Review

Craniomaxillofacial Trauma &

Reconstruction
1-9
Controversies and Contemporary ª The Author(s) 2021
Article reuse guidelines:
Management of Orbital Floor Fractures sagepub.com/journals-permissions
DOI: 10.1177/19433875211026430
journals.sagepub.com/home/cmt

Shivam Patel, BS1 , Tom Shokri, MD2, Kasra Ziai, MD1,

and Jessyka G. Lighthall, MD3

Abstract
Substantial controversy exists regarding the timing of intervention and management of patients with orbital floor
fractures. Recent advances in computer-aided technology, including the use of 3-dimensional printing, intraoperative
navigational imaging, and the use of novel implants, have allowed for improvement in prospective management modalities.
As such, this article aims to review the indications and timing of repair, surgical approaches, materials used for repair, and
contemporary adjuncts to repair. Indications for orbital floor fracture repair remain controversial as many of these
fractures heal without intervention or adverse sequelae. Intraoperative navigation and imaging, as well as endoscopic
guidance, can improve visualization of defects mitigating implant positioning errors, thereby reducing the need for sec-
ondary corrective procedures. Patient-specific implants may be constructed to fit the individual patient’s anatomy using
the preoperative CT dataset and mirroring the contralateral unaffected side and have been shown to improve
pre-operative efficiency and minimize postoperative complications. With increased data, we can hope to form
evidence-based indications for using particular biomaterials and the criteria for orbital defect characteristics, which may be
best addressed by a specific surgical approach.

Keywords
intraoperative imaging, implant, orbital floor fracture, virtual surgical planning, intraoperative, navigation

Introduction terms. Articles not written in the English language were

excluded.
Orbital floor fractures are a common outcome of trauma
sustained to the midface. They are most commonly seen in
the first 30 years of life.1-4 The complex anatomy and Results
proximity to vital structures present a reconstructive chal- Indications and Timing of Repair
lenge to the surgeon. Furthermore, the approach to the
management of these fractures is a source of continued Indications for orbital floor fracture repair remain contro-
controversy. Recent advances in computer-aided technol- versial as many of these fractures heal without intervention
ogy, including 3-dimensional printing, implementation of or adverse sequelae. Putterman et al 2 recommended
planning software, intraoperative navigational imaging,
endoscopic guidance, and novel implants, have allowed for 1
Department of Otolaryngology-Head and Neck Surgery, College of
improvement in prospective management modalities. How- Medicine, The Pennsylvania State University, Hershey, PA, USA
ever, these innovations have also spurred further delibera- 2
Department of Otolaryngology-Head and Neck Surgery, Otolaryngology
tion for the optimal approach and surgical correction of and Facial Plastic Surgery Associates, Fort Worth, TX, USA
3
these complex injuries.3,4 Facial Plastic and Reconstructive Surgery, Department of
Otolaryngology-Head and Neck Surgery, College of Medicine, The
Pennsylvania State University, Hershey, PA, USA

Methods Corresponding Author:

Jessyka G. Lighthall, MD, Facial Plastic and Reconstructive Surgery,
A Pubmed and Cochrane search was performed with no
Department of Otolaryngology-Head and Neck Surgery, College of
date restrictions for literature on management of orbital Medicine, The Pennsylvania State University, 500 University Drive,
floor fractures. The search terms used were “orbital floor H091, Hershey, PA 17033-0850, USA.
fractures,” “management,” and various combinations of the Email: [email protected]
2 Craniomaxillofacial Trauma & Reconstruction XX(X)

