Int. J. Oral Maxillofac. Surg.

2007; 36: 193–199

doi:10.1016/j.ijom.2006.11.002, available online at http://www.sciencedirect.com

Leading Clinical Paper

Trauma

Reconstruction of orbital wall C. Jaquiéry1, C. Aeppli1,

P. Cornelius2, A. Palmowsky3,
C. Kunz1, B. Hammer4

defects: critical review of 72

1
Clinic for Reconstructive Surgery,
Maxillofacial Unit, University Hospital, Basel,
Switzerland; 2Maxillofacial Unit,
Bundeswehrkrankenhaus, Ulm, Germany;

patients 3
Eye Clinic, University Hospital, Basel,
Switzerland; 4 Craniofacial Center Hirslanden,
Aarau, Switzerland

C. Jaquiéry, C. Aeppli, P. Cornelius, A. Palmowsky, C. Kunz, B. Hammer:

Reconstruction of orbital wall defects: critical review of 72 patients. Int. J. Oral
Maxillofac. Surg. 2007; 36: 193–199. # 2006 International Association of Oral and
Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

Abstract. Between January 1996 and December 2001, 72 out of 354 patients were
included in a retrospective study analysing the outcome of repaired orbital wall
defects. Selection was dependent on the availability of pre and postoperative CT
scans and on ophthalmologic examination. In particular, orthoptical assessment was
performed up to 1 year after operation. In 72 patients, 83 orbital wall defects were
analysed and allocated to one of five categories. Accuracy and type of
reconstruction were assessed in unilateral orbital wall defects (n = 61) and
compared with functional outcome. Reconstruction was performed by using PDS
membrane (39%), calvarian bone (13%), titanium mesh (7%) or a combination of
these materials (37%). Postoperatively, 91% of the patients had normal vision
without double images within 208 at every gaze. Accuracy of reconstruction
correlated with severity of orbital injury and functional outcome. Functional
outcome between category II and III fractures showed no significant difference. The
Key words: orbital defects; orbital reconstruc-
medial margin of the lateral infraorbital fissure being preserved (category II tion; functional outcome; Harms’ tangent
fracture) facilitates reconstruction technically. Accuracy of orbital reconstruction is screen.
one important factor to obtain best functional outcome, but other determinants like
displacement and/or atrophy of intramuscular cone fat should be considered. Accepted for publication 8 November 2006

Orbital fractures are common facial inju-
ries6. They usually occur in the context
of zygomatic-orbital fractures, as pure
blow-out fractures or are part of pan-
facial injuries. If the size of the orbital
defect is considered to be functionally
relevant and reconstruction is indicated,
best functional and cosmetic results can
be obtained with early revision and
repair 9. Reconstruction of orbital
defects has to be preceded by reposition
and rigid fixation of the orbital rim and
the zygomatic complex, in order to
achieve an intact outer facial frame 10.
Meticulous dissection back into the pos-
terior orbit until uninjured areas are
reached is crucial and establishes the
basis for further reconstruction12. It
has been previously reported that enlar-
gement and deformation of the orbit give
rise to visible enophthalmos2,21. As a
consequence, disturbance of eye motility
together with double images is likely to
occur. The severity of an orbital trauma
is not only dependent on the size of a
defect and the number of orbital walls
involved, but also on the localization of
the defect and any technical difficulties
during surgical repair. Defects of the
anterior part of the orbital floor only
slightly influence the position of the
globe, whereas defects within the pos-
tero-medial wall may lead to relapse of
the orbital content resulting in
enophthalmos 13. Surgically, a defect
of the orbital floor with intact medial

0901-5027/030193 + 07 $30.00/0 # 2006 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
194 Jaquiéry et al.

Table 1. Classification of orbital wall defects

Category Description Note
Category I Isolated defect of the orbital floor or the medial
wall, 1–2 cm2, within zones 1 and 2
Category II Defect of the orbital floor and/or of the medial Bony ledge preserved at the medial margin of the
wall, >2 cm2, within zones 1 and 2 infraorbital fissure
Category III Defect of the orbital floor and/or of the medial Missing bony ledge medial to the infraorbital fissure
wall, >2 cm2, within zones 1 and 2
Category IV Defect of the entire orbital floor and the medial Missing bony ledge medial to the infraorbital fissure
wall, extending into the posterior third (zone 3)
Category V Same as IV, defect extending into the orbital roof

border of the lateral infraorbital fissure
can easily be repaired, the angle between
orbital floor and lateral wall being pre-
served. Lack of this anatomical land-
mark increases technical difficulties
and compromises the accuracy of recon-
struction. The aim of the present study
was the critical analysis of 83 orbital
fractures considering (i) size of defect,
(ii) localization of defect and (iii) dis-
tinct anatomical landmarks involved, all
of which determine the technical
demands during surgical repair. The
strategy of reconstruction (surgical
approach, one or a combination of dif-
ferent materials used) was dependent on
the results of the preoperative analysis of
the defect. Ophthalmological outcome
was assessed quantitatively and com-
pared with accuracy of orbital recon-
struction.
the defect in the two-dimensional orbital
sketch.
Patient data
Between January 1996 and December
2001 a total of 354 patients were oper-
ated in the clinic for reconstructive sur-
gery, maxillofacial unit, University
Hospital Basel, following orbital frac-
tures. Of these, 72 (17 females, 65 males)
could be included in the retrospective
study. Patient inclusion was dependent
on the following criteria: (i) preoperative
and postoperative CT scans (axial and
coronal sections), (ii) detailed surgeon’s
report on the reconstruction and materi-
als used, (iii) preoperative and postopera-
tive ophthalmologic examination and
postoperative ophthalmologic follow
up, until no further improvement of dou-
ble vision could be achieved. Mean age
at time of surgery was 39 years (range
13–82) and mean follow-up time was 4.3
years (2–9). On an average of 2.8 days
after trauma (0–30) the patients were
operated on by a maxillofacial surgeon.
The different reasons for orbital trauma

Patients and methods

Classification of orbital wall defects

Due to the complex three-dimensional

osseous structure of the internal orbit, a
clinically relevant description of orbital
fractures including different sizes of
defects cannot be achieved without sim-
plification. It was therefore decided to use Fig. 1. Left and right orbital sketch: (1) orbital floor, anterior third, (2) orbital floor, middle
a two-dimensional model, aiming to third, (3) orbital floor, dorsal third, (4) infraorbital fissure, (5) supraorbital fissure, (6) optical
visualize the missing third dimension nerve, (7) lateral wall, (8) nasal–lachrymal duct, (9) medial border of the infraorbital fissure.
and display the volume-relevant areas.
By de-folding a three-dimensional orbital
model, a trefoil-like orbital scheme can be
obtained. Using this diagram, most orbital
defects can be described and evaluated
semi-quantitatively (Fig. 1). Defects of
the lateral wall were not considered, for
the reasons discussed below. A detailed
description of the classification of orbital
defects is shown in Table 1 and illustrated
in (Figs. 2–6). Two experienced maxillo-
facial surgeons independently assigned
the fracture and defect pattern of every
patient to one of the five categories, using
preoperative computed tomographic (CT)
scans (axial and coronal sections), and Fig. 2. Orbital wall defects, category I. Schematic depiction of defects and corresponding
depicted the extent and localization of coronal section of CT scan. Borders of defect are marked by arrows.
 Orbital wall defects 195

Fig. 3. Orbital wall defects, category II. (a) Schematic depiction of defects, (b) corresponding coronal section of CT scan, and (c) orbital model
visualizing extent and topography of a middle-sized defect. Preserved bony ledge of the infraorbital fissure marked by arrow.

