orbital vector analysis. The relationship between the prevalence of the malpositioning of the lower eyelid and each factor was statistically analyzed. The distance between the soft tissue and bone at the lateral canthal area was statistically significant (P = 0.031). The distance between the soft tissue and bone at lateral canthal area illustrates the lateral side or periorbital anatomical morphology. It could be inferred that patients with a negative orbital vector were relatively more vulnerable to scar formation or lower eyelid malpositioning caused by iatrogenic factors. Therefore, it could be analyzed as a risk factor to predict the malpositioning of the lower eyelid postoperatively.

Introduction A closed globe trauma is often associated with orbital wall fractures. In addition to diplopia, further eye disturbances can be observed. The aim of this preliminary prospective study was to investigate the optical coherence tomography (OCT) findings in patients that presented with orbital fractures in association with diplopia but without decreased visual acuity or further ocular symptoms. Methods Only patients who were admitted and surgically treated for orbital wall fractures and that presented diplopia were included in this study. Patients with post traumatic ocular symptoms were excluded. All the patients that were diagnosed with an orbital fracture underwent an ophthalmological assessment, including best-corrected visual acuity (BCVA), examination of fundus oculi, Hess Scheme, OCT, and OCT angiography. Results Five patients met the inclusion criteria and were enrolled. Hess Scheme examinations confirmed the presence of diplopia in all the included patients. The examination of fundus oculi did not reveal any pathology in 4 patients, whereas in a patient a commotio retinae (Berlin's Edema) was diagnosed in the infero-papillary field. Following OCT assessment, a pachycoroid was observed in 4 patients. Conclusions A thorough ophthalmological assessment in patients that have suffered from orbital fractures is fundamental. In particular, OCT examinations seem to provide more insight into the detection and monitoring of choroidal changes after ocular trauma without visible macular changes.

OBJECTIVE Chemosis is a common occurrence after orbital reconstruction surgery by the transconjunctival approach. The authors propose an early tarsorrhaphy approach for treating severe conjunctival chemosis following orbital fracture repair. METHODS All severe conjunctival chemosis patients following orbital fracture repair were divided into 2 groups: tarsorrhaphy performed immediately when the eyelids could not close completely due to prominent conjunctival edema (early tarsorrhaphy, n = 10); and tarsorrhaphy performed 3 days after the appearance of severe chemosis (delayed tarsorrhaphy, n = 10). Once the conjunctiva subsided, the sutures were immediately removed. The duration of conjunctival edema was recorded. RESULTS The average time to resolution of severe chemosis was significantly shorter in the early versus delayed tarsorrhaphy group (3.5 ± 0.5 versus 7.2 ± 1.73 days, P

Orbital blowout fractures are common. The same goes for its surgical complications when the efficiency of the dissection of entrapped or herniated intraorbital contents into the fracture could not be completely and safely dissected out. The authors describe a modification of the commonly used Howarth periosteal elevator for dissection of intraorbital content displacement or herniation on orbital blowout fracture. The instrument was modified by marking out the instrument from the tip into 10, 20, 25, 30, and 40 mm on both of its concave and convex surfaces to allow safe orbital soft tissue dissection and distance control. From the authors' experience, these simple modifications from its original instrument design allow better intraoperative control and appreciation of any intact important intraorbital anatomical structures such as inferomedial strut and posterior ledge. At the same time of importantly getting complete orbital fracture dissection and visualization, it causes less trauma to surrounding soft tissue with the markings ensuring unnecessary orbital exploration or visualization. Dissection can be kept for optimum maneuverability at the required or intended location based on the preoperative scan or dimension of anatomical orbital implant.

Orbital floor fractures can produce acute constitutional symptoms and poor ocular outcomes. This study aims to determine the clinical and radiological predictors of tissue entrapment in pediatric orbital floor fractures and to explore the effect of operative timing on ocular outcomes. The authors reviewed medical records from pediatric patients with orbital floor fractures from 2007 to 2015. One hundred fifty-two patients with 159 orbital floor fractures were included. One hundred twenty-two (80.3%) patients were male, and the mean age was 12.2 years. Twelve patients sustained orbital floor fractures with tissue entrapment. At presentation extraocular movement (EOM) restriction, diplopia, nausea, and vomiting were all associated with tissue entrapment (P < 0.001). Among patients with trapdoor fractures (determined by facial computed tomography), the presence of nausea and/or vomiting was predictive of tissue entrapment: positive predictive value 80%, negative predictive value 100%. For all the patients, regardless of fracture configuration, the presence of nausea and/or vomiting was valuable in ruling out tissue entrapment: sensitivity 83.3%, negative predictive value 98.1%. In tissue entrapment patients, poorer ocular outcomes (EOM restriction and diplopia) were associated with the length of operation (P = 0.007), but not the time interval to operation (P = 0.146). The authors conclude that nausea and vomiting are valuable predictors of tissues entrapment, particularly when EOM restriction and diplopia are equivocal. In the authors' study, radiological findings were also predictive of entrapment, but inconsistent language in this area limits the external validity of these results. The authors' study draws attention to the relationship between operation length and poorer ocular outcomes, suggesting that case severity/complexity and surgeon technique/experience may influence outcomes.

Reconstruction of a large orbital fracture extending to the posterior wall of the maxillary sinus is difficult and challenging. In this study, the authors present transconjunctival or transcaruncular approach using endoscopy and layered porous polyethylene barrier sheets to manage large orbital floor wall fracture.A retrospective review of all patients who underwent reconstruction of large orbital floor wall fractures between June 2009 and July 2015 was conducted. Patient demographics, degree of enophthalmos, ocular motility and diplopia test results, and surgical complications were reviewed.This study included 53 eyes of 53 patients. The mean time from trauma to surgery was 34.1 days (range, 1-360 days). The average postoperative follow-up period was 6.1 months (range, 3-14 months). The degrees of enophthalmos preoperatively, and 1 week, 1 month, and 3 months postoperatively were -1.98 mm (range, -1.5 to -3 mm), 0.13 mm (range, -1.0 to +1.5 mm), -0.09 mm (range, -2.0 to +1.5 mm), and -0.43 mm (range, -2.0 to +1.0 mm), respectively. The mean improvement in enophthalmos at 3 months postoperation was 1.55 mm (P0.001). There was only 1 patient with residual 2 mm enophthalmos at 3 months postoperation. There were no definite surgical complications in any patient.Sufficient dissection to the posterior extent of the fracture and reconstruction of the orbital floor slope are the most important surgical factors to prevent residual enophthalmos. The authors believe using an endoscope and layered porous polyethylene are effective techniques in challenging patients with large orbital wall fracture.