observation of all fractures for 4-6 months with late Children tend to have greater bone elasticity allowing
intervention if necessary for the development of enophthal- the orbital floor to bend and form a trapdoor (“white-eyed”
mos or diplopia. On the contrary, other studies noted a fracture), where a bone fragment often hinged medially is
significant increase in poor outcomes with the late repair transiently displaced inferiorly, allowing herniation of
of the fractures (>2 months).3 In 2002, Burnstine4 pub- orbital contents into the maxillary sinus, thereby
lished recommendations for repair, which are widely resulting in entrapment as the fragment returns to its prior
employed by reconstructive surgeons but are primarily position.7,14,15 The blood flow to the entrapped tissue is
based on expert opinion. Despite these recommendations, compromised, resulting in muscle or fat ischemia, fibrosis,
there is still no consensus about which patients would ben- and diplopia. In contrast, adult patients have more brittle
efit from surgical intervention, nor is there agreement about bones, which are more likely to break, resulting in tissue
when the repair should be performed. Nevertheless, in all prolapse and an increase in orbital volume, which place the
cases, a thorough history, clinical exam, and review of patient at risk for the development of enophthalmos hypo-
imaging are required to identify patients that may warrant globus, and diplopia.
urgent surgical exploration. In an attempt to better stratify patients, investigators
Urgent surgical repair is described as operative interven- have attempted to establish parameters to predict patients
tions in the first 24-48 hours after injury. Immediate inter- at high risk of late complications that may benefit from
vention should be considered for early enophthalmos and earlier intervention. These studies are largely based on
hypoglobus, diplopia with evidence of muscle entrapment, CT findings evaluating the size (area) of the floor defect,
hemorrhage, non-resolving oculocardiac reflex, and the calculated change in orbital volume, or the degree of
white-eyed blowout fractures in patients <18 years old soft tissue herniation. Conventionally, defect size has been
(restriction of ocular mobility, entrapped soft tissue on used as an indication for surgical repair, with fractures
imaging, and minimal periorbital ecchymosis or edema larger than 2 cm2 or defects greater than 50% of the orbital
on the exam).4 The oculocardiac reflex (OCR), though rare, floor being the standard criteria for intervention.3,16 Nota-
bly, studies have found that as little as a 5% increase in total
results from pressure on the globe due to entrapped peri-
orbital volume (*1.25 mL) is a predictor of clinically
orbital soft tissues and subsequent increase in efferent
significant enophthalmos (>2 mm)16-19 while others note
vagal tone causing syncope, bradycardia, potential heart
that volume changes up to 1.5-2 mL or more can be
block, nausea, and vomiting. The incidence of OCR varies
observed.16,20,21 Also, a linear association between an
widely in the literature depending on the clinical scenario,
increase in orbital volume and enophthalmos has been
with a reported fatality risk of 1 in 3,500 cases.5 Therefore,
demonstrated.22
an immediate surgical exploration is indicated to prevent
Despite the criteria for early surgical intervention men-
fatal cardiac arrhythmia.5,6 Immediate repair has been
tioned above, 7-10% of patients treated nonoperatively
shown to improve ocular motility in patients with signs
develop late enophthalmos.3,23 Late correction of estab-
of muscle entrapment due to the prevention of ischemic lished enophthalmos has been associated with poor func-
necrosis, resultant fibrosis, and strabismus. Delayed treat- tional and cosmetic results due to fat atrophy and orbital fat
ment of muscle entrapment has been shown to correlate scarring to the maxillary antrum.3,24 However, in a study by
with a higher incidence of persistent postoperative diplo- Chen et al,25 authors conducted a study to evaluate the
pia. 7-9 Several studies have shown that repair within long-term enophthalmos outcomes following surgical man-
48 hours of injury significantly reduces this risk.4,10-13 agement of different types of orbital fractures at various
Except for cases requiring urgent intervention, substan- time intervals (<2 weeks, 2-4 weeks, and >4 weeks). The
tial controversy exists regarding the timing of treatment authors found no statistically significant differences in the
and identification of patients requiring surgical correction enophthalmos improvement rates with surgical interven-
rather than observation. Bansagi and Meyer10 evaluated tion at these various time intervals.
34 patients <18 years old with orbital floor fractures and Diplopia secondary to muscle contusion or edema is also
found that early surgical intervention, defined as less than common after orbital injury and should continue to
2 weeks, resulted in a complete return of ocular motility improve 2 weeks after injury. Patients with persistent diplo-
compared with late intervention groups. Egbert et al11 pia associated with evidence of soft-tissue entrapment on
observed a median time for improvement of preoperative computed tomographic (CT) imaging or positive forced
duction deficits of 4 days for patients who underwent sur- duction test require surgical exploration and possible
gery within 7 days of the initial injury and 10.5 days for repair.4 A study by Hawes and Dortzbach3 showed a cor-
those who underwent repair after 14 days (P ¼ 0.030). relation between the time of repair and increased post-
However, the timing of surgery did not affect the complete operative diplopia. Authors found 38% of patients
resolution of duction deficits or diplopia. Therefore, the undergoing surgery 2 months or longer after injury experi-
authors concluded that early surgical repair resulted in enced persistent diplopia compared to only 7% who had
more rapid improvement than a conservative delayed surgery within 2 months. Similarly, Yu et al26 evaluated the
approach.11 impact of fracture type and timing of surgical intervention
Patel et al. 3

reconstitute orbital volume allowing for the resolution of

symptoms and intact vision. Patients that do not present
with findings necessitating immediate intervention are
routinely seen at a 2-week follow-up, at which time they
are evaluated for unresolved or progressive symptoms such
as infraorbital nerve hypoesthesia, diplopia, delayed
enophthalmos, change in visual acuity, or hypoglobus. The
development of these signs within the first 5-6 weeks after
an injury should be considered a strong relative indication
for surgery.31 Progressive hypoesthesia of the V2 distribu-
tion of the infraorbital nerve has been demonstrated as a
relative indication for surgical repair in patients with orbital
floor fracture.32,33