Fig. 4. Orbital wall defects, category III (see legend to Fig. 3; missing bony ledge of the infraorbital fissure marked by arrow).

are listed in Table 2. In 72 patients, a

total of 83 fractures were treated.
From each patient’s history the follow-
ing data were extracted:

- type of incision (low mid-eyelid inci-

sion, lateral canthothomy, upper ble-
pharoblasty incision, coronal approach);
- pattern of the fracture, especially
whether the lateral wall of the orbit
was involved or not;
- type of material used for reconstruction
(bone grafts, resorbable membrane (PDS,
Fig. 5. Orbital wall defects, category IV (see legend to Fig. 2). Ethicon, Germany), titanium meshes
(orbital plate, Synthes, Switzerland)).

Assessment of reconstruction
Accuracy of unilateral reconstruction
(n = 61) was assessed according to ELLIS
& TAN7 using selected coronal sections of

Table 2. Orbital fracture: social context of the

trauma (n = 72)
Reason Number Percentage
Traffic 20 28
Sports 17 24
Fall 13 18
Job 11 15
Violence 11 15

Fig. 6. Orbital wall defects, category V (see legend to Fig. 2). Total 72 100
196 Jaquiéry et al.

Table 3. Distribution of orbital fractures

(n = 83)
Category Number Percentage
I 4 5
II 34 41
III 34 41
IV 4 5
V 7 8
Total 83 100

Table 4. Fractures with displacement of the

lateral wall (n = 83)
I II III IV V
0/4 1/34 6/34 3/4 6/7

Table 5. Fractures where coronal approaches

were used (n = 83)
I II III IV V
Fig. 7. Harms’ tangent screen. This depicts a quantitative assessment of binocular single vision.
The clear area marks the area of binocular single vision, the striped background the area of 0/4 1/34 5/34 4/4 7/7
binocular double vision. This example shows double vision in up-gaze starting from 208 within a
lateral view of 208 and double vision in down-gaze starting from 308 within a lateral view of 308.
examination was performed prior to sur-
gery. In addition to impaired vision, pre-
sence of double vision was examined
quantitatively using the Harms’ tangent
screen (Fig. 7). After reconstruction, the
patients were followed up orthoptically
until no further improvement of vision
could be observed. In general, a stable
ophthalmologic situation was achieved
after 9–12 months of observation.

Results
In 72 patients, 83 orbital wall fractures
could be evaluated. The distribution of the
fractures is listed in Table 3. Accurate
reduction of the lateral wall is a prerequi-
site for adequate orbital reconstruction.
Involvement of the lateral wall is
described in Table 4. Many orbital frac-
Fig. 8. Reconstructed orbital wall defect (category III). Postoperative CT (coronal section) tures can be managed by local approaches,
showing reconstruction of orbital wall defect (category III) using titanium mesh (""). As but if the defect involves more than the
compared to the unaffected side, the level of the reconstructed orbital floor is lower, due to the entire floor (category III) a coronal
fact that the medial margin of the infraorbital fissure as an anatomical landmark is missing. This approach may be required. The number
may result in visible enophthalmos and functional disorders (double images). of coronal approaches as a fraction of the
total number of operated fractures in each
category is listed in Table 5.
postoperative CT scans. The quality of reconstruction the mean of the three
reconstruction was considered to be ideal assessments was taken for further evalua-
Material used for reconstruction
(3), satisfactory (2) or poor (1). In parti- tion.
cular, the transition between the medial Three different types of material were
wall and the orbital floor as well as the used for reconstruction of orbital wall
Ophthalmologic examination
transition between floor and lateral wall defects (Fig. 8): bone grafts harvested
was evaluated at three distinct localiza- All 72 patients were assessed ophthalmo- from the calvaria (tabula externa), tita-
tions (i.e. directly dorsal to the orbital rim, logically. If both orbits were fractured nium meshes and resorbable membranes.
in the middle of the reconstructed area and (n = 11), the patient was assigned to the The use of these materials, as well as a
slightly anterior to the end of the recon- fracture site with the ‘higher’ category. combination of autologous bone grafts and
struction) and compared with the unaf- Depending on the patient’s compliance, an alloplastic material, is described in
fected contra-lateral orbit. For each ophthalmologic or, if possible, orthoptic Table 6.
 Orbital wall defects 197

Table 6. Materials used for reconstruction (n = 83) was followed up orthoptically. Out of
I (n = 4) II (n = 34) III (n = 34) IV (n = 4) V (n = 7) 72 patients 47 (65%) had normal vision
without double images at any gaze (ideal).
No material 3/4
PDS 1/4 10/34 16/34 Using the Harm’s tangent screen, normal
Titanium meshes 5/34 1/34 vision up to 208 (good) was assessed in 19
Bone 7/34 4/34 (26%) and normal vision up to 108 (satis-
Bone + PDS/Ti mesh 7/34 13/34 4/4 7/7 factory) in 4 (5%) patients. Impaired
vision was present in three additional
patients, who recovered completely dur-
Table 7. Assessment of reconstruction (n = 61) ing the observation period. In another two
I (n = 3) II (n = 24) III (n = 30) IV (n = 1) V (n = 3) patients elevation of the globe within the
operated orbit, together with eye motility
3 2.73 2.37 3 2.22
disturbance and double images, was
noticed. Magnetic resonance imaging
(MRI) and CT scans revealed inflamma-
Table 8. Ophthalmologic examination, post-traumatic (n = 72) tion related thickening of the soft tissue
I (n = 3) II (n = 29) III (n = 31) IV (n = 3) V (n = 6) around the PDS sheeting (Fig. 9). Total
recovery of vision and eye motility within
No examination 3/3 10/29 11/31 2/3 3/6
No double vision 10/29 13/31 6 months could be observed in both
No double vision within 208 6/29 2/31 2/6 patients. Presence and degree of post-
No double vision within 108 2/29 1/31 operative double vision are summarized
Double vision at all gaze 1/29 2/31 in Table 9. Enophthalmos, defined as
Amaurosis 2/31 1/3 1/6 more than 2 mm of difference in projec-
tion measured by exophthalmometry 18,
was found in only 4 (5%) out of 72
patients.

Fig. 9. Soft-tissue inflammation around PDS sheeting. Postoperative MRI (coronal section)
showing thickening of the tissue around the PDS sheeting, which corresponds to soft-tissue
inflammation (arrows).
Accuracy of reconstruction
Assessment of orbital reconstruction is
summarized in Table 7. Almost ideal
reconstruction could be observed for cate-
gory II defects (2.73 out of 3 scores). Due
to technical difficulties during surgical
repair, reconstruction of category III
defects was less accurate (2.37 out of 3
scores). But even in category V fractures,
satisfactory results could be achieved
(2.22 out of 3 scores).
Ophthalmologic examination
Prior to surgery 44 (61%) out of 72
patients could be examined. Normal
vision without double images was
assessed in 25 (35%) of the patients.
Due to rupture of the globe (n = 2) and
injured optical nerve (n = 2), four patients
suffered from amaurosis of the affected
eye. Presence and degree of post-trau-
matic double vision are summarized in
Table 8. Postoperatively, every patient
Discussion
The aim of this report was to critically
review the outcome of 72 patients with 83
orbital fractures considering (i) extent and
severity of the defect, (ii) the difficulty and
technical demands during surgical repair,
(iii) accuracy of reconstruction, and (iv)
degree of functional and morphological
disorders in long-term follow up. Selec-
tion of patients was dependent on the
availability of preoperative and postopera-
tive clinical and radiological data. In par-
ticular, a postoperative orthoptical
examination was performed in order to
quantitatively assess functional outcome.
The question as to whether or not orbital
wall defects of limited size should be
operated on and reconstructed is not dis-
cussed here.
More than 80% of the orbital wall frac-
tures assessed were allocated to category
II (n = 34) or III (n = 34). These types of
fractures, involving the orbital floor and
the medial wall, are mainly caused by
indirect and blunt high-energy trauma
and are encountered frequently 14,25.