Objective The aim of the study was to precisely assess the severity of traumatic orbital defects and techniques for personalized orbital reconstruction. Methods A retrospective study was conducted in 97 patients with traumatic orbital defects who were treated in our hospital between July 2003 and June 2012. Pre- and postoperative spiral computed tomography scans were performed in all patients. A spatial orientation technique was used to measure the three-dimensional position of the globe and calculate the changes in the orbital volume. Subsequently, a computer-assisted technique and a rapid prototyping technique were used to create a personalized orbital model to aid in the planning of surgery as well as the preforming of implants and bone plates. During surgery, the herniated orbital contents were returned; the preformed titanium mesh, Medpor, or other implants were placed; the orbital shape in the defect site was precisely restored; and normal proportions between the orbital walls and orbital contents were regained. The treatment outcomes were evaluated with respect to postoperative appearance, patients' satisfaction, ophthalmologic examination, and computed tomography scan. The complications were analyzed accordingly. Results Satisfactory results were achieved in all patients with the following exceptions: 1 patient with an unsatisfactory facial appearance; 2 patients with old trauma and an unfavorable correction of enophthalmos who experienced diplopia with no significant improvement within 6 months after surgery; and 2 patients of mild postoperative lower eyelid ectropion. All other patients achieved satisfactory treatment effects, that is, the orbital shape in the defect site was precisely restored, and normal proportions between the orbital walls and orbital contents were regained. There were no other severe complications reported. Conclusions In patients with traumatic orbital defects, accurate digital evaluations of the three-dimensional position of the globe and changes in the orbital volume aid in surgical planning with a personalized model and promote early surgery with minimal trauma. When the orbital volume was restored and the position of the globe was maintained or corrected, the precise reconstruction of the anatomic shape of the orbit was concurrently completed. Personalized orbital reconstruction can improve the efficacy of plastic surgery in patients with orbital deformities.

In surgical repair of orbital fracture, implant materials play an important role in restoring the functional and anatomic structure of the orbit. Alloplastic implant materials are widely used for this surgery, but they have the risk of complications such as infections, pain, and extrusion. Because they are artificial implants, infection can occur more than autologous implants and is the most challenging problem to manage. Sino-cutaneous fistula is a rare complication of chronic sinusitis and it can be caused by this implant materials. The authors report a case of formation of sino-cutaneous fistula after using Medpor (Stryker Co, MI) implant in orbital blowout fracture repair.

Orbital fractures are common. In patients where there is significant loss of the medial wall and orbital floor, anatomic prebent 3-dimensional plates allow efficacious restoration of orbital volume. However, the large size of these plates can result in technical difficulties with plate placement, especially in fractures with complete loss of 2 walls of the orbit. In this article, the authors review the pertinent anatomy of the bony orbit with respect to fracture and landmarks in fracture reduction. The authors also note the 3 most commonly encountered problems with the placement of anatomic plates: poor exposure, failure to identify the posterior ledge for the plate, and rotational issues with plate placement resulting in impingement. Technical tips are given to help overcome these issues intraoperatively.

OBJECTIVE: Enophthalmos is a severe complication of primary reconstruction of orbital floor fractures. The goal of secondary reconstruction procedures is to restore symmetrical globe positions to recover function and aesthetics. The authors propose a new method of orbital floor reconstruction using a mirroring technique and a customized titanium mesh, printed using a direct metal laser-sintering method. METHODS: This reconstructive protocol involves 4 steps: mirroring of the healthy orbit at the affected site, virtual design of a patient-specific orbital floor mesh, CAM procedures for direct laser-sintering of the customized titanium mesh, and surgical insertion of the device. Using a computed tomography data set, the normal, uninjured side of the craniofacial skeleton was reflected onto the contralateral injured side, and a reconstructive orbital floor mesh was designed virtually on the mirrored orbital bone surface. The solid-to-layer files of the mesh were then manufactured using direct metal laser sintering, which resolves the shaping and bending biases inherent in the indirect method. An intraoperative navigation system ensured accuracy of the entire procedure. RESULTS: Clinical outcomes were assessed using 3dMD photogrammetry and computed tomography data in 7 treated patients. CONCLUSION: The technique described here appears to be a viable method to correct complex orbital floor defects needing delayed reconstruction. This study represents the first step in the development of a wider experimental protocol for orbital floor reconstruction using computer-assisted design-computer-assisted manufacturing technology. PMID: 27438454 DOI: 10.1097/SCS.0000000000002907

The best treatment of pediatric orbital fractures is debated and different strategies are proposed in the literature. Resorbable materials, due to their features and the specific requirements of the pediatric population, seem a very suitable choice. The authors present their experience by describing 3 cases and explaining their mesh modeling technique. Two fractures were caused by accidental falls, whereas the other resulted from aggression. Clinical and radiological evaluation (computed tomography scanning) was performed before surgery. No complications occurred either immediately after surgery or in the long term (maximum follow-up of 3 y). As there has been little experience of the use of resorbable mesh in maxillofacial pediatric traumatology, the authors describe their technique, which may facilitate the use of this material in orbital fractures.

PURPOSE To describe ocular motility and effectiveness of an extended conjunctival incision with reattachment of the inferior oblique muscle to repair combined orbital medial and inferior wall fractures. METHODS The authors retrospectively studied 20 eyes from 20 patients who underwent combined orbital medial and inferior wall fractures surgery with reattachment of the inferior oblique muscle from January 2007 to December 2011. Single large L-shaped implant was inserted into the fracture site. All patients were evaluated preoperatively and postoperatively at 1, 3, and 6 months, by computed tomography, Hertel exophthalmometry, the Hess test of ocular motility, and the Goldmann diplopia test. RESULTS Sixteen patients (80%) had no significant enophthalmos or diplopia after surgery. Inferior oblique motility was not changed in 12 patients (60%) after reattachment of the inferior oblique muscle. After 1 month, inferior oblique underaction was presented in 8 patients (40%) and in 4 patients (20%) after 6 months. Finally, only 2 patients (10%) had the inferior oblique underaction remained, it was not improved. CONCLUSIONS The extended conjunctival incision with reattachment of the inferior oblique muscle for combined orbital wall fracture repair offers a wide surgical field and space for a single large implant insertion and corrects the enopthalmos. The reattachment of the inferior oblique muscle does not contribute to the development of inferior oblique underactions or diplopia that was resolved spontaneously within 6 months after surgery.