Approach
The controversy surrounding the management of orbital
Figure 1. Preoperative coronal soft tissue view of the orbital floor fractures extends to the surgical approach as well.
floor and medial wall fracture with inferior rectus (IR) muscle Unfortunately, there is still an insufficient level of evidence
herniation. Shape of the inferior rectus muscle has been shown to coupled with an inconsistency in outcome measures
be a better predictor of late enophthalmos.
that has resulted in difficulty establishing a definitive
evidence-based approach. Traditionally, external transorbi-
on diplopia outcomes and demonstrated that patients tal approaches have been used to repair orbital fractures,
treated within 2 weeks of orbital injury exhibit a higher which provide exposure of the orbital floor and inferior
rate of diplopia resolution compared to those treated orbital rim by one of several incisions: subciliary, subtarsal,
between 2-4 and more than 4 weeks. transconjunctival, or transcaruncular.
Several studies have described rounding of the inferior The subciliary incision has been associated with a higher
rectus (IR) muscle as a relative indication for operative risk of cicatricial ectropion and may lead to significant
management. Matic and colleagues 27 found that a scarring.34 The subtarsal incision is generally considered
height-to-width ratio >1 in the inferior rectus muscle is the least technically demanding and provides the most
predictive of late enophthalmos but not persistent diplopia direct access to the orbital rim and floor but has been noted
(Figure 1). The authors postulate that the shape of the to leave substantial visible scarring.35-37 This remains a
inferior rectus muscle may be a better predictor of point of contention, as prior studies had shown that a
post-traumatic enophthalmos than orbital floor defect size subtarsal incision within a skin crease of the lower lid
or orbital volume measurements as these values are only produced a superior aesthetic result compared to the
reflective of the status of osseous support while the former options mentioned above. 38,39 The transconjunctival
is representative of both bony and soft-tissue support.27,28 approach is the most extensively investigated method. This
A recent retrospective study by Gabrick et al29 correlated approach avoids scar formation and risk of ectropion; how-
radiographic features of non-surgically managed orbital ever, it is technically more advanced and does come with a
floor fractures with long-term patient-reported outcome risk of entropion. Complication rates in one meta-analysis
measures (FACE-Q). They found a significant association were found to be the highest in the subciliary approach
between rounding the IR muscle and the appearance- (19.1%) followed by the subtarsal approach (9.7%), and
related psychosocial distress (P ¼ 0.006). This factor the lowest rate of complications was with transconjunctival
should be considered when making decisions regarding the access (2.1%).40
repair of orbital floor fractures. An alternative method to orbital floor management is a
transantral approach under endoscopic guidance that is
well-described in the literature.41,42 This approach has been
Delayed Repair associated with minor complications such as transient
Proponents of the delayed approach to the treatment of infraorbital hypoesthesia or anesthesia; however, it allows
orbital fractures suggest that this allows for the resolution successful reconstruction of orbital floor defects while
of traumatic edema before the repair allowing for proper minimizing manipulation of the globe and eliminating a
identification of enophthalmos not initially appreciated lower eyelid incision. The transantral endoscopic approach
on the exam and facilitating surgical exposure.30 The has also shown efficacy in repairing complex orbital
goal of orbital fracture repair is not to achieve bone healing fractures beyond an isolated floor fracture.42 Certainly, a
or prevent malunion like other fracture repairs but to surgeon’s familiarity with a particular technique and the
4 Craniomaxillofacial Trauma & Reconstruction XX(X)

facial reconstruction.50 Autologous cartilaginous grafts

have also been shown to have utility in orbital reconstruc-
tion due to their ease of harvesting, malleability, reliable
support without resorption, and fewer postoperative
complications.51,52 The primary sources for cartilaginous
grafting are auricular concha, rib, and nasal septum.53
Cartilage grafts are unique in that they have low anaerobic
metabolism and are relatively avascular, which is thought
to improve graft viability and reduce resorption rates
compared to bone grafts.51

Allografts and Xenografts

Allografts used to reconstruct orbital floor fractures include
lyophilized dura mater (LyoDura) and banked deminera-
Figure 2. Sagittal view of a normal orbital floor in an S-shape
configuration. lized human bone (DHB). Lyodura is digested by macro-
phages and eventually replaced with endogenous
collagenous connective tissue post-operatively.54 Allo-
patient’s distinct presentation are important factors in
genic human or animal dura grafts undergo sterilization
decision-making regarding the most appropriate approach.
to decrease disease transmission; however, evidence in the
literature has demonstrated that allografts are associated
Reconstruction of the Orbital Floor—Orbital Implants with increased donor-to-patient disease transmission
Many materials have been described in the literature for risks.55-57 DHB grafts are produced in biocompatible,
orbital floor repair and may be divided into biological or resorbable sheets and are both osteoconductive and
alloplastic composition. The findings in the literature have osteoinductive due to their ability to provide type 1 col-
been inconsistent and are largely retrospective case series lagen; however, the utility of DHB implants in orbital floor
with limited subjects without conclusive data.43-45 Addi- reconstruction remains undetermined. Sallam Ahmed
tionally, individual surgeon preferences vary on the type et al58 demonstrated that DHB sheets used in the setting
of orbital implant.46 The choice of material is dependent on of enophthalmos provided inadequate structural support
biocompatibility instead of the strength of graft material.47 and were an insufficient form of repair due to an elevated
Biological materials offer several potential advantages, rate of resorption of DHB compared to the autologous
including improved biocompatibility but are limited by bone.
their donor site morbidity.48,49 Synthetic, or alloplastic
grafts, have been associated with higher rates of complica- Alloplastic Implants
tions in the literature, including infection and extrusion of
the material, but have the advantage of being readily Alloplasts can be subdivided into resorbable and
obtainable, avoiding donor site complications.50 Generally, non-resorbable plates. Resorbable alloplastic grafts include
rates of complications remain low and are attributed to the polymers composed of poly-L-lactic acid, polydioxanone,
state of the orbital soft tissue at the time of repair. Regard- polyglycolic acid, or composite polymers.55,59-63 These
less of the type of implant chosen, key factors to consider materials have been associated with delayed enophthalmos
include assuring implants are placed on stable bony ledges, and severe inflammatory reactions resulting in ocular mus-
normal orbital volume is restored, soft-tissue contents are cle adhesions and diplopia. Resorbable grafts provide tem-
adequately reduced, and the normal orbital floor shape is porary support and are replaced by fibrous granulation
restored. Rather than being a straight line and conical, the tissue as the material degrades, thereby providing resis-
anatomic orbital floor is S-shaped (Figure 2). tance against herniation forces during the initial healing
phase and maintaining orbital contents.55,60,61
Permanent, non-resorbable, alloplastic implants offer a
Biological Materials longer-term rigid option for reconstruction and are com-
Autologous bone grafts have historically been considered monly used in orbital floor fracture repair but have higher
the “gold standard” for orbital floor reconstruction as they risks of implant-associated infections. Porous polyethylene
offer both short and long-term viability by providing rigid- is malleable while also allowing rigid fixation and vascular
ity, molding capacity, minimal immune reactivity, vascu- ingrowth due to open pore structure. However, if placed in
larity, and biocompatibility.45 Calvarial bone grafts can be close proximity to extraocular muscles, it may form adhe-
used as full-thickness, split-thickness, bone chips, bone sions.64-68 Titanium mesh implants are easily contoured
shavings, and dust.44 The parietal bone has been described and biocompatible but may be difficult to position in deep
as being the most suitable, with regard to shape, for use in orbital fractures and have also been shown to be associated
Patel et al. 5