Table 9. Ophthalmologic examination, postoperative (n = 72)

I (n = 3) II (n = 29) III (n = 31) IV (n = 3) V (n = 6)
No double vision (ideal) 3/3) 17/29 22/31 1/3 2/6
No double vision within 208 (good) 12/29 6/31 1/6
No double vision within 108 (satisfactory) 1/31 1/3 2/6
Double vision at all gaze (poor)
Amaurosis 2/31 1/3 1/6
198 Jaquiéry et al.
The incidence of complex and comminu-
ted orbital fractures, represented by cate-
gories IV (n = 4) and V (n = 7), has been
dramatically decreased by airbag deploy-
ment 5.
Displacement of the lateral wall of the
orbit
As shown in Table 4, involvement of the
lateral wall is dependent on the complex-
ity of injury to the zygomatic complex and
should be classified separately from
defects of the orbital walls. Anatomical
repositioning of the zygomatic complex
restores the continuity of the lateral wall.
Every reconstruction of an orbital defect
should be preceded by proper reduction
and fixation of a zygomatic complex frac-
ture. In category III fractures displacement
of the lateral wall was found in 18% (6/34)
whereas in category II fractures it was
found in 3% (1/34) only. Functional out-
come (Table 9) showed no significant
difference between category II and III
fractures. This suggests that involvement
of the lateral wall does not increase the
difficulty of repairing an orbital wall
defect.
Coronal approach
Operating on pan-facial fractures, the use
of a coronal approach together with local
incisions is unquestioned in order to
entirely expose every fracture line and
subsequently define the sequence of repair
3,10
. Concomitant injury (i.e. skull-base
fracture) may influence the technique of
surgical exposition, especially if the repair
of the fractures and revision of the skull
base can be carried out simultaneously. A
coronal incision facilitates access to the
upper half of the whole orbit and may be
required even in a middle-sized defect of
the medial wall (category II), under the
condition that the defect is localized in the
upper and dorsal part of the medial wall 22.
Category II and III fractures generally can
be managed by local approaches (Table 5).
It has previously been demonstrated that
most postoperative complications in the
context of pan-facial injuries are due to
insufficient exposure and inadequate repo-
sition and fixation of fractures 11. This
supports the importance of thorough and
meticulous exposure as well as accurate
repair of orbital wall defects.
Reconstruction of orbital wall defects
Anatomical reconstruction of the entire
orbit is a prerequisite of normal position
and motility of the eye. Defects less than
1 cm2 and localized anteriorly of the equa-
tor of the eye ball were surgically exposed
and revised but not repaired. Defects of the
orbital floor and the medial wall of limited
size were managed by resorbable mem-
branes like PDS sheeting 4. Reconstruc-
tion of larger defects requires a stable
material in order to support the orbital
content and to prevent the risk of second-
ary enophthalmos24. MRI and CT scans of
two patients whose orbits were repaired by
using the flexible PDS sheeting only
showed the presence of fibrotic scar tissue
around the membrane followed by func-
tional disorders (reduced eye motility,
double vision) (Fig. 9)17. For reconstruc-
tion of middle-sized defects (II and III),
the PDS sheeting was replaced by a non-
resorbable polyethylene membrane (Med-
por1, Porex, Surgical Inc., USA) in order
to avoid inflammatory reactions during
degradation19, and by using rigid titanium
meshes where support of the orbital con-
tent was needed 7. Complex orbital frac-
tures required in general more than one
material for reconstruction (Table 6).
After thorough dissection of the orbital
content, flexible PDS sheeting was placed
around the peri-orbital tissue in order to
protect the soft tissue during reconstruc-
tion and to facilitate accurate placement of
reconstructive material. After completion
of reconstruction this sheeting was usually
left in place. Titanium meshes or larger
autologous bone grafts were used to pro-
vide stability; additional bone chips were
introduced to fill up gaps and to tune
projection by comparing the reconstruc-
tion with the unaffected orbit. Cranial
bone grafts were preferentially used as
they are easy to harvest 26, and remain
stable and preserve their volume if ade-
quately fixed 16. The choice of material
(alloplastic or autologous, or a combina-
tion of both) is essentially dependent on
the size and localization of the defect.
With correct use, complications of orbital
reconstruction are not material related, as
demonstrated by ELLIS & TAN7. In terms of
anatomical accuracy, titanium meshes
may be favoured over autologous bone
grafts, but functionally no significant dif-
ferences were found 7. Placement of a
single reconstructive piece (cranial bone
graft or titanium mesh) to repair a large
defect (III, IV or V) is often restricted by
limited access to the internal orbit and
bears the risk of iatrogenic damage to
periorbital tissue. Precise reconstitution
of orbital volume and ‘tuning’ of projec-
tion can more easily be achieved by using
more than one piece of reconstructive
material. As recently demonstrated8, com-
puter-assisted surgery (CAS) may be a
helpful tool in the context of orbital recon-
struction. This technique enables the sur-
geon to virtually plan the reconstruction
and pre-form alloplastic material to be
used intraoperatively. The reconstruction
can be checked immediately, if CT is
available during the operation. CAS may
shorten the time required for orbital repair
and possibly improve the quality of recon-
struction, but cannot replace a surgeon’s
experience.
Ophthalmologic examination
Injuries of the orbit are frequently com-
bined with impaired vision (double
images) due to reduced eye motility
caused by hematoma, ischemia of the
eye muscles, and entrapment of orbital
soft tissue as well as nerve injuries1,17.
Defect-dependent enlargement of the
orbital volume together with trauma-
induced atrophy of the periorbital tissue
leads to relapse of the eyeball within the
orbit and to visible enophthalmos fol-
lowed again by disturbed motility of
the affected eye 23. Postoperatively,
enophthalmos was found in only 4
(5%) out of 72 patients and was therefore
not an issue in this study. Extent of
reduced eye motility can be related to
the degree of orbital destruction 15. More
important from a functional point of view
is the ability of the patient to achieve
binocular single vision, the area of which
can be measured using the Harms’ tan-
gent screen. In Switzerland, driving of a
motor vehicle may be permitted if drivers
have double-image free vision of at least
208 at every gaze. Examination of bino-
cular single vision using the Harms’ tan-
gent screen requires cooperation of the
patient; hence, due to the severity of the
trauma it was not possible to measure the
degree of binocular single vision in every
patient preoperatively. Follow up within
12 months (Table 9) demonstrates that,
with increasing complexity of the orbital
fracture, reduced binocular single vision
can be expected. Within the category II
and III fractures, only one patient was left
with binocular single vision of equal to or
less than 108. Interestingly, no significant
difference between functional outcomes
of category II and III fractures could be
found, although reconstruction of cate-
gory III fractures was technically more
demanding and the result less accurate.
Apart from precise reconstruction of
shape and volume of the bony orbit2,
postoperative disturbance of eye motility
including enophthalmos could also be
due to displacement and/or atrophy of
intramuscular cone fat20. This additional