Blow-out fractures affect the volume and surface area of the orbital cavity. Estimation of these values after the trauma may help in deciding whether or not a patient is a candidate for surgery. Recent studies have provided estimates of orbital volume and area of bone defect, and correlated them with the degree of enophthalmos. However, a large degree of biological variation between individuals may preclude such absolute values from being successful indicators for surgery.Stereological methods have been used to estimate orbital cavity volume in a few studies, but to date these have not been used for surface area. To authors' knowledge, this study is the first to have measured the entire surface area of the orbital cavity.The volume and surface area of the orbital cavity were estimated in computed tomography scans of 11 human cadavers using unbiased stereological sampling techniques. The mean (± SD) total volume and total surface area of the orbital cavities was 24.27 ± 3.88 cm and 32.47 ± 2.96 cm, respectively. There was no significant difference in volume (P = 0.315) or surface area (P = 0.566) between the 2 orbital cavities.The stereological technique proved to be a robust and unbiased method that may be used as a gold standard for comparison with automated computer software. Future imaging studies in blow-out fracture patients may be based on individual and relative calculation involving both herniated volume and fractured surface area in relation to the total volume and surface area of the uninjured orbital cavity.

Orbital cellulitis and abscess have been described in the literature as complication that usually occur secondary to infection in the maxillary, ethmoidal, and frontal sinuses. If left untreated, it can lead to blindness, cavernous sinus thrombosis, meningitis, or cerebral abscess. Orbital fractures are a common sequela of blunt orbital trauma, but are only rarely associated with orbital cellulitis. So, the authors present rare orbital cellulitis after orbital blow-out fracture. A 55-year-old Asian complains of severe orbital swelling and pain on the left side. These symptoms had started 2 days earlier and worsened within the 24 hours before hospital admission resulting in visual disturbances such as diplopia and photophobia. Contrast-enhanced computed tomography scan showed considerable soft tissue swelling and abscess formation on the left side. Patient was subjected to surgical drainage under general anesthesia in the operation room. In this case, the postoperative period was uneventful and the rapid improvement of symptoms was remarkable. In conclusion, the abscess of the orbit is a surgical emergency in patients whose impairment of vision or ocular symptoms cannot be controlled with medical therapy using antibiotics. In our case, orbital cellulitis can occur after blunt orbital trauma without predisposing sinusitis. Early and prompt diagnosis and surgical drainage before severe loss of visual acuity rescue or recover the vision in case of orbital cellulitis.

OBJECTIVES Absorbable plates are sometimes grafted for treating orbital fractures. These plates cannot be readily processed to fit the shape of the fracture site, particularly when the fracture encompasses a broad area from the medial toward the inferior wall. Preparing the plates in a standard shape beforehand will be useful. Thus, in this study, the authors measured the orbital wall distance in healthy orbits to determine the mean orbital size with the ultimate goal of developing and clinically applying a standard plate for orbital fracture. METHODS Measurements were performed for the left eye orbit on computed tomography images using a three-dimensional medical image processing workstation. The authors measured the orbital wall distances and angle of healthy orbits in 40 males and 40 females to determine the mean size of the orbit. RESULTS In healthy orbits, no significant difference was noticeable in the angle between medial wall and inferior wall between males and females. The medial, inferior, and medial + inferior wall distances were markedly longer in males than in females (P

Orbital fractures are common, accounting for nearly 40% of all facial fractures. Open repair is required to restore preinjury orbital volume and relieve any extra-ocular muscle entrapment. Monitoring for postoperative intraorbital hemorrhage, and its consequent potential for visual impairment, has triggered most surgeons to observe their patients in the hospital overnight postoperatively. The real risk of postoperative hemorrhage in this patient group, however, is uncertain and the need to contain healthcare costs clear. The objective of this study was thus to determine the incidence of emergent postoperative complications in patients undergoing orbital fracture repair to determine the feasibility of performing this operation on an outpatient basis. Patients who sustained isolated orbital fractures and underwent open repair at this level-1 trauma center between January 2002 and January 2012 using International Classification of Disease-9 and Current Procedural Terminology 2012 coding were identified. Demographic data and postoperative complications were identified by reviewing the electronic medical record. Furthermore, critical analysis of available published evidence was performed. Ninety-three patients who satisfied the inclusion criteria were selected. There were no patients of an intraorbital hematoma or other immediate postoperative complications that required operative intervention. Average hospital length of stay was 0.85 days. Repair of orbital fractures on an outpatient basis appears to be safe. The theoretical risk of a complicating intraorbital hematoma seems to be between 0 and 3.2%. This can be minimized through: the use of open surgical access site and perforated floor replacement materials, careful early monitoring, education of patients, and admission of those at potentially elevated risk.

After restoration of orbit wall fracture, preventing sequelae is important. An absorbable mesh is commonly used in orbit wall fracture, yet it has limitation due to orbit sagging when bony defect is larger than the moderate size (1 × 1 cm2). In this study, the authors present a satisfactory result in treating orbit wall fracture larger than the moderate size with a combination of absorbable mesh and demineralized bone matrix.From 2009 to 2012, 63 patients with bony defect larger than the moderate size, who were treated with a combination of absorbable mesh and demineralized bone matrix, were reviewed retrospectively. The site of bony defect, size, and applied amount of demineralized bone matrix were reviewed, and a 2-year follow-up was done. Facial computed tomography scans were checked preoperative, immediate postoperative, and 2-year postoperative.Among the 63 patients, there were 52 men and 11 women. Mean age was 33.3 years. The most common cause was blunt blow (35 cases); mean defect size was 13.36 × 12.82 mm2 in inferior wall fracture and 20.69 × 14.41 mm2 in medial wall fracture. There was no complication except for 3 cases of infraorbital nerve hypoesthesia. A 2-year follow-up computed tomography showed that the surgical site preserved bony formation without herniation. In treating moderate-sized bony defect in orbit wall fracture, absorbable mesh and demineralized bone matrix can maintain structural stability through good bony formation even after degradation of absorbable mesh.