with fibrosis, scar formation, and orbital adherence decrease in implant placement variation between the pre-
syndrome.68-70 A systematic review by Avashia et al43 operative and actual reconstructions. Postoperative
evaluated implant material for orbital reconstruction, follow-up also showed significantly fewer ophthalmologic
concluding that the evidence supporting one material’s complications in the group with navigation, including
superiority over another is inadequate. Therefore, the diplopia, infraorbital hypoesthesia, ophthalmoplegia, and
surgeon must rely on his or her operative expertise in con- enophthalmos. In another study by Essig et al,77 the authors
junction with the implant type’s unique characteristics to evaluated the quality of orbital reconstruction in 94 patients.
develop an individualized surgical approach that fits the Of those reconstructed using intraoperative navigation,
patient’s specific needs. implant position was accurate within 1 millimeter of the
contralateral unaffected orbit used for preoperative model-
ing with virtual surgical planning. The deviation between
Contemporary Adjuncts to Repair: Virtual Surgical
the reconstructed defect and preoperative virtual planning
Planning, Intra-Operative Imaging, and Navigation was maximal when defects were in the orbital floor’s ante-
Intra-operative navigation using preoperative imaging can rior third. When comparing navigation-assisted surgery
improve visualization of defects mitigating implant posi- versus conventional surgery in patients with complex orbi-
tioning errors, thereby reducing the need for secondary tal floor fractures, a statistically significant reduction was
corrective procedures.69-72 This modality is beneficial in only achieved using navigation.
orbital fractures involving the junction of the orbital floor Another useful adjunct that may decrease the need for
and medial wall or complete separation of the floor, where navigation and repeat imaging is endoscopic-assisted sur-
standard transconjunctival approaches may not provide gery. The standard 2.9 or 4 mm 30-degree scopes may be
adequate exposure and result in misplacement of recon- used to identify walls and confirm adequate soft-tissue
structive implants requiring repeat surgery.73 reduction and implant placement. Endoscopic guidance
Intraoperative CT scanning is also emerging as a bene- may be used transorbitally (through lid incision), transna-
ficial adjunct to improve patient outcomes. A study by sally, or transantrally. A novel study investigated orbital
Shaye et al74 reviewed 38 facial reconstructive procedures floor reconstruction performed via transantral endoscopy
that implemented intra-operative CT using parameters with the aid of virtual reality surgical planning
including fracture complexity, procedure type, scan time, and 3D-printed surgical guides.78 The authors recruited
and subsequent revision rate. Notably, the average total 14 patients with orbital floor fractures and obtained
scan time was approximately 14.5 minutes and did not high-resolution CT images where a virtual 3D reconstruc-
show significant variability based on the procedure’s com- tion of the defect was developed for intraoperative gui-
plexity. Immediate revision or implant position was dance. Their preliminary results from postoperative CT
required in 24% of patients (9 total, 8 of which were scans showed a complete floor reconstruction resulting in
defined as complex). Therefore, the authors concluded that the restoration of the correct globe position, barring any
intraoperative imaging is an expeditious and reliable complications.
adjunct in reconstructive surgery and may be particularly
useful in confirming optimal results in complex cases that
would otherwise require secondary procedures for implant
Three-Dimensional Printing and Implant Contouring
repositioning. Three-dimensional printing has increasingly gained popu-
Although intraoperative CT is useful, it still requires larity by surgeons for presurgical planning and
repeated imaging after each corrective measure, increasing intra-operative guidance. Computer-aided design and
radiation exposure. However, final postoperative confirma- printing (CAD-CAM) are used to fabricate rapid prototypes
tive imaging is not needed. Intraoperative navigation, using using the following techniques: stereolithography using
optical systems wherein infrared cameras detect light photocurable resin, selective laser sintering (fusion of poly-
waves emitted by light-emitting diodes (LED) mounted mers such as polystyrene or titanium), and fused deposition
on the patient’s head, have no additional radiation expo- modeling employing the extrusion of thermoplastic mate-
sure, and allow the surgeon to orient without interrupting rials. Stereolithographic (SLA) models have been shown,
the procedure. Additionally, this technique allows for more although anecdotally, to increase predictability in post-
detailed visualization of the bony structures and soft operative outcomes and decrease operating times compared
tissue.75 to treatments without the use of these models.79
Cai et al76 evaluated 58 patients with orbital trauma in a Three widely used implant contouring techniques
prospective matched-controlled trial who underwent orbital include template contouring using an SLA model, pre-
reconstruction. Half of these patients (n ¼ 28) were recon- formed implants, and patient-specific implants. Template
structed with the Kolibri navigation system (BrainLab, contouring can be significantly facilitated, as noted above,
Munich, Germany), while the control group (n ¼ 29) was by the fabrication of 3-dimensional rapid prototype models
reconstructed without the aid of a navigation system. The using preoperative CT datasets and 3-D printing. Titanium
navigation group displayed a statistically significant mesh can then be shaped onto the model replicating the
6 Craniomaxillofacial Trauma & Reconstruction XX(X)