aspect should not be underestimated and
may contribute to the functional out-
comes observed in this study.
In conclusion, best functional and cos-
metic results of functionally relevant orbi-
tal defect fractures can be achieved by
early revision and repair. Small and mid-
dle-sized defects (categories I, II and III)
can be repaired using a single material
only, whereas reconstruction of complex
orbital defect fractures requires in general
a combination of different materials.
Accuracy of reconstruction is a prerequi-
site for anatomical positioning of the eye-
ball in order to prevent functional
disorders. Postoperative functional (dis-
turbed eye motility) and morphological
(enophthalmos) disorders are also influ-
enced by displacement and/or atrophy of
periorbital soft tissue.
Acknowledgements. The authors would
like to thank Peter Bucher and Stephan
de Maddalena for photographic work up.
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tomography. Plast Reconstr Surg 1986:
77: 203–214.
22. Marin PC, Love T, Carpenter R, Iliff
NT, Manson PN. Complications of orbi-
tal reconstruction: misplacement of bone
grafts within the intramuscular cone.
Plast Reconstr Surg 1998: 101: 1323–
1327 discussion 1328-1329.
23. Meyer C, Groos N, Sabatier H, Wilk
A. Long-term outcome of surgically trea-
ted orbital floor fractures. Apropos of a
series of 242 patients. Rev Stomatol Chir
Maxillofac 1998: 99: 149–154.
24. Potter JK, Ellis E. Biomaterials for
reconstruction of the internal orbit. J Oral
Maxillofac Surg 2004: 62: 1280–1297.
25. Shere JL, Boole JR, Holtel MR,
Amoroso PJ. An analysis of 3599 mid-
facial and 1141 orbital blowout fractures
among 4426 United States Army Sol-
diers, 1980–2000. Otolaryngol Head
Neck Surg 2004: 130: 164–170.
26. Tessier P, Kawamoto H, Posnick J,
Raulo Y, Tulasne JF, Wolfe SA. Tak-
ing calvarial grafts, either split in situ or
splitting of the parietal bone flap ex
vivo—tools and techniques: V. A 9650-
case experience in craniofacial and max-
illofacial surgery. Plast Reconstr Surg
2005: 116: 54S–71S discussion 92S-94S.
Address:
Claude Jaquiéry
Clinic for Reconstructive Surgery
Maxillofacial Unit
University Hospital
Spitalstrasse 21
CH – 4031 Basel
Switzerland
Tel: +41 61 265 73 40;
Fax: +41 61 265 74 58
E-mail: cjaquiery@uhbs.ch
Int. J. Oral Maxillofac. Surg. 2015; 44: 308–315
http://dx.doi.org/10.1016/j.ijom.2014.12.002, available online at http://www.sciencedirect.com

Systematic Review
Trauma

Controversies in orbital L. Duboisa,, S. A. Steenena,

P. J. J. Goorisa, M. P. Mouritsb,
A. G. Beckinga

reconstruction—I. Defect-driven
a
Department of Oral and Maxillofacial
Surgery, Academic Medical Centre of
Amsterdam, Academic Centre for Dentistry
Amsterdam, University of Amsterdam,

orbital reconstruction: A Amsterdam, The Netherlands; bDepartment

of Ophthalmology, Orbital Unit, Academic
Medical Centre of Amsterdam, University of

systematic review
Amsterdam, Amsterdam, The Netherlands

L. Dubois, S. A. Steenen, P. J. J. Gooris, M. P. Mourits, A. G. Becking: Controversies

in orbital reconstruction—I. Defect-driven orbital reconstruction: A systematic
review. Int. J. Oral Maxillofac. Surg. 2015; 44: 308–315. # 2014 International
Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights
reserved.

Abstract. In the 1980s, computed tomography was introduced as an imaging modality

for diagnosing orbital fractures. Since then, new light has been shed on the field of
orbital fracture management. Currently, most surgeons are likely to repair orbital
fractures based on clinical findings and particularly on data obtained from computed
tomography scans. However, an important but unresolved issue is the fracture size,
which dictates the extent and type of reconstruction. In other fields of trauma
Keywords: Orbit; Trauma; Classification of
surgery, an increasing body of evidence is stressing the importance of complexity-
facial fractures; Orbital fractures; Orbital recon-
based treatment models. The aim of this study was to systematically review all struction; Indication.
articles on orbital reconstruction, with a focus on the indication for surgery and the
defect size and location, in order to identify the reconstruction methods that show Accepted for publication 1 December 2014
the best results for the different types of orbital fractures. Available online 24 December 2014

Introduction
Orbital defects are one of the most com-
monly encountered facial fractures because
of the exposed position and thin bony walls
of the midface area. Orbital fractures may
occur alone or in combination with other
midfacial fractures, including zygomatic
complex fractures, Le Fort II and III frac-
tures, naso-orbito-ethmoidal fractures, and
frontal bone/orbital roof fractures. The
classic blowout fractures are believed to
result from buckling of the orbital rim and
retropulsion of the orbital content.1 Ap-
proximately half of all orbital fractures
consist of isolated wall fractures,2 which
primarily comprise orbital floor defects and
medial wall fractures.
The management of orbital fracture
treatment remains controversial, and a
particular subject of debate is the indica-
tion for surgery. Most surgeons are apt to
repair orbital fractures based on clinical
findings and particularly on data obtained
from computed tomography (CT) scans,
and the key question is, what fracture size
needs reconstruction? In the early 1970s,
Putterman et al. advocated guidelines with
a conservative approach. In particular,
the primary recommendation was to wait
watchfully and follow the course of the
patient’s recovery to detect the possible
development of post-traumatic diplopia,
enophthalmos, and hypoglobus.3,4 Later
insights led to well-defined indications
for immediate surgery (Table 1).5,6
Strong indications for immediate repair
include (1) diplopia with radiological evi-
dence of compressed orbital tissue resulting

0901-5027/030308 + 08 # 2014 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Table 1. Burnstine criteria for orbital fracture surgery timing.
Immediate Early Observation
Time frame Within 24 h 1–14 days >14 days
Indications ! Diplopia with CT evidence of an ! Symptomatic diplopia with positive ! Minimal diplopia (not in primary or
entrapped muscle or peri-orbital tissue forced duction, evidence of an downgaze), good ocular motility, and
associated with a non-resolving entrapped muscle or peri-muscular soft no significant enophthalmos or hypo-
oculocardiac reflex: bradycardia, heart tissue on CT examination, and minimal ophthalmos
block, nausea, vomiting, or syncope clinical improvement over time
! ‘White-eyed blowout fracture’, ! Large floor fracture causing latent
young patient (<18 years), history of enophthalmos
peri-ocular trauma, little ecchymosis ! Significant hypo-ophthalmos
or oedema (white eye), marked ! Progressive infraorbital hypaesthesia
extraocular motility vertical
restriction, and CT examination
revealing an orbital floor fracture with
entrapped muscle or peri-muscular soft
tissue
! Early enophthalmos/hypoglobus
causing facial asymmetry
CT, computed tomography.