BACKGROUND: Selective inferior orbital fissure (IOF) content transection for the purpose of surgical access to the posterior orbital floor is a technique that facilitates visualization of the posterior bony ledges of traumatic orbital floor defects. It also has potential advantages in achieving stable placement of reconstructive materials. Although not new, the surgical technique has not yet been described, and the morbidity of the technique has not been quantified. This article describes the procedure and assesses the morbidity specific to the division of related neural structures. METHODS: The technique and surgical anatomy are described and illustrated with intraoperative photographs. Postoperative assessment of neural structures relevant to the division of IOF contents is performed. These values are compared with the nonoperated side to evaluate the morbidity of the technique. RESULTS: The technique, which is consistently used by the senior author in the repair of orbital floor defects with very small posterior ledges or which extend to and involve the IOF, facilitates better visualization of the posterior ledge and posterolateral ledge in such cases. Surgical outcomes including facial sensation and lacrimal function on the operated side remain within the reference range and are not significantly different when compared with the contralateral nonoperated side. CONCLUSIONS: Selective IOF transection aids in the direct visualization of the posterior bony ledges in the repair of posterior orbital floor defects. It therefore may facilitate the placement of reconstructive materials on bony ledges circumferentially, providing stable reconstruction, potentially reducing implant-related complications without causing increased morbidity.

Although bilateral orbital fracture can cause serious eyeball and facial skeletal problems, few reports have been issued on the topic. We analyzed the clinical features of bilateral orbital fracture by reviewing the medical records of 147 patients and compared bilateral and unilateral fractures by reviewing the literature.Bilateral orbital fracture was most common in men aged between 50 and 59 years. A traffic accident was the leading cause of trauma, and average time between trauma and surgery was 12.2 days. Bilateral medial fracture accompanied by nasal fracture accounted for the overwhelming majority, and impure blowout fracture in at least 1 eye occurred in 69.4% of the 147 patients. Associated ocular injuries seemed to be similar for bilateral and unilateral fracture. Thirty-five patients (23.8%) had other multiple traumas affecting other than the eyes, and this significantly increased the need for surgery (P < 0.05). Of the 48 patients who underwent surgery, including 4 cases of bilateral surgery, 21 patients who had ocular motility restriction with central diplopia within 30 degrees almost completely recovered. No significant relation between the timing of surgery and improvement was found. Although unilateral surgery was performed in most cases, facial asymmetry related to enophthalmos was unclear at 6 months postoperatively.In summary, bilateral orbital fracture was found to be clinically distinguishable from unilateral fracture in several aspects. We hope these findings provide a reference guide to the approach and management of bilateral orbital fracture.

Background The management of orbital floor fractures is diverse and continues to evolve. The purpose of the current study was to provide an updated summary of the literature, with a focus on interspecialty differences, and contrast that with current treatment strategies of actively practicing plastic surgeons. Methods A survey was conducted of surgeons who currently manage orbital floor fractures. The results are summarized and compared with a 10-year literature review (2002-2012) of surgical approaches, indications and timing of surgery, and implant selection in various surgical disciplines. Inclusion criteria included studies in English language with 10 or more patients. Results The survey response rate was 56%, of which 86 surgeons were identified to currently manage orbit fractures. A third of participants reported they are less likely to operate on these fractures relative to earlier in their career. Six factors were found to have the greatest influence on surgeon's operative decision: enophthalmos, hypophthalmos, positive forced duction, defect size, motility restriction, and persistent diplopia. The most common preferred approach to the orbit is midlid/infraorbital (45%) followed by transconjunctival (31%) and subciliary (24%). Medpor and titanium are the most preferred implants (83%) compared with autologous bone (5%). Conclusions Significant interdisciplinary and intradisciplinary differences in the management of orbital fractures exist. The most significant trends are the growing popularity of alloplastic versus autogenous materials for orbital floor reconstruction and the fact that one-third of surgeons are more likely to opt for a nonoperative (conservative) approach compared with earlier in their careers.

Treatment of orbital fractures involves restoration of lost bone anatomy and orbital volume. Among the materials used for this purpose, the titanium mesh is widely used due to its effectiveness and low complication rate related to distortion especially in non-traumatic events. This study shows an atypical and late complication involving the deformation of the titanium mesh used during reconstruction of the orbital floor in a patient with orbital zygomatic complex fracture 5 months after the procedure and without traumatic etiology.

Orbital fractures are high prevalent and result in several complications such as diplopia, muscular entrapment, visual impairment, and enophthalmos. The goal of orbital reconstruction is to restore orbital anatomy, volume, and globe symmetry. This case report aims to describe the use of transantral endoscopy and 3D printed model for treatment of an orbital floor fracture. A 54-year-old woman presented orbital floor fracture with diplopia and extraocular muscle entrapment. The surgical treatment was performed using a standard titanium mesh bended over 3D printed model, and transantral endoscopy to verify fracture extension and implant adaptation. The postoperative evaluation demonstrates correction of diplopia and ocular motility restriction. Computed tomography scan showed reestablishment of the orbital anatomy. The association of transantral endoscopy and 3D printed models is a feasible technique to improve orbital reconstruction.

The frontal bone fractures occur very often in service units in oral and maxillofacial surgery. Bicoronal access is the most common for the surgical treatment of frontal bone fractures. However, patients are surprised when they receive notice that such invasive access will be made. This approach allows adequate visualization of the fracture site, but may be associated with complications, which can be avoided by the use of less invasive techniques. We describe an alternative approach that aims to minimize the complications of a coronal incision.

Concomitant fractures of the inferior and medial orbital wall can cause more severe orbital symptoms and lead to incomplete reduction postoperatively. This report presents the case of a 17-year-old boy, presenting with persistent diplopia and enophthalmos after floor reduction for concomitant fractures. At the time of the fracture, surgery was performed for only the orbital floor by a plastic surgeon, because the medial wall fracture was minimal. However, he presented with persistent orbital symptoms after surgery. An aggravated medial wall fracture was discovered via computed tomography (CT) examination. It was treated with a minimal-invasive method using an endoscopic approach.

Blowout fracture is a common condition in the oculoplastics clinic. One of the indications for its repair is entrapment of the inferior rectus muscle within the fracture site. Herein, the authors present 3 patients of inferior rectus muscle sheath entrapment without entrapment of the muscle itself. The outcome of treatment was excellent in all patients. The aim of this report is to present the special clinical and radiologic findings in such patients.