Figure 3. A, Coronal view of isolated orbital floor fracture medial to the infraorbital nerve. B, Coronal view after reduction and
placement of an anatomical 3-dimensional pre-bent titanium implant.

orbital contour (Figure 3). Park et al80 used this technique technologically advanced approaches, insufficiency in
on 104 patients and demonstrated accurate volume recon- the level of evidence still exists, preventing the devel-
structions with an average of <1.5 ml discrepancy from the opment of a convincing general guideline or algorithmic
planned volume and minimal complication rates. Pre- approach to reconstruction. With increased data, we can
formed implants have a standardized orbital contour based hope to form evidence-based indications for the use of
on a composite of several hundred standard CT datasets. particular biomaterials or criteria for orbital defect char-
Metzger et al81 evaluated the use of pre-bent titanium mesh acteristics, endoscopic guidance, or the use of preopera-
implants in cadaveric orbits and found that these contoured tive planning and intraoperative imaging or navigation,
implants provide accurate contours within 1 mm difference which may be best addressed by a specific surgical
for both medial and orbital floor repair. approach.
Patient-specific implants are constructed to fit the indi-
vidual patient’s anatomy using the preoperative CT dataset Author Contributions
and mirroring the contralateral unaffected side as detailed
Drs Lighthall and Patel had full access to all of the data in the
above. Gander et al82 implemented CT imaging to create a study and take responsibility for the integrity of the data and the
virtual implant using the mirrored contralateral unaffected accuracy of the data analysis. Study concept and design: Patel,
orbit template in 12 patients. They reported an efficient Shokri, and Lighthall. Acquisition, analysis, or interpretation of
preoperative planning time ranging from 30-36 minutes, data: Patel and Shokri. Drafting of the manuscript: All authors.
with implant manufacturing taking approximately 4-6 days. Critical revision of the manuscript for important intellectual con-
The authors reported correction of enophthalmos and diplo- tent: Lighthall. Administrative, technical, or material support:
pia resolution with no need for reoperation to reposition Patel and Ziai. Study supervision: Lighthall.
implants or correct ocular bulb displacement in any of the
patients. Select studies detailing contemporary manage- Declaration of Conflicting Interests
ment techniques are further presented in Online Supple- The author(s) declared no potential conflicts of interest with
mental Table 1.76,79-91 respect to the research, authorship, and/or publication of this
article.

Conclusion Ethical Publication Statement

Orbital floor fractures involve complex soft tissue and The authors confirm that they have read the Journal’s position on
bony reconstruction. Although there has been consider- issues involved in ethical publication and affirm that this report is
able progress in the diagnosis, perioperative care, and consistent with those guidelines.
Patel et al. 7

