Orbital anatomy and trauma /certified fixed orthodontic courses by Indian dental academy

ORBITAL FRACTURE
INDIAN DENTAL ACADEMY
Leader in continuing dental education
www.indiandentalacademy.com


INTRODUCTION



The importance of orbit is to protect vital
structures by allowing fractures to occur.
Because the globe is surrounded by fat and the
medial wall and floor of the orbit are thin, force
that is transmitted to the globe allows fracture of
the orbit without significant globe injury. This
accounts for the significantly higher incidence of
fractures of the orbit as compared to open globe
injuries.

AIM





To manage trauma or any injury to the
orbital region both functionally and
esthetically.
To correct diplopia and enopthalmos.
To know proper anatomy so that
structures related to this area can be
restored back to there anatomical position.


CLASSIFICATION OF ORBITAL
FRACTURES
I. ISOLATED FRACTURES OF ORBIATL RIM:

SUPERIOR
 INFERIOR
 LATERAL
 MEDIAL
II. ISOLATED FRACTURE OF ORBITAL WALLS:
 ROOF
 FLOOR
 MEDIAL
 LATERAL



III. ORBITAL WALL FRACTURES:
1. BLOW OUT FRACTURE:
 pure blow out fracture
 impure blow out fracture
2. BLOW IN FRACTURE


PATHOPHYSIOLOGY
Bone conduction theory “buckling
“
 Less energy
 Small fractures limited anterior
floor
Hydraulic theory
 More energy
 Larger fracture involving entire
floor and medial wallentire wall
 Should suspect more
extensive orbit involvement
with associated injuries (globe
rupture)(rupture)

CLINICAL DIAGNOSIS
BASED ON AREA INVOLVED

:

PERIORBITAL TISSUES:

OEDEMA

SUBCONJUNCTIVAL HEMORRHAGE

CIRCUMORBITAL ECCHYMOSIS

SURGICAL EMPHYSEMA
EYELIDS:

ABNORMALITY OF PALPEBRAL FISSURE

PTOSIS

PSEUDOPTOSIS
LIGAMENTS:

ANTIMONGOLOID SLANT

MONGOLOID SLANT

TELECANTHUS
EYE:

PRESERVATION OF VISION

LIMITATION OF OCCULAR MOVEMENTS

DIPLOPIA

ENOPTHALMOS
LACRIMAL APPARATUS:

EPIPHORA
NEUROLOGICAL DEFICITS:

PARESTHESIA .

BASED ON TIMING:
Early features:
 Limitation of elevation of eye.
 Paresthesia of infra orbital nerve.
 Alteration of ocular level.
Late features(after 7 to 10 days):
 Diplopia
 Lowering of ocular level
 Enopthalmos
 Deepening of supratarsal fold.
 Narrowing of palpebral fissure


INVESTIGATIONS
RADIOGRAPHIC FINDINGS:

PLAIN RADIOGRAPHY.

WATERS PROJECTION.
C.T SCAN &MRI:

Coronal scanning

Axial scanning

Saggital scanning
MRI used for assessment of soft tissue
displacement

SPECIAL
TESTS
FORCED
DUCTION
TEST
/TRACTION
TEST
ELECTROMY
OGRAPHYdone by
opthalmologist.
ORBITOGRAP www.indiandentalacademy.com

OPTHALMOLOGIC
EVALUATION







Periorbital examination
Visual acuity
Pupillary size and shape
Ocular motility
Fundoscopic examination
Hyphema

DIPLOPIA
Two images of same object
Monocular diplopia
Binocular diplopia
CAUSES:
EDEMA/HEMATOMA
RESTRICTED

MOTILITY
NEUROGENIC
INJURY
EVALUATION:
Testing ductions
Forced duction test
Electromyography
Corneal light reflex

MANAGEMENT
TWO APPRACHES:

CONSERVATIVE APPROACH

SURGICAL APPROACH


MANAGEMENT
CONSERVATIVE APPRACH:
 Several authors have put forward there
concepts whether to observe or to do
some early treatment or wait for some
time to carry on some surgical procedure.


MANAGEMENT
OBSERVATION:

minimal diplopia

good ocular motility

no signs of enopthalmos
EARLY INTERVENTION:(WITHIN TWO WEEKS)

early enopthalmos causing facial asymmetry

white eyed floor fracture (children)
LATE INTERVENTION:(AFTER TWO WEEKS)

symptomatic diplopia with positive forced duction test

late enopthalmos

progressive infra orbital hypoesthesia


Orbital Floor


When to explore? (Shumrick study)








Persistent diplopia with positive forced duction
Obvious enophthalmos
Comminuted orbital rim by CT
>50% floor disruption by CT
Combined floor/medial wall defects by CT
Fracture of zygoma body by CT
“Blow-in” fx with exophthalmos by PE or CT

PUTTERMANS REVISED INDICATION:

7 days of systemic corticosteroids for the
resolution of the diplopia within first 3 weeks.
 Hawer & Dartzbach evaluated size of orbital floor
defects &felt that fracture involving more than half
the floor should be reconstructed within first 2
weeks to avoid enopthalmos
 Hertel exopthalmometry(enopthalmos):alignin the
ruler through both the medial canthi &noting where
the ruler bisects each eye.