The aim of this systematic review is to summarize and evaluate the effect of orbital fractures (blowout fractures and nonblowout fractures) on visual acuity. In PubMed search and Scopus search, the terms "orbital fracture OR maxillofacial injury OR facial trauma OR craniofacial fracture," and "visual acuity OR functional outcome OR visual outcome OR improving document of visual acuity OR blindness OR optic nerve neuropathy" were used, which resulted in 1634 and 1152 papers, respectively. Of the 2226 titles excluding 560 duplicated titles, 227 abstracts were reviewed. Of the 227 abstracts reviewed, the authors found 56 potentially relevant full-text articles, of which 5 studies met our inclusion criteria. The odds ratio and 95% confidence intervals from each study were abstracted. The statistical analysis was performed with review manager (The Nordic Cochrane Centre). A summary of 5 studies affirmed that 43 patients among 532 orbital fractures (8.1%) had decreased visual acuity. Twelve patients among 159 blowout fractures (7.5%) had decreased visual acuity. Thirty-one patients among 373 orbital fractures other than pure blowout fractures (8.3%) had decreased visual acuity. In orbital fractures other than pure blowout fractures, the frequency of decreased visual acuity was higher than pure blowout fractures (n = 532, odds ratio, 2.23, 95% confidence interval = 1.06-4.70). Surgeons should acknowledge this with patients before surgery. Language: en

Background Repairing orbital wall fractures can result in serious complications, including enophthalmos, diplopia, or even blindness. Especially, surgeons worry about damaging the optic nerve while dissecting the optic canal area. We avoid these complications by using a navigation system that was adapted to stereotactic concept based on three-dimensional imaging of the patient's anatomy. Here, we report 5 cases of orbital wall fracture that were repaired using a navigation system. Methods The Navigation System II (Stryker, Freiburg, Germany) and the iNtellect Cranial Navigation (version 1.1) platform were used for each operation. A computer-assisted navigation surgery was performed according to the following procedures: (1) image set, (2) planning, (3) apparatus setup, (4) registration, and (5) intraoperative navigation. Operations were performed under general anesthesia. Dissection was performed up to the periosteum immediately anterior to the optic canal, near the fracture. Vulnerable surrounding structures were identified with the intraoperative pointer. After navigation, we inserted an implant into the defect, successfully, avoiding damage to the optic canal and optic nerve. Results None of the patients had any surgical complications. Postoperative computed tomography scans demonstrated that the fractures were corrected, and continuity was maintained without displacement. The three-dimensional image allowed us to easily visualize intraoperative anatomical structure, allowing us to avoid unnecessary procedures and to correct the orbital wall. The mean volume of fractured orbital cavity was 29.2 cm(3) (range, 28.3-30.4 cm(3)) preoperatively and 27.0 cm(3) (range, 25.9-28.5 cm(3)) postoperatively; thus, the defects were corrected by 2.2 cm(3) (range, 1.3-2.8 cm(3)) on average. Conclusions We used a navigation system to perform accurate and safe surgery in patients with extensive orbital wall fracture, including around the optic canal. By using the functions to visualize the locations indicated by the pointer, we were able to perform successful dissections and implantations in areas adjacent to the optic canal. The good outcomes obtained here provide evidence that surgical correction of the orbital wall using a navigation system is useful in cases of deep, extensive orbital wall fracture.

Timing of surgical management of facial fractures may differ from the current standard when an associated severe ophthalmologic injury exists; this may necessitate a delay in repair to protect the patient's vision. We set out to demonstrate that good functional and aesthetic outcomes can be achieved in cases where zygoma bone fracture repair had to be delayed for more than 21 days after injury with a specific surgical plan.Using the electronic database from Montreal General Hospital, a level I trauma center, a retrospective review of all facial fractures occurring from 1994 to 2009 was performed. Our review returned a total of 22,727 trauma patients admitted to Montreal General Hospital. Of these, 2672 sustained 1 or more facial fractures. Among the facial trauma patients, 945 patients' injuries included a zygoma fracture, 324 (35.3%) of which were managed operatively. Seven cases had their surgery delayed for more than 21 days after injury, 2 of which were managed using simple osteotomies and plate fixations, without the need for bone grafts. Both patients demonstrated a satisfactory outcome with improvement relative to their preoperative status. We provide a detailed description of our most recent case of a 73-year-old woman in whom the surgical repair of the lateral orbital rim and orbital floor was delayed for 10 weeks to allow healing of her associated traumatic retinal detachment.For patients with associated ocular injuries who cannot undergo orbital fracture repair within 21 days of the trauma, delayed surgery may still result in an acceptable aesthetic result.

The purpose of this study was to develop and validate a technique for objective quantitative evaluation of outcomes of orbital reconstruction. Facial three-dimensional images were captured using a Vectra three-dimensional camera. Morphometric analysis was based on interactive anthropometric identification. The analysis was applied to a population of healthy adults (n = 13) and a population of patients following primary repair of unilateral orbital fractures (n = 13). Morphologic results following reconstruction were evaluated by identifying residual asymmetries. All subjects further completed the Derriford Appearance Questionnaire and the Orbital Appearance and Function Questionnaire.Normative reference values for periorbital asymmetry were determined in a reference population. The mean asymmetry was less than 1.6 mm for each measured morphologic feature. In the trauma population, primary orbital reconstruction effectively restored normal periorbital symmetry in 16 of 20 measured parameters. The fracture population showed no significant differences in the degree of asymmetry in globe projection, lower eyelid position, or ciliary margin length.The overall DAS59 scores were significantly higher in the fracture population (P = 0.04). This was due to significantly higher physical distress and dysfunction scores (P = 0.02), as well as a trend toward higher general and social self-consciousness scores (P = 0.06). No significant difference in facial self-consciousness was noted (P = 0.21). Thus, although primary orbital reconstruction was effective in restoring periorbital morphology, patients still experienced a higher level of physical distress and dysfunction than their nontraumatized counterparts. This was in accordance with patient self-report, which indicated that a greater percentage of patients were significantly bothered by functional outcomes postoperatively as opposed to appearance.