Funding 16. Manson PN, Grivas A, Rosenbaum A, Vannier M, Zinreich J,

The author(s) received no financial support for the research, Iliff N. Studies on enophthalmos: II. The measurement of
authorship, and/or publication of this article. orbital injuries and their treatment by quantitative computed
tomography. Plast Reconstr Surg. 1986;77(2):203-214.
ORCID iD 17. Bite U, Jackson IT, Forbes GS, Gehring DG. Orbital volume
Shivam Patel, BS https://orcid.org/0000-0003-2221-3675 measurements in enophthalmos using three-dimensional CT
imaging. Plast Reconstr Surg. 1985;75(4):502-508.
18. Manson PN, Iliff N. Management of blow-out fractures of the
Supplemental Material
orbital floor. II. Early repair for selected injuries. Surv
Supplemental material for this article is available online.
Ophthalmol. 1991;35(4):280-292.
19. Parsons GS, Mathog RH. Orbital wall and volume relation-
References ships. Arch Otolaryngol Head Neck Surg. 1988;114(7):
1. Smith B, Regan WF Jr. Blow-out fracture of the orbit: 743-747.
mechanism and correction of internal orbital fracture. 20. Ploder O, Klug C, Voracek M, Burggasser G, Czerny C.
Am J Ophthalmol. 1957;44(6):733-739. Evaluation of computer-based area and volume measurement
2. Putterman AM, Stevens T, Urist MJ. Nonsurgical management from coronal computed tomography scans in isolated blow-
of blow-out fractures of the orbital floor. Am J Ophthalmol. out fractures of the orbital floor. J Oral Maxillofac Surg.
1974;77(2):232-239. 2002;60(11):1267-1272.
3. Hawes MJ, Dortzbach RK. Surgery on orbital floor fractures. 21. Yab K, Tajima S, Ohba S. Displacements of eyeball in orbital
Influence of time of repair and fracture size. Ophthalmology. blowout fractures. Plast Reconstr Surg. 1997;100(6):
1983;90(9):1066-1070. 1409-1417.
4. Burnstine MA. Clinical recommendations for repair of iso- 22. Raskin EM, Millman AL, Lubkin V, della Rocca RC, Lisman
lated orbital floor fractures: an evidence-based analysis. RD, Maher EA. Prediction of late enophthalmos by volu-
Ophthalmology. 2002;109(7):1207-1210.
metric analysis of orbital fractures. Ophthal Plast Reconstr
5. Sires BS, Stanley RB Jr, Levine LM. Oculocardiac reflex
Surg. 1998;14(1):19-26.
caused by orbital floor trapdoor fracture: an indication for
23. Catone GA, Morrissette MP, Carlson ER. A retrospective
urgent repair. Arch Ophthalmol. 1998;116(7):955-956.
study of untreated orbital blow-out fractures. J Oral Maxillo-
6. Mendelblatt FI, Kirsch RE, Lemberg L. A study comparing
fac Surg. 1988;46(12):1033-1038.
methods of preventing the oculocardiac reflex. Am J
24. Dulley B, Fells P. Long-term follow-up of orbital blow-out
Ophthalmol. 1962;53:506-512.
fractures with and without surgery. Mod Probl Ophthalmol.
7. Grant JH 3rd, Patrinely JR, Weiss AH, Kierney PC, Gruss
1975;14:467-470.
JS. Trapdoor fracture of the orbit in a pediatric population.
25. Chen H-H, Pan C-H, Leow A-M, Tsay P-K, Chen C-T.
Plast Reconstr Surg. 2002;109(2):482-489.
Evolving concepts in the management of orbital fractures
8. Harley RD. Surgical management of persistent diplopia in
with enophthalmos: a retrospective comparative analysis.
blowout fractures of the orbit. Ann Ophthalmol. 1975;7(12):
Formos J Surg. 2016;49(1):1-8.
1621-1626.
26. Yu DY, Chen CH, Tsay PK, Leow AM, Pan CH, Chen CT.
9. Kushner BJ. Paresis and restriction of the inferior rectus mus-
cle after orbital floor fracture. Am J Ophthalmol. 1982;94(1): Surgical timing and fracture type on the outcome of diplopia
81-86. after orbital fracture repair. Ann Plast Surg. 2016;76(suppl 1):
10. Bansagi ZC, Meyer DR. Internal orbital fractures in the S91-S95.
pediatric age group: characterization and management. 27. Matic DB, Tse R, Banerjee A, Moore CC. Rounding of the
Ophthalmology. 2000;107(5):829-836. inferior rectus muscle as a predictor of enophthalmos in
11. Egbert JE, May K, Kersten RC, Kulwin DR. Pediatric orbital orbital floor fractures. J Craniofac Surg. 2007;18(1):127-132.
floor fracture: direct extraocular muscle involvement. 28. Banerjee A, Moore CC, Tse R, Matic D. Rounding of the
Ophthalmology. 2000;107(10):1875-1879. inferior rectus muscle as an indication of orbital floor fracture
12. Jordan DR, Allen LH, White J, Harvey J, Pashby R, Esmaeli with periorbital disruption. J Otolaryngol. 2007;36(3):
B. Intervention within days for some orbital floor fractures: 175-180.
the white-eyed blowout. Ophthal Plast Reconstr Surg. 1998; 29. Gabrick K, Smetona J, Iyengar R, et al. Radiographic predic-
14(6):379-390. tors of FACE-Q outcomes following non-operative orbital
13. Wachler BS, Holds JB. The missing muscle syndrome in floor fracture management. J Craniofac Surg. 2020;31(4):
blowout fractures: an indication for urgent surgery. Ophthal e388-e391.
Plast Reconstr Surg. 1998;14(1):17-18. 30. Cole P, Boyd V, Banerji S, Hollier LH Jr. Comprehensive
14. Holt GR, Holt JE. Management of orbital trauma and foreign management of orbital fractures. Plast Reconstr Surg. 2007;
bodies. Otolaryngol Clin North Am. 1988;21(1):35-52. 120(7 suppl 2):57S-63S.
15. Soll DB, Poley BJ. Trapdoor variety of blowout fracture of 31. Rinna C, Ungari C, Saltarel A, Cassoni A, Reale G. Orbital
the orbital floor. Am J Ophthalmol. 1965;60:269-272. floor restoration. J Craniofac Surg. 2005;16(6):968-972.
8 Craniomaxillofacial Trauma & Reconstruction XX(X)