16
Fig. 1. Classification of orbital fractures (modification of the model by Jaquiéry et al. ).
310 Dubois et al.
in early ischemic necrosis and oculocardiac
reflex,7,8 (2) life-threatening white-eyed
blowouts or trapdoor fractures in children
with eye motility disturbances, and (3)
radiological evidence of orbital tissue com-
pression9,10 accompanied by oculocardiac
reflex, early enophthalmos, or hypoglobus
producing facial asymmetry that affects
function and cosmesis.11,12 In addition, to
prevent the fibrosis of injured orbital tissue,
early repair within 2 weeks has been pro-
posed for some indications, such as clini-
cally unimproved diplopia with
radiological evidence of orbital tissue com-
pression.13 Further, several studies have
shown that early reconstruction of large
orbital defects is essential for good func-
tional results.14–16 The most difficult man-
agement decisions occur with regard to
patients with smaller orbital defects. For
example, patients with orbital fractures
who have good ocular motility and only
slight displacement of the orbital content
are often treated expectantly. Estimating
the benefit of surgery in these cases is
challenging, since the behaviour of the soft
tissues over time is unpredictable. Thus, the
indication for surgical intervention in these
types of cases remains controversial.
The clinical outcomes of treatment for
the different types of orbital fracture are
difficult to compare. The decision to
choose a certain implant material must
be based on the size and location of the
defect and the remaining structural sup-
port in combination with clinical symp-
tomatology.17 In the case of linear
fractures with small defects and entrap-
ment of the orbital content, the placement
of a membrane may be suitable, whereas
in larger defects affecting one wall or
multiple walls, a stronger, supportive ma-
terial may be necessary.18
Jaquiéry et al.16 proposed a simplified
two-dimensional model to describe these
fractures semi-quantitatively in a trefoil-
shaped diagram of the internal orbit. Five
categories of the extent of the fracture
were defined; fractures with a higher clas-
sification were associated with a lower
accuracy of reconstruction due to reposi-
tioning of the globe (Fig. 1). In our expe-
rience, the current process of surgical
decision-making is rarely influenced by
this classification.
The aim of this study was to systemati-
cally review all prospective and retro-
spective clinical trials on orbital
reconstruction. Particular focus was
placed on the indication for surgery in
relation to defect size and location, in
order to identify the reconstruction meth-
ods that show the best results for the
different types of orbital fracture.
Methods The PubMed search terms were as fol-
lows: (((((‘‘Orbital Fractures’’[Mesh])) OR
A systematic literature search in PubMed
(orbital fracture*[tiab] OR orbit fracture*[-
(updated until 4 October 2013; all indexed
tiab] OR orbital trauma*[tiab] OR orbit
years) was performed using multiple
trauma*[tiab] OR orbital injur*[tiab] OR
search terms, combining the subjects ‘or-
orbit injur*[tiab] OR orbital wall fracture*[-
bital fracture’, ‘reconstruction material’,
tiab] OR orbital wall injur*[tiab] OR orbital
‘volume’, and ‘classification’. The search
wall trauma*[tiab] OR orbital floor frac-
excluded case series with 10 or fewer
ture*[tiab] OR orbital floor injur*[tiab]
subjects. The language was restricted to
OR orbital floor trauma*[tiab] OR blow-
English and German. All human clinical
out fracture*[tiab] OR blowout fracture*[-
studies (prospective and retrospective) on
tiab] OR supraorbital fracture*[tiab] OR
various surgical reconstruction methods
trapdoor fracture*[tiab] OR malar frac-
used for orbital fracture treatments met
ture*[tiab] OR tripod fracture*[tiab] OR
our entry criteria. Preclinical animal and
orbitozygomatic fracture*[tiab] OR orbito-
cadaveric studies, as well as clinical stud-
zygomatic fracture*[tiab] OR zygomatico-
ies comparing different incisions or
orbital fracture*[tiab] OR zygomaticoorbital
approaches rather than reconstruction
fracture*[tiab] OR tripartite fracture*[tiab]
methods, were excluded. Fig. 2 shows a
OR (le fort[tiab] AND fracture*[tiab]) OR
flow diagram of the inclusion process.
(lefort[tiab] AND fracture*[tiab])))) AND
Two authors (SS and LD) appraised the
((‘‘Prostheses and Implants’’[Mesh] OR
relevance of the articles based on the
prosthes*[tiab] OR implant*[tiab]) OR
abstracts (in a primary review process,
(‘‘Internal Fixators’’[Mesh] OR internal fix-
according to the PRISMA criteria (Pre-
at*[tiab] OR plate*[tiab] OR reconstruct*[-
ferred Reporting Items for Systematic
tiab] OR membrane*[tiab] OR sheet*[tiab]
Reviews and Meta-Analyses)19). In a sec-
OR mesh*[tiab]) OR (‘‘Bone Transplanta-
ondary review, full articles were retrieved,
tion’’[Mesh] OR bone transplant*[tiab] OR
and relevant articles were included. Dis-
bone graft*[tiab] OR ‘‘Cartilage’’[Mesh]
agreement was resolved through discus-
OR cartilage[tiab] OR ‘‘Fascia Lata’’
sion with a third person (PG).
Initial PubMed search (October 4, 2013)
1048 Articles (1964–2013)
Primary review Excluded (808)
(Title and abstract) Off-topic/no data
Reviews
Approach/incision
Language restriction
Cadaveric studies
Animal studies
Case series (≤10 cases)
240 Articles
Excluded (8)
Secondary review
Double publication of data
(Full articles)
No data or <11 subjects
232 Articles
15 Prospective studies
4 RCTs
1 CCT
217 Retrospective studies
Fig. 2. Flow diagram of the present systematic review, performed in accordance with the
PRISMA criteria.
 Controversies in orbital reconstruction—I. Defect-driven orbital reconstruction: A systematic review 311