We sought to investigate the correlation between type of orbital fracture and occurrence of traumatic enophthalmos. The 119 patients with orbital fractures were divided into the enophthalmos group (71 cases) and the nonenophthalmos group (48 cases). The 2 groups were compared by location and type of orbital fracture based on observation of computed tomography scans. We found the incidence of medial wall fractures significantly higher in the enophthalmos group (76.06%) than in the nonenophthalmos group (22.92%, χ(2) = 32.63, P < 0.05). The incidence of combined medial-inferior wall fractures was also significantly higher in the enophthalmos group (52.93%) than in the nonenophthalmos group (12.5%, χ(2) = 23.21, P < 0.05). However, the incidence of lateral-inferior wall fractures was significantly lower in the enophthalmos group (36.62%) than in the other group (58.33%, χ(2) = 4.11, P < 0.05). In most cases of lateral-inferior orbital wall fracture in the enophthalmos group, the zygomatic complex was displaced toward the lateral-posterior direction. The combined medial-inferior wall fracture is likely the primary type of multiple wall fracture leading to traumatic enophthalmos. Enophthalmos caused by a combined lateral-inferior fracture may be correlated with lateral-posterior displacement of the zygomatic complex.

Anisocoria may indicate a life-threatening neurosurgical emergency, unlike bilateral mydriasis. In patients with periorbital fracture, anisocoria can be caused by direct or indirect injury to the oculomotor nerve, excessive retraction of the orbital contents, or constriction of the muscles responsible for eyeball movement. Herein, the author reports a patient, 15-year-old boy, who developed anisocoria after an operation for a blowout fracture. The anisocoria was improved, self-limiting, and transient. The author has also reviewed the literature regarding anisocoria.

Retrobulbar hematoma is an uncommon but potentially devastating complication following repair of orbital fractures. Since 2007, the senior author routinely fenestrates the solid porous polyethylene implants commonly used for orbital reconstruction. The perforated implant may facilitate drainage of postoperative bleeding and may potentially reduce the risk of retrobulbar hematoma. This study examines the rates of retrobulbar hematoma in patients who underwent orbital fracture reconstruction with placement of fenestrated or nonfenestrated implants.A retrospective chart review of patients with orbital fracture reconstruction using an implant performed by the senior author between 2006 and 2016 was conducted. Data collected included age, sex, implant type, and presence of retrobulbar hematoma.One hundred four patients were included in the study. One patient who was treated with a nonperforated implant was found to have a postoperative retrobulbar hematoma. The retrobulbar hematoma did not cause visual changes or increased intraocular pressure, so the patient was observed and did not undergo any surgical intervention. The hematoma resolved spontaneously without further sequela. No patients with fenestrated implants had a retrobulbar hematoma.Fenestration of solid implants used in orbital floor reconstruction is simple and easy to perform, and may reduce the incidence of postoperative retrobulbar hematoma.

Pure orbital fractures have the tendency to occur on medial wall and orbital floor; because these points are more fragile, the endoscopy can be utilized for accomplishing the task of repositioning the herniated content, as well as serving as an additional tool, helping to view the orbital defects through a transantral approach. The presented case is a female patient, 12 years old, who was diagnosed as having a pure blowout fracture, on right orbital floor, type trapdoor, with orbital content herniated toward the maxillary sinus. It was realized that a surgical procedure for reduction of orbital content through video endoscopy, via antral, allowed a great viewing of soft and hard structures, checking the positioning of implants and its relation with the orbital cavity, enabling installing through a small surgical access and minimum detachment, and favoring postoperative recovery.

The objective of this study was first to establish a method to measure forces and displacement of the orbital content in defects of the orbital floor in truncated fresh and unfixed heads and second to characterize reconstruction materials with regard to punctuation strength and compression.Orbital floor defects (10 × 20 mm and 15 × 20 mm; 3 mm behind the orbital rim) were prepared after Le Fort I osteotomy. The values of force and displacement were recorded in 6 freshly frozen human heads. In addition, the punctuation strength of 2 reconstruction materials (polydioxanone [PDS] foil and collagen membrane) was evaluated using a Zwick Z010 TN1 universal testing machine. The forces of the orbital content (28.41 [SD, 1.6] g) applied to the defects of 10 × 20 mm and 15 × 20 mm with an intact periorbita were 0.04 (SD, 0.003) N (0.0002 MPa) and 0.07 (SD, 0.02) N (0.0002 MPa), respectively, and with a split periorbita were 0.06 (SD, 0.03) N (0.0003 MPa) and 0.08 (SD, 0.06) N (0.00026 MPa), respectively. The displacement values without reconstruction materials of the 10 × 20-mm and 15 × 20-mm defects were 0.94 (SD, 0.7) mm and 1.2 (SD, 0.5) mm, respectively. The PDS foil could withstand forces of 118.9 (SD, 14.1) N (0.375 MPa), and the collagen membrane could withstand forces of 44.5 (SD, 5.3) N (0.14 MPa). This is the first study to report forces charging the orbital floor. The presented results support the use of PDS foils and collagen membranes as reconstruction materials for orbital floor defects, at least in smaller and medium-sized fractures.

The clinical presentation and management of pediatric orbital fractures have many unique features that differentiate them from orbital injuries encountered in the adult population. An understanding of the particular anatomic and mechanical properties of pediatric orbital bone and soft tissue helps to explain most of these differences. This article reviews the epidemiology, anatomy, growth implications, pathomechanics, particular clinical features, assessment, and surgical management of pediatric orbital fractures.

The term "orbital blow-out fracture" is referred to as the mechanism by which an impact to the eyeball is transposed as a mechanical energy to the orbital walls, causing them to fracture. Despite a proper surgical technique, a successful anatomic reconstruction of the orbit, and an accurate follow-up, 3 complications are still frequently observed at long-term follow-up: diplopia, enophthalmos, and hypesthesia of the infraorbital nerve territory. In this retrospective study, we analyze the incidence, the specific characterization, and the potential risk factors of these 3 complications.The records of 75 patients who underwent surgical repair of isolated orbital blow-out fracture from January 2001 to December 2007 at the Maxillofacial Surgery Unit of the Novara Major Hospital were reviewed retrospectively. Patients who had other coexisting facial fractures or orbital rim involvement were excluded from this study. The mean follow-up reached 39 months (range, 6-81 months). Enophthalmos was measured by a Hertel exophthalmometer; diplopia was evaluated by an optometrist with cover test, red glass test, and Hess-Lancaster test; and hypesthesia of the infraorbital nerve territory was checked by clinical examination. The studied parameters included patient's age and sex, time interval between trauma and surgery, location of the fracture, and implant material. The χ test for nonparametric data was used, and a P value of less than 0.05 was considered statistically significant.Sex, location of the fracture, and implant material were not considered statistically significant (P0.05). The unique variable that influenced our data was the time interval between trauma and surgery (P0.05).Although the surgical technique was executed properly and the immediate postoperative recovery was uneventful, diplopia, enophthalmos, and infraorbital nerve dysfunction were the frequent complications. We stress the fact that orbital blow-out fracture is generally not considered a technically demanding procedure, but the outcome can be very disappointing; the surgical procedure must be managed very carefully by experienced surgeons to lower the high rates of these 3 common complications. However, we can report that the incidence of diplopia, enophthalmos, and infraorbital nerve dysfunction are decreased by an immediate intervention and an early surgical repair of the orbital blow-out fracture. Patients who had surgery within 2 weeks of trauma have a lower risk to develop postoperative complications; this study supports an early surgical treatment of orbital blow-out fractures, when it is indicated.