32. Boush GA, Lemke BN. Progressive infraorbital nerve 50. Tessier P. Autogenous bone grafts taken from the calvarium
hypesthesia as a primary indication for blow-out fracture for facial and cranial applications. Clin Plast Surg. 1982;9(4):
repair. Ophthal Plast Reconstr Surg. 1994;10(4):271-275. 531-538.
33. Tengtrisorn S, McNab AA, Elder JE. Persistent infra-orbital 51. Kruschewsky Lde S, Novais T, Daltro C, et al. Fractured
nerve hyperaesthesia after blunt orbital trauma. Aust orbital wall reconstruction with an auricular cartilage graft
N Z J Ophthalmol. 1998;26(3):259-260. or absorbable polyacid copolymer. J Craniofac Surg. 2011;
34. De Riu G, Meloni SM, Gobbi R, Soma D, Baj A, Tullio A. 22(4):1256-1259.
Subciliary versus swinging eyelid approach to the orbital 52. Castellani A, Negrini S, Zanetti U. Treatment of orbital floor
floor. J Craniomaxillofac Surg. 2008;36(8):439-442. blowout fractures with conchal auricular cartilage graft: a
35. Kothari NA, Avashia YJ, Lemelman BT, Mir HS, Thaller SR. report on 14 cases. J Oral Maxillofac Surg. 2002;60(12):
Incisions for orbital floor exploration. J Craniofac Surg. 1413-1417.
2012;23(7 suppl 1):1985-1989. 53. Kraus M, Gatot A, Fliss DM. Repair of traumatic inferior
36. Subramanian B, Krishnamurthy S, Suresh Kumar P, orbital wall defects with nasoseptal cartilage. J Oral
Saravanan B, Padhmanabhan M. Comparison of various Maxillofac Surg. 2001;59(12):1397-1400.
approaches for exposure of infraorbital rim fractures of 54. Stöss H, Pesch HJ. Dura transplantation. Multi-sequential
zygoma. J Maxillofac Oral Surg. 2009;8(2):99-102. transplants of solvent dehydrated dura mater. Animal experi-
37. Feldman EM, Bruner TW, Sharabi SE, Koshy JC, Hollier LH ment studies on the question of sensitization. Fortschr Med.
, Jr. The subtarsal incision: where should it be placed? J Oral 1977;95(15):1018-1021.
Maxillofac Surg. 2011;69(9):2419-2423. 55. Jank S, Emshoff R, Schuchter B, Strobl H, Brandlmaier I,
38. Holtmann B, Wray RC, Little AG. A randomized comparison Norer B. Orbital floor reconstruction with flexible Ethisorb
of four incisions for orbital fractures. Plast Reconstr Surg.
patches: a retrospective long-term follow-up study. Oral Surg
1981;67(6):731-737.
Oral Med Oral Pathol Oral Radiol Endod. 2003;95(1):16-22.
39. Wolfe SA. Treatment of post-traumatic orbital deformities.
56. Campbell DG, Li P. Sterilization of HIV with irradiation:
Clin Plast Surg. 1988;15(2):225-238.
relevance to infected bone allografts. Aust N Z J Surg.
40. Ridgway EB, Chen C, Colakoglu S, Gautam S, Lee BT. The
1999;69(7):517-521.
incidence of lower eyelid malposition after facial fracture
57. Marx RE, Carlson ER. Creutzfeldt-Jakob disease from
repair: a retrospective study and meta-analysis comparing
allogeneic dura: a review of risks and safety. J Oral
subtarsal, subciliary, and transconjunctival incisions. Plast
Maxillofac Surg. 1991;49(3):272-274.
Reconstr Surg. 2009;124(5):1578-1586.
58. Sallam Ahmed M, Hashem H, Shokier H. Use of deminera-
41. Chen CT, Chen YR. Endoscopically assisted repair of orbital
lized bone sheets in reconstruction of orbital floor trap door
floor fractures. Plast Reconstr Surg. 2001;108(7):2011-2018.
fracture. J Appl Sci Res. 2010;6(6):653-658.
42. Cheong EC, Chen CT, Chen YR. Broad application of the
59. Al-Sukhun J, Lindqvist C. A comparative study of 2 implants
endoscope for orbital floor reconstruction: long-term follow-
used to repair inferior orbital wall bony defects: autogenous
up results. Plast Reconstr Surg. 2010;125(3):969-978.
bone graft versus bioresorbable poly-L/DL-Lactide [P(L/
43. Avashia YJ, Sastry A, Fan KL, Mir HS, Thaller SR. Materials
used for reconstruction after orbital floor fracture. DL)LA 70/30] plate. J Oral Maxillofac Surg. 2006;64(7):
J Craniofac Surg. 2012;23(7 suppl 1):1991-1997. 1038-1048.
44. Ilankovan V, Jackson IT. Experience in the use of calvarial 60. Buchel P, Rahal A, Seto I, Iizuka T. Reconstruction of orbital
bone grafts in orbital reconstruction. Br J Oral Maxillofac floor fracture with polyglactin 910/polydioxanon patch
Surg. 1992;30(2):92-96. (Ethisorb): a retrospective study. J Oral Maxillofac Surg.
45. Chowdhury K, Krause GE. Selection of materials for orbital 2005;63(5):646-650.
floor reconstruction. Arch Otolaryngol Head Neck Surg. 61. Hollier LH, Rogers N, Berzin E, Stal S. Resorbable mesh in
1998;124(12):1398-1401. the treatment of orbital floor fractures. J Craniofac Surg.
46. Aldekhayel S, Aljaaly H, Fouda-Neel O, Shararah AW, Zaid 2001;12(3):242-246.
WS, Gilardino M. Evolving trends in the management of 62. Iizuka T, Mikkonen P, Paukku P, Lindqvist C. Reconstruction
orbital floor fractures. J Craniofac Surg. 2014;25(1):258-261. of orbital floor with polydioxanone plate. Int J Oral
47. van Leeuwen AC, Ong SH, Vissink A, Grijpma DW, Bos RR. Maxillofac Surg. 1991;20(2):83-87.
Reconstruction of orbital wall defects: recommendations 63. Kontio R, Suuronen R, Salonen O, Paukku P, Konttinen YT,
based on a mathematical model. Exp Eye Res. 2012;97(1): Lindqvist C. Effectiveness of operative treatment of internal
10-18. orbital wall fracture with polydioxanone implant. Int J Oral
48. Zins JE, Whitaker LA. Membranous versus endochondral Maxillofac Surg. 2001;30(4):278-285.
bone: implications for craniofacial reconstruction. Plast 64. Tuncer S, Yavuzer R, Kandal S, et al. Reconstruction of
Reconstr Surg. 1983;72(6):778-785. traumatic orbital floor fractures with resorbable mesh plate.
49. Young VL, Schuster RH, Harris LW. Intracerebral hematoma J Craniofac Surg. 2007;18(3):598-605.
complicating split calvarial bone-graft harvesting. Plast 65. Hwang K, Kim DH. Comparison of the supporting strength of
Reconstr Surg. 1990;86(4):763-765. a poly-L-lactic acid sheet and porous polyethylene (Medpor)
Patel et al. 9