[Mesh] OR fascia lata*[tiab] OR ‘‘Perios- Table 2. Overview of retrospective studies on surgical orbital fracture repair, 1964–2013.
teum’’[Mesh] OR periosteum*[tiab] OR Number Number
‘‘Dura Mater’’[Mesh] OR dura[tiab] OR Fracture type Reconstruction materials of studiesa of patients
‘‘Gelatin’’[Mesh] OR gelatin[tiab] OR Orbital floor/pure Resorbable alloplastic
‘‘Sclera’’[Mesh] OR sclera*[tiab]) OR blowout Porous polyethylene 12 824
(‘‘Biocompatible Materials’’[Mesh] OR PGA 910/PDA mesh 2 41
biomaterial*[tiab] OR bioceramic*[tiab] Ethisorb Dura 1 44
OR animal derived[tiab]) OR (‘‘Durapati- PDA plate/foil 2 26
te’’[Mesh] OR durapatite[tiab] OR hydro- Resorbable PDS sheet 4 429
xyapatite[tiab] OR hydroxylapatite[tiab] PGA membrane 2 24
OR bioactive glass[tiab] OR ‘‘Titanium’’[- PLA membrane 2 79
PMMA 2 N/A
Mesh] OR titanium[tiab] OR ‘‘Cobalt’’[-
Fibrin glue and scaffold 1 10
Mesh] OR cobalt[tiab] OR Collagen membrane 1 23
‘‘Silicones’’[Mesh] OR silicone*[tiab]) Autograft
OR (‘‘Polymers’’[Mesh] OR polymer[tiab] Temporalis fascia 1 32
OR polymers[tiab] OR polymeric[tiab] OR Lyoph. tensor fascia lata 1 12
polyethylene*[tiab] OR nylon*[tiab] OR Lyoph. dura mater 4 185
teflon[tiab] OR ‘‘poly(lactic acid)’’[Supple- Maxillary bone 4 150
mentary Concept] OR ‘‘poly(lactic acid)’’[- Mandibular cortex 4 124
tiab] OR polylactic acid[tiab] OR poly-D,L- Iliac cancellous bone 2 106
lactic acid[tiab] OR poly-L-lactic acid[tiab] Calvarial bone 4 102
Antral bone 1 11
OR ‘‘poly(lactic-co-hydroxymethyl glyco-
Autogenous cartilage 7 91
lic acid)’’[Supplementary Concept] OR Heterologous bone 1 20
PLA/PGA[tiab] OR polydioxanone*[tiab] Bovine processed bone 1 N/A
OR polyglactin 910[tiab]) OR (‘‘Alloys’’[- Non-resorbable alloplastic material
Mesh] OR alloy*[tiab]))) NOT case Titanium mesh 5 214
reports[pt]. Kirschner wire fixation 2 56
Bioactive glass plates 3 85
Hydroxylapatite 2 103
Results Silicone implants 11 590
Implants and balloon 5 426
From the systematic search, a total of 231
Stent 1 N/A
studies including 15,032 patients with or- PTFE sheets 4 440
bital injuries were identified (Tables 2 and Not specified/various 23 2546
3).
Orbital floor and Porous polyethylene 1 39
medial wall Titanium mesh 3 68
Retrospective studies Bone graft 1 41
Mandibular cortex 1 46
The majority of studies in the literature CAD/CAM anatomical plates 1 15
were retrospective in nature (94%; Nylon foil ‘wraparound’ 1 98
n = 217), providing either descriptive data Not specified/various 4 176
on a single institution’s experience with a
Medial wall Porous polyethylene 3 185
heterogeneous series of orbital fracture Hydroxylapatite 1 48
reconstructions, or describing uncon- Customized titanium mesh 1 22
trolled data on a single treatment modali- PGA 910/PDA mesh 1 31
ty. The clinical and radiological outcome Not specified/various 4 97
measurements of these studies were het-
Lateral wall Bone graft 1 85
erogeneous and sometimes subjective.
Moreover, the complications were not al- Orbital roof PGA 910/PDA mesh 1 85
ways reported, and the follow-up periods Not specified/various 4 251
were variable. The defect locations and ‘Large’, ‘extensive’, Porous polyethylene 3 198
sizes were often poorly specified. An over- ‘complex’ or CAD/CAM titanium sheets 2 29
view of the surgical treatment of orbital comminuted Titanium and LactoSorb 1 20
fractures reported for all retrospective orbital fractures Titanium implants 2 65
studies from 1964 to 2013 is shown in PLA/PGA plates and screws 1 11
Table 2. Bone grafts 1 49
Not specified/various 2 89

Prospective studies
Zygomatico-orbital Porous polyethylene 2 27
As shown in Table 3, 14 prospective stud- fractures Autogenous conchal cartilage 1 52
ies were performed. Five of these were Maxillary wall graft 1 7
controlled clinical trials, of which four Hydroxylapatite 1 5
were randomized. In total, 380 orbital Titanium mesh 2 93
fractures were included in the prospective Plates and screws 3 112
studies. The highest level of evidence was Not specified/various 7 625
312 Dubois et al.
Table 2 (Continued )
Number Number
Fracture type Reconstruction materials of studiesa of patients
Heterogeneous/mixed Macropore 1 106
Titanium implant 5 284
CAD/CAM titanium sheets 1 1411
Resorbable sheets 12 176
Vitallium mesh 1 46
Autogenous graft 8 274
Biodegradable plates and screws 1 295
Bioactive glass plates 2 71
Polyethylene + hydroxyapatite 2 450
X-ray film implant 1 56
Not specified/various 16 2019
Total 217 14,650
Lyoph., lyophilized; N/A, not available; PDA, polydioxanone; PDS, poly-p -dioxanone; PGA,
polyglycolic acid; PLA, polylactic acid; PTFE, polytetrafluoroethylene; PMMA, poly(methyl
methacrylate).
a
Some studies present more than one type of reconstruction material.
found in a randomized controlled trial by tures, which might be due to limited case
Bayat et al.20. This study showed a statis- loads and the small number of patients
tical difference only in the advantage of available in these centres. In addition, the
nasal cartilage over conchal cartilage as number of randomized controlled trials on
the best reconstructive material in pre- orbital reconstruction was limited, and
venting enophthalmos after 3–6 months only one of these studies described both
of follow-up (P = 0.008). The remaining the defect size and localization in relation
controlled clinical trials provided no sta- to the type of fracture.18 Hence, because of
tistically significant data. Descriptions of the small sample sizes, the heterogeneity
the actual defect size and location of the of groups, and the poor description of the
fractures were limited. defect sizes and locations, no solid evi-
The indication for surgery was not de- dence-based conclusions or guidelines can
scribed in four of the 14 prospective stud- be drawn on defect-driven reconstruction.
ies.17,21–23 For the remaining studies, the Further reproducible trials using multi-
reasons for surgical intervention were di- centre settings are needed to develop
verse. Although the Burnstine criteria guidelines for defect-driven orbital recon-
were applied in several studies (Table struction.
1),5,6 most studies used less objective In the general treatment of skeletal
criteria. The clinical parameters of motili- fractures, a common concept is that the
ty disturbance and diplopia were reported surgeon bases the decision regarding
as an indication for intervention in only six which hardware to use on the complexity
studies.24–28 Enophthalmos was an indica- of the fracture. For most fractures, classi-
tion for surgery in four studies, but not all fications and treatment models have been
authors described the degree of enophthal- established based on the fracture complex-
mos.20,24–26 The defect size (as measured ity, bony buttresses, and support.32 How-
by CT scan) was used as an indication for ever, in orbital fractures, the bony walls
surgery in five studies.26,28–31 Meanwhile, are generally comminuted and the parts
incarcerated or prolapsed orbital tissue in are often useless for reconstruction. In
the maxillary sinus was the indication for contrast to other midfacial fractures, or-
intervention in two different reports.18,30 bital defects need reconstruction rather
The defect size and location were men- than reduction and fixation of fragments,
tioned in six of 14 studies.18,27–31 Becker but the indication for this intervention is
et al.18 focused on the reconstruction of arbitrary. In some institutions, a surgical
small orbital defects (<1 cm). In the study approach is advocated even in cases of
of Lieger et al.31, which used the Jaquiéry small defects with no functional im-
classification,16 only large orbital defects pairment, whereas in other centres, a
were reconstructed. non-surgical approach is the treatment
of choice.
The strength of the reconstruction ma-
Discussion
terial in most cases is probably of limited
In this systematic review, most of the relevance in the effective repair of fracture
studies showed substantial heterogeneity defects; instead, the choice of material is
in the types and sizes of the orbital frac- typically dependent on biocompatibility.33
For instance, previous work by van Leeu-
wen et al. has demonstrated that only
minimal stress resistance is necessary in
recontouring the orbital volume.33 Be-
cause of the low mechanical loads and
minimal physical requirement imposed
on the implant by the peri-orbital tissue,
only relatively little orbital implant
strength is required. However, the me-
chanical model introduced by van Leeu-
wen et al. does not incorporate
cantilevered reconstructions as seen in
larger defects, in which the posterior sup-
port can be limited because of a missing or
fractured edge. Moreover, these defects
conflict with the two-point circumferential
model (Fig. 3). As such, the properties of
the reconstruction material can be relevant
in larger defects.
The debate on the ideal material for
orbital reconstruction continues as well.
The magnitude of the fracture (either the
size of the defect or the orbital volume
change) can be the most critical factor in
choosing the appropriate orbital implant.
Small defects are known to heal solely by
the formation of scar tissue, whereas larg-
er defects associated with enophthalmos
and hypoglobus require a more rigid ma-
terial (e.g. titanium or bone graft) to sup-
port the orbital contents and retain the
contour of the orbit.34
Three-dimensional measurements
might be the best indicator of the risk of
occurrence of clinically disabling
enophthalmos. The best non-invasive in-
strument to quantify orbital fractures is CT
with thin-cut axial and coronal recordings,
although it often fails to measure the exact
level of bony involvement.35 Wide expo-
sure of the fractured area seems to be the
gold standard for emphasizing the extent
of the defect,36 but descriptions of the
actual defect size and location are rare
in most studies. As such, international
research would greatly benefit from a
clinical classification system for orbital
fractures that considers the three-dimen-
sional aspect of the orbit and thus the
subsequent volume of the orbital soft tis-
sue displacement.
The decision with regard to the appro-
priate implant could be made based on the
complexity of the fracture. In the literature
it is suggested that surgery is indicated in
large fractures with involvement of more
than 50% of the orbital wall, or where the
surface is larger than 2 cm.5 The question
remains as to whether these indications
can be quantified accurately and whether
they are adequately reproducible. Overall,
patients with combined fractures of the
orbital floor and medial wall, with loss
of the medial strut, should be considered at
Table 3. Overview of prospective studies on surgical orbital fracture repair, 2001–2013.
Enophthalmos/ Eye motility Infra-orbital
Diplopia (any gaze) proptosis/dystopia disorder hypaesthesia
Indication for Defect Reconstruction Number of Follow-up
Study [Ref.] Design surgery size Defect location materials patients (postop.) Preop. Postop. Preop. Postop. Preop. Postop. Preop. Postop.
Kruschewsky RCT Decreased ocular N/A Floor " medial Auricular cartilage 20 6 Months 25% vs. 0% vs. 88% vs. 0% vs. 0% 13% vs. 0% vs. 0% 38% vs. 25% vs.
et al.25 mobility; diplopia; wall " other facial graft (8) vs. blade 42% 0% 83% 8% 42% 17%
enophthalmos; fractures absorbable polyacid (P = N/A) (P = N/A) (P = N/A) (P = N/A) (P = N/A)