Purpose The clinical outcomes of blowout fracture repair classified by 2 types of orbital implants (Macropore and Medpor) were compared. Procedures The medical records of 331 patients with orbital fractures that were treated surgically by 1 surgeon at Gachon University Gil hospital, from March 2007 to March 2009, were reviewed. Patients who had diplopia or limited extraocular motion, significant enophthalmos (>2 mm), or a large fracture on a computed tomographic scan (>50% of the floor area) were enrolled. The clinical outcomes were compared between patients who received surgical repair using Macropore and those who had surgical repair using Medpor. Results One hundred six patients had surgical repair using Macropore and 225 patients were surgically treated with Medpor. Both the Macropore (n = 106) and the Medpor groups (n = 225) showed significant clinical improvement. The degree of preoperative/postoperative diplopia and limited extraocular motion was not different between the 2 groups. In addition, there was no difference in the preoperative/postoperative enophthalmos between the 2 groups. Conclusions Both Macropore and Medpor were associated with equally safe and satisfactory patient outcomes without notable complications.

Purpose: To assess the combination of an endoscopic transethmoidal approach (ETEA) and a transconjunctival inferior fornix approach (TIFA) for repairing combined orbital floor and medial wall blowout fractures (COF-MWBOFs). Methods: Patients with unilateral COF-MWBOFs were randomized to 2 groups: ETEA combined with TIFA or medial canthal incision (MCI) combined with TIFA. Thin porous polyethylene sheets were implanted to cover the orbital defects. The postoperative follow-up time was 6 months. For both groups, degree of diplopia, enophthalmos, ocular motility, and complications were recorded and compared. Results: Our study included 32 patients in the ETEA group and 27 patients in the MCI group. The time from trauma to surgery ranged from 10 to 48 days. The herniated orbital contents were completely reduced in 96.9% (31/32) of the ETEA group and in 77.8% (21/27) of the MCI group (P = 0.040). At the 6-month review, the success rate of enophthalmos correction in the ETEA group achieved 96% (24/25), higher than that in the MCI group (66.7%, 12/18; P = 0.015). The improvement of the enophthalmos was better in the ETEA group than in the MCI group (4.5 ± 0.7 mm versus 3.2 ± 1.2 mm) at 6 months (P = 0.000). We found no difference in the resolution rate of diplopia within a 30-degree visual field or extraocular muscle function between the 2 groups. Complications in the MCI group included 1 patient with optic neuropathy after the procedure and 4 patients with medial canthal webbing. Conclusions: Endoscopic transethmoidal approach combined with TIFA is a promising technique for repairing extensive COF-MWBOFs.

We report a case of an orbital fracture and an eyeball rupture caused by a golf-club injury. A 75-year-old man was struck in his right eye by a golf club while watching behind his son swinging a hybrid-type golf club at his home. A 70-mm muscle-depth laceration was present in the infraorbital area with active bleeding. Computed tomographic imaging of the face revealed a rupture of the right eyeball; fractures in the superior, medial, lateral, and inferior wall of the right orbit; a fracture in the right zygomaticofrontal junction; and a small amount of pneumocephalus in the parafalx region. Under general anesthesia, evisceration of the right eyeball was performed. Not only golfers but also people just watching or passing by can be injured by an errantly struck golf ball or swung golf club. Elderly people as well as children should be instructed in technique and safety and also be supervised when playing golf. Also, the public should be educated about the risk of eye injuries and the benefits of wearing a protective eyewear.

Orbital fractures are frequently observed in maxillofacial trauma and can cause a wide range of functional impairments and esthetic deformities. Many approaches have been used for the repair of medial orbital wall fractures. It has been necessary to use grafts or splints in these approaches. We introduced a new technique to treat our patient with diplopia that resulted from a medial orbital fracture. In this new method that involves rotational repositioning of the fractured segment, there is no need for a graft from another location or synthetic material. This technique has several advantages compared with using synthetic materials or other types of autogenous grafts. However, the limitation of this method is that our technique cannot be applied to all cases of medial orbital wall fracture.

Reconstruction of the fractured orbit serves to prevent functional and aesthetic posttraumatic sequels. In 2004, the surgical protocol at our unit was modified with respect to techniques for surgical access, types, and materials for reconstruction. The modifications were as follows: (a) introduction of medial orbital wall reconstructions through a bicoronal approach, (b) transconjunctival approach instead of the subciliary approach, and (c) porous polyethylene or porous polyethylene-titanium instead of autologous bone grafts. To evaluate the different surgical techniques and materials used, orbital reconstructions performed at our unit from 2000 to 2007 were retrospectively studied. In total, 177 primary or first-time secondary reconstructions were performed in 176 patients. The overall rate of early complications requiring medical or surgical intervention was 6.4%, and the reoperation rate was 3.4%. There were no statistically significant differences in the frequency of cicatricial eyelid complications between the subciliary and the transconjunctival approaches. There was a reduction in operative time with the use of implants compared with the use of bone. The overall rate of infections was 2%; however, there were no infections in the group treated with implants. Seven patients had secondary surgery for persistent enophthalmos, 4 of them due to defects in the medial orbital wall that had not been corrected at the time of primary reconstruction of the orbital floor. In conclusion, porous polyethylene/porous polyethylene-titanium is a safe material for orbital reconstructions. Reconstruction of the medial orbital wall is important to prevent posttraumatic enophthalmos, particularly in combined medial wall-orbital floor fractures.