CONTRAVERSIES:
 Oedema
 Diplopia may resolve rapidly after injury
has settled.
 Motility problems if not treated
immediately.
 Asymptomatic patient may develop
diplopia or enopthalmos if not treated

TRAP DOOR FRACTURES:(mechanical
incarceration of the extra ocular muscle):
 This can be diagnosed by CT & by forced
duction test.
Timing of repair:
 children: within 5 days produces better
results
 adults: no specific time period. But treated
after 14 days has good long period results.

SURGICAL MANAGEMENT:
 Crikelair & co workers said….in case of
persistent diplopia or enopthalmos after 2
weeks –surgical repairing of orbital
fractures is needed.
 Persistent diplopia for 4 months following
trauma-contralateral eye muscle surgery
or contralateral fat resection to mask
enopthalmos.

Depending on the area & extent &also
aesthetic consideration the following
incisions are given for the particular area..
ORBITAL FLOOR:
 SUBCILIARY INCISION.
 TRANSCONJUNCTIVAL INCISION
 SUB TARSAL INCISION



SUBCILIARY APPROACH


SUBTARSAL APPROACH


SUBCILIARY &SUBTARSAL INCISION:
ADVANTAGES:
 Easy &quick to do
 In case of edema also estimation of giving incision
can easily be made
 Scar inversion is greatly diminished.
DISADVANTAGES:
 Vertical lid shortening
 Increased incidence of impairments with subciliary
incision.

TRANSCONJUCTIVAL
APPROACH


TRANSCONJUNCTIVAL
INCISION
:

Advantages:

Excellent aesthetics results.
 Quick to do.
 No skin muscle disssection
 Low incidence of ectropian.
 Scar can be seen only b cos of lateral extension which heals
rapidly.
Disadvantages:
 Limitation of access
 Medial extent can be limited.



ORBITAL ROOF & LATERAL WALL:

EYE BROW INCISION

UPPER BLEPHAROPLASTY INCISION

BI CORONAL INCISION

LATERAL CANTHOTOMY INCISION.


EYEBROW INCISION


UPPER BHLEPHAROPLASTY
INCISION


BICORONAL INCISION


LATERAL
CANTHOTOMY&CANTHOLYSI
S


MEDIAL ORBITAL APPROACH:

CORONAL INCISION

LATERAL NASAL INCISION

TRANSCONJUNCTIVAL APPROACH

SUB CILIARY INCISION


MATERIALS FOR
RECOSTRUCTION
FUNCTIONS:
 To seal off antral cavity from orbit
 To provide a physiologically acceptable &physically inert
smooth surface.
 Restore the contour &dimension of the orbit
 To provide some indirect support for the globe
IDEAL REQUISITES:
 Easy to mould
 Easy to fixate
 Biocompatible
 Strong & readily available.


MATERIALS FOR
RECOSTRUCTION
GRAFTS
 AUTOGRAFTS(BONE OR CARTILAGE)
 HOMOGRAFTS(LYOPHILISED
DURAMATER)
 ALLELOGRAFTS(TEFLON OR
SILASTIC)


Orbital Floor
Bone Grafting


Need to
support
floor full 4
cm


AUTOGRAFTS:













antral wall
septal cartilage
cancellous bone from mastoid
calvarial bone
inner plate of ileum.
8 ,9,&10 ribs at costosternal junction (children)
TO SECURE THE GRAFT:
soft stainless steel wire
microplate or miniplate
titanium mesh
ADVANTAGE: high tissue compatibility
DISADVANTAGE: second surgical procedure.









HOMOGRAFTS:
disadvantages :
greater susseptibility to infection
increased rate of resorption.
Lyophilised human dura-commonly
used,gets absorbed &replaced by fibrous
tissue
available in pre sterilised packets.

IMPLANTS:
RESORBABLE
NON RESORBABLE IMPLANTS.
resorbable implants:
polydiaxane
polylactides
non resorbable implants:
titanium
silicone
polyethylene
teflon
ADVANTAGES:
second operation to harvest bone is
not necessary
DISADVANTAGES:
materials become fibrotically
encapsulated causing infection

COMPLICATIONS
HEMORRHAGE /ORBITAL HEMATOMA
RETROBULBAR HEMMORHAGE
BLINDNESS
DIPLOPIA
SUPERIOR ORBITAL FISSURE
SYNDROME
ORBITAL APEX SYNDROME
CARATICO CAVERNOUS FISTULA

ORBITAL HEMATOMA &ITS
TREATMENT


RETROBULBAR
HEMORRHAGE


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