for the reconstruction of orbital floor fractures. J Craniofac updated protocol for minimally invasive management.
Surg. 2010;21(3):847-853. J Craniomaxillofac Surg. 2019;47(12):1943-1951.
66. Romano JJ, Iliff NT, Manson PN. Use of Medpor porous 79. Mehra P, Miner J, D’Innocenzo R, Nadershah M. Use of 3-D
polyethylene implants in 140 patients with facial fractures. stereolithographic models in oral and maxillofacial surgery.
J Craniofac Surg. 1993;4(3):142-147. J Maxillofac Oral Surg. 2011;10(1):6-13.
67. Han DH, Chi M. Comparison of the outcomes of blowout 80. Park SW, Choi JW, Koh KS, Oh TS. Mirror-imaged rapid
fracture repair according to the orbital implant. J Craniofac prototype skull model and pre-molded synthetic scaffold to
Surg. 2011;22(4):1422-1425. achieve optimal orbital cavity reconstruction. J Oral Maxil-
68. Ellis E 3rd, Tan Y. Assessment of internal orbital recon- lofac Surg. 2015;73(8):1540-1553.
structions for pure blowout fractures: cranial bone grafts 81. Metzger MC, Schön R, Weyer N, et al. Anatomical
versus titanium mesh. J Oral Maxillofac Surg. 2003;61(4): 3-dimensional pre-bent titanium implant for orbital floor
442-453. fractures. Ophthalmology. 2006;113(10):1863-1868.
69. Mischkowski RA, Zinser MJ, Ritter L, Neugebauer J, Keeve 82. Gander T, Essig H, Metzler P, et al. Patient specific implants
E, Zöller JE. Intraoperative navigation in the maxillofacial (PSI) in reconstruction of orbital floor and wall fractures.
area based on 3D imaging obtained by a cone-beam device. J Craniomaxillofac Surg. 2015;43(1):126-130.
Int J Oral Maxillofac Surg. 2007;36(8):687-694. 83. Novelli G, Tonellini G, Mazzoleni F, Bozzetti A, Sozzi D.
70. Wong KC, Kumta SM, Antonio GE, Tse LF. Image fusion for Virtual surgery simulation in orbital wall reconstruction:
computer-assisted bone tumor surgery. Clin Orthop Relat integration of surgical navigation and stereolithographic
Res. 2008;466(10):2533-2541. models. J Craniomaxillofac Surg. 2014;42(8):2025-2034.
71. Gellrich NC, Schramm A, Hammer B, et al. Computer- 84. Shyu VB, Hsu CE, Chen CH, Chen CT. 3D-assisted quanti-
assisted secondary reconstruction of unilateral posttraumatic tative assessment of orbital volume using an open-source
orbital deformity. Plast Reconstr Surg. 2002;110(6): software platform in a Taiwanese population. PLoS One.
1417-1429. 2015;10(3):e0119589.
72. Zizelmann C, Gellrich NC, Metzger MC, Schoen R, 85. Felding UA, Bloch SL, Buchwald C. The dimensions of the
Schmelzeisen R, Schramm A. Computer-assisted reconstruc- orbital cavity based on high-resolution computed tomography
tion of orbital floor based on cone beam tomography. Br of human cadavers. J Craniofac Surg. 2016;27(4):1090-1093.
J Oral Maxillofac Surg. 2007;45(1):79-80. 86. Strong EB, Fuller SC, Wiley DF, Zumbansen J, Wilson MD,
73. Schramm A, Suarez-Cunqueiro MM, Rücker M, et al. Metzger MC. Preformed vs intraoperative bending of tita-
Computer-assisted therapy in orbital and mid-facial recon- nium mesh for orbital reconstruction. Otolaryngol Head Neck
structions. Int J Med Robot. 2009;5(2):111-124. Surg. 2013;149(1):60-66.
74. Shaye DA, Tollefson TT, Strong EB. Use of intraoperative 87. Kozakiewicz M, Szymor P. Comparison of pre-bent titanium
computed tomography for maxillofacial reconstructive mesh versus polyethylene implants in patient specific orbital
surgery. JAMA Facial Plast Surg. 2015;17(2):113-119. reconstructions. Head Face Med. 2013;9(1):32.
75. Ewers R, Schicho K, Undt G, et al. Basic research and 88. Kozakiewicz M. Computer-aided orbital wall defects treat-
12 years of clinical experience in computer-assisted naviga- ment by individual design ultrahigh molecular weight
tion technology: a review. Int J Oral Maxillofac Surg. 2005; polyethylene implants. J Craniomaxillofac Surg. 2014;
34(1):1-8. 42(4):283-289.
76. Cai EZ, Koh YP, Hing EC, et al. Computer-assisted naviga- 89. Stuck BA, Hülse R, Barth TJ. Intraoperative cone beam
tional surgery improves outcomes in orbital reconstructive computed tomography in the management of facial fractures.
surgery. J Craniofac Surg. 2012;23(5):1567-1573. Int J Oral Maxillofac Surg. 2012;41(10):1171-1175.
77. Essig H, Dressel L, Rana M, et al. Precision of posttraumatic 90. Cheung K, Voineskos SH, Avram R, Sommer DD. A sys-
primary orbital reconstruction using individually bent tita- tematic review of the endoscopic management of orbital floor
nium mesh with and without navigation: a retrospective fractures. JAMA Facial Plast Surg. 2013;15(2):126-130.
study. Head Face Med. 2013;9(1):18. 91. Gunarajah DR, Samman N. Biomaterials for repair of orbital
78. Tel A, Sembronio S, Costa F, et al. Endoscopically assisted floor blowout fractures: a systematic review. J Oral
computer-guided repair of internal orbital floor fractures: an Maxillofac Surg. 2013;71(3):550-570.