BACKGROUND The mechanism of injury, the clinical presentation, the natural history, and the indications for the treatment of orbital fractures in the pediatric population are less well described than they are in adults. The purpose of this study was to describe the specific characteristics and management of trapdoor fractures of the orbital floor in the pediatric population. METHODS We enrolled 18 pediatric patients younger than 13 years who underwent endoscopic reconstruction of trapdoor fractures of the orbital floor between March 2000 and October 2006 at the Gil Medical Center and the Ansan Hospital, Korea University. Causes, locations, and clinical characteristics such as restriction of extraocular muscle movement were reviewed retrospectively. RESULTS Ten of 18 patients (55.6%) exhibited nausea and vomiting, which rapidly resolved after surgery. Surgery was undertaken within 2 weeks after injury (82.3%), and most of the extraocular muscle movement restrictions improved within 2 months postoperatively. Temporary postoperative hypertropia occurred in 5 floor fractures (5/16, 31.2%). CONCLUSIONS Trapdoor fractures of the orbital floor revealed a high incidence of persistent diplopia associated with extraocular muscle and soft tissue entrapment in the pediatric population, but actual entrapment of the muscle belly was confirmed in only 27.8% of patients endoscopically. Temporary hypertropia (31.2%) occurred in trapdoor fractures of the orbital floor but improved after 2 months of follow-up in every patient. Marked motility restriction and nausea/vomiting are predictive of trapdoor fractures. Prompt surgical intervention is needed in patients with such symptoms.

The aim of this study was to prospectively evaluate the accuracy and predictability of new three-dimensionally preformed AO titanium mesh plates for posttraumatic orbital wall reconstruction.We analyzed the preoperative and postoperative clinical and radiologic data of 10 patients with isolated blow-out orbital fractures. Fracture locations were as follows: floor (N = 7; 70%), medial wall (N = 1; 1%), and floor/medial wall (N = 2; 2%). The floor fractures were exposed by a standard transconjunctival approach, whereas a combined transcaruncular transconjunctival approach was used in patients with medial wall fractures. A three-dimensional preformed AO titanium mesh plate (0.4 mm in thickness) was selected according to the size of the defect previously measured on the preoperative computed tomographic (CT) scan examination and fixed at the inferior orbital rim with 1 or 2 screws. The accuracy of plate positioning of the reconstructed orbit was assessed on the postoperative CT scan. Coronal CT scan slices were used to measure bony orbital volume using OsiriX Medical Image software. Reconstructed versus uninjured orbital volume were statistically correlated.Nine patients (90%) had a successful treatment outcome without complications. One patient (10%) developed a mechanical limitation of upward gaze with a resulting handicapping diplopia requiring hardware removal. Postoperative orbital CT scan showed an anatomic three-dimensional placement of the orbital mesh plates in all of the patients. Volume data of the reconstructed orbit fitted that of the contralateral uninjured orbit with accuracy to within 2.5 cm(3). There was no significant difference in volume between the reconstructed and uninjured orbits.This preliminary study has demonstrated that three-dimensionally preformed AO titanium mesh plates for posttraumatic orbital wall reconstruction results in (1) a high rate of success with an acceptable rate of major clinical complications (10%) and (2) an anatomic restoration of the bony orbital contour and volume that closely approximates that of the contralateral uninjured orbit.

Often, complex, optimal management of the orbital fracture is directly dependent on thorough initial evaluation, correct injury assessment, and timely initiation of chosen therapy. Most often, secondary to assault or motor vehicle collision, these fractures are frequently associated with additional traumatic injury. With recent advances in imaging, alloplastic materials, and bone fixation technology, the evolution of orbital fracture management now enables reconstruction of even the most severe injuries.

Trauma is the fourth major cause of mortality in the Western countries, of which approximately one half involve maxillofacial injury. Statistics reported by emergency room officials show motor vehicles cause many of the injuries and deaths that occur in Iran. Having completed a retrospective descriptive study of 200 patients who experienced maxillofacial trauma, the authors report its occurrence with respect to age, sex, trauma type, and site of injury so as to evaluate the operational functionality of the Department of Otolaryngology and Head & Neck Surgery of Hazrat-e Rasoul Akram Hospital from 2000 to 2004. Mandibular fractures (36.2%) occurred in the subsequently listed sites and at the specified frequencies: mandibular angle (9.7%), mandible body (6.9%), parasymphysis, ramus and subcondyle at 5.6% each, and symphysis at 2.8%. No condylar fractures were reported. Frontal bone fracture was observed in 9.7% of the patients with eye globe injury occurring simultaneously in 8.3% of corresponding cases. Orbital fracture (63.9%) also occurred in various cases as follows: orbital floor 39%, lateral rim 24%, inferior rim 22%, medial wall 11%, and the superior rim and orbital roof at 2% each. Motor vehicle accidents were the most common causes of trauma (42%). The most common fracture was in the zygoma (43%) with 8.3% of them being orbital injury. Fractures of mandibular bones (36.2%) and the maxilla (33%) were the most commonly seen in trauma occurring to the maxillomandibular region.

The orbit is located in the middle third of the face, composed of several bones and surrounded by complex anatomic structures so that orbital fractures (OF) often involve other parts of the face. A staging system for classifying OF is of paramount importance in order to exchange information between trauma centers. Several classifications have been proposed for describing OF but they have not a single method applicable to the whole orbit. Here, a classification for OF that can be summarized with four abbreviations is proposed. Four letters define the localization (F = frontal, N = nasal, M = maxillary and Z = zygomatic bone fracture), two acronyms describe fragment shift (in = blow-in or out = blow-out), four numbers define ocular movement impairment (1 = superior, 2 = internal, 3 = inferior, and 4 = external extrinsic muscular deficit) and two acronyms describe eye position (EX = exophthalmos and ENO = enophthalmos). To evaluate the suitability of the proposed classification a retrospective study on a series of 190 OFs is performed. Age, gender, new stage, clinical diagnosis at admission, type of surgery, and need for graft for orbital reconstruction are considered. A good correlation between the proposed classification and the studied variables is detected. In conclusion, the proposed classification is a simply and precise method to stage OF. It can summarize OF and be used in the daily practice. However, it is our belief that a multi-center study should be performed before the effectiveness of the proposed classification can be clearly stated.