Controversies in orbital reconstruction—I. Defect-driven orbital reconstruction: A systematic review

ocular functional copolymer (12)
compromise
Becker et al.18 RCT Incarcerated or <1 cm Isolated floor (13) Collagen membrane 24 (20; 2 lost 6 Months 21% of 0% vs. 0% vs. 0% 0% vs. 0% 29% of 0% vs. 0% 60% of 0% of total
prolapsed orbital associated zygomatic (12) vs. PDS foil to follow-up total 0% total total
tissue (CT) fracture (11) (n = 11) 0.15 mm (12) in both groups)
Bayat et al.20 RCT Enophthalmos N/A Floor " medial Nasal septal cartilage 22 3–6 Months (P = NS) 9% vs. (P = NS) Less in nasal (P = NS) (P = NS) (P = NS) (P = NS)
<2 mm wall " other facial (11) vs. conchal 9% septal group
fractures cartilage (11) (P = 0.008)
Dietz et al.26 RCT Increased orbital N/A N/A Perforated PDS foil 28 >6 Months 75% vs. 88%50% vs. 79% vs. 86%86% vs. 75% vs. 50% vs. 50%10% vs. N/A
(multi-centre)pressure; 0.15 mm (14) vs. (P = N/A) 50% (P = N/A) 86% 88% 9%
enophthalmos; titanium dynamic (P = N/A)
persistent diplopia; mesh (14)
visual impairment;
hypoparesthesia;
ION; severe
dislocation (fracture
gap >3 cm)
Al-Sukhun andCCT >2 cm >2 cm Floor " medial Autogenous bone 39 36 Weeks 33% vs. 13%0% vs. 7% 46% vs. 20%13% vs. 13% 21% vs. 0% vs. 0% 8% vs. 7% 0% vs. 0%
29
Lindqvist wall graft (24) vs. PLA (P = NS) (P = NS) (P = NS) (P = NS) 20% (P = NS)
70/30 plate (15) (P = NS)
Lieger et al.31 Pilot without >2 cm or >1 wall; Jaquiéry Floor " medial Low-profile titanium 27 12 Weeks 25–52% 26% 26% 11% (n = 11) 36% 14% N/A N/A
controls expecting functional category wall mesh
or aesthetic deficit III–IVa
Noda et al.27 Pilot without Persistent diplopia Jaquiéry Linear (2), Periosteal suturing 15 5–36 Months 100% 40% N/A 0% 100% 40% N/A N/A
controls (<30 upward gaze, category middle (7),
<40 downward I–IIIa posterior (6)
gaze)
17
Wajih et al. Cohort study N/A N/A Floor Autogenous graft 26 6 Months 61% 11.5% vs. 50% 11.4% vs. 15.3%39% 2.8% vs. 3.8% preop.
(14) vs. porous 26.9% (P = 0.47) 7.7%
polyethylene (12) (P = 1.24) (P = 0.574)
Folkestad and Cohort study N/A N/A Floor (51) with Various 51 12 Months 33% 9.5% 11% 16% 0% 82% 60% postop.
Granström22 associated facial (P = N/A)
fracture (45)
Kontio et al.23 Cohort study N/A N/A Isolated floor (11) Iliac cortex 24 5–13 Months 85% 0% 19% 38% N/A 0% N/A N/A
and floor with
associated facial
fracture (13)
Kontio et al.24 Cohort study Deficiency in eye N/A PDS implant 16 13–46 Weeks56% 25% 13% 38% N/A N/A 69% 6% (P = N/A)
movements; diplopia; (n = 11)
hypophthalmos;
enophthalmos
Scolozzi Preliminary >2 cm defect; >2 cm Non-preformed (1) vs. 20 6–12 Months N/A N/A N/A N/A N/A N/A N/A N/A
30
et al. CCT evidence of soft (n = 11) 3D-preformed
tissue entrapment titanium mesh plates
(n = 11)
Cai et al.21 Matched N/A N/A Kolibri intraoperative 58 12 Months N/A 2% vs. 10%N/A 3% vs. 10% N/A 3% vs. 3% N/A 0% vs. 4%
control trial (n = 11) navigation device (P = 0.039) (P = NS) (P = NS)
(29) vs. controls (29)
Fernandes Case series >1.5 cm Restriction >1.5 cm Polyethylene implant 10 1–26 Weeks 90% 11% N/A 0% N/A 7% 0% 0%
et al.28 of gaze suggesting (n = 11)
entrapment; diplopia
CCT, controlled clinical trial; CT, computed tomography; ION, infra-orbital nerve; N/A, not available; NS, not statistically significant; PDS, poly-p -dioxanone; PLA, poly-L/DL-lactide; RCT, randomized clinical trial.
a
Orbital wall defect categorization by Jaquiéry et al.16. In cases where the studied category was unclear, the defect types are listed descriptively in this table.

313
314 Dubois et al.
Fig. 3. Cantilevered reconstruction of orbital defects (Jaquiéry IV).
higher risk of developing clinically signif-
icant enophthalmos.37 In these fractures,
the three-dimensional changes of the
orbit are more significant and the accurate
form of an orbital implant becomes more
important. Therefore in such cases pre-
formed or patient-specific implants may
be advantageous.
The indication for surgery in solitary
medial wall fractures is even more contro-
versial. No specific prospective studies
have been published on this subject. Gen-
erally accepted indications are a positive
forced duction test or persistent diplopia,
with CT evidence of an entrapped mus-
cle.37 Although enophthalmos is often
mentioned as an indication for surgery
as well, the enophthalmos rarely becomes
significant (more than 2 mm) in the first 2
weeks after trauma.
An easily usable anatomical classifica-
tion is essential for clinical communica-
tion, and the classification introduced by
Jaquiéry gives a good anatomical impres-
sion of the defects (Fig. 1). The first
studies using this practical tool have been
published.31,33,38 However, although this
model describes the extent of the orbital
fracture, it does not address the amount of
volumetric change in the orbit. Nonethe-
less, the latter may very well be essential
in the clinical decision-making process.
Specifically developed software for the
quantification of volumetric changes
would be helpful.
In conclusion, currently available stud-
ies were analysed in this systematic review
and it was found that the data are insuffi-
cient to provide a robust basis for guide-
lines recommending the best
reconstruction method(s) for each type
of orbital fracture. Furthermore, in the
near future, it will hopefully be possible
to identify those defects for which the
use of certain biomaterial properties will
increase the predictability of the orbital
reconstruction. It is the authors’ opinion
that uniform standardized tests (e.g.,
Hertel exophthalmometry and Goldman
screens) and validated questionnaires, in
combination with a three-dimensional
volume-based defect classification, should
be used by default in orbital fracture
research in the coming decade. Further
reproducible trials using a multi-centre
setting are needed to address the contro-
versies in orbital fracture management.
Funding
None.
Competing interests
None declared.
Ethical approval
Not required.
Patient consent
Not required.
Acknowledgement. We would like to thank
Ingeborg M. Nagel, clinical librarian, for
assistance in finding appropriate search
terms.
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Corresponding author
Tel.: +31 20 5661364
fax: +31 20 5669032
E-mail: L.Dubois@amc.uva.nl
Int. J. Oral Maxillofac. Surg. 2015; 44: 433–440
http://dx.doi.org/10.1016/j.ijom.2014.12.003, available online at http://www.sciencedirect.com

Systematic Review
Trauma

Controversies in orbital L. Duboisa, S. A. Steenena,

P. J. J. Goorisa, M. P. Mouritsb,
A. G. Beckinga

reconstruction—II. Timing of
a
Department of Oral and Maxillofacial
Surgery, Academic Medical Centre of
Amsterdam, Academic Centre for Dentistry
Amsterdam, University of Amsterdam,

post-traumatic orbital Amsterdam, The Netherlands; bDepartment

of Ophthalmology, Orbital Unit, Academic
Medical Centre of Amsterdam, University of

reconstruction: A systematic
Amsterdam, Amsterdam, The Netherlands

review
L. Dubois, S. A. Steenen, P. J. J. Gooris, M. P. Mourits, A. G. Becking:
Controversies in orbital reconstruction—II. Timing of post-traumatic orbital
reconstruction: A systematic review. Int. J. Oral Maxillofac. Surg. 2015; 44: 433–
440. # 2014 International Association of Oral and Maxillofacial Surgeons. Published
by Elsevier Ltd. All rights reserved.

Abstract. The timing of orbital reconstruction is a determinative factor with respect to

the incidence of potential postoperative orbital complications. In orbital trauma
surgery, a general distinction is made between immediate (within hours), early
(within 2 weeks), and late surgical intervention. There is a strong consensus on the
indications for immediate repair, but clinicians face challenges in identifying
patients with minimal defects who may actually benefit from delayed surgical
treatment. Moreover, controversies exist regarding the risk of late surgery-related
orbital fibrosis, since traumatic ocular motility disorders sometimes recover
Keywords: Orbit; Trauma; Classification;
spontaneously and therefore do not necessarily require surgery. In this study, all
Orbital fractures; Blowout fractures;
currently available evidence on timing as an independent variable in orbital fracture Reconstruction; Timing.
reduction outcomes for paediatric and adult patients was systematically reviewed.
Current evidence supports guidelines for immediate repair but is insufficient to Accepted for publication 1 December 2014
support guidelines on the best timing for non-immediate orbital reconstruction. Available online 25 December 2014

Introduction
Clinical decision-making in the manage-
ment of patients with orbital fractures is
challenging, and various aspects of orbital
fracture management are still debated.
Controversies exist regarding the indica-
tions for surgery, the timing of surgery,
and the best reconstruction material. To
date, no uniformly accepted guidelines
have been developed for the maximal
interval between trauma and reconstruc-
tive surgery. However, in many other
fields of trauma surgery, an increasing
body of evidence is stressing the impor-
tance of the optimal timing of surgery.1
Early revision and repair of blowout
fractures has been considered the first-line
treatment for optimal surgical outcome.2
The major clinical outcome parameters in
patients with orbital fractures include
functional impairment (vision, extraocular
muscle motility disorders, and diplopia),
cosmetic disturbance (enophthalmos), and
infraorbital hypaesthesia. Ocular motility
disturbances due to orbital fractures are
often related to contused ocular muscles

0901-5027/040433 + 08 # 2014 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
434 Dubois et al.
and post-traumatic oedema. In the 1970s,
it was observed that contused ocular mus-
cles usually recover spontaneously within
1 or 2 weeks, thus a conservative approach
was suggested in order to avoid surgery-
related complications.3 The introduction
of computed tomography (CT) provided
increasingly accurate information on the
extent of the fractures and the presence of
herniated tissue, and resulted in CT-based
treatment protocols in the 1980s and
1990s. The focus of the debate on optimal
timing has since then shifted from the
indications for early intervention towards
the question of which patients are eligible
for delayed repair. In general, a distinction
needs to be made between immediate
(within hours), early (within 2 weeks),
and delayed late orbital reconstruction.
There is consensus on the indications for
immediate surgery. An emergency situa-
tion in orbital trauma exists if a retrobulbar
haematoma develops with apical compres-
sion of the globe or the optic nerve in
combination with impaired vision. These
conditions are an indication for immediate
surgery within 6 h after presentation.4,5,6
Another indication for urgent surgical in-
tervention is muscle incarceration and pos-
sible ischaemia in the paediatric patient.
New light was shed on the timing issue
by Jordan et al.7 in 1998, who found that
although children under the age of 16 years
presenting with diplopia and vertical gaze
restriction (‘white-eyed blowout fractures’)
might show little or no radiological evi-
dence of muscle entrapment, this patient
category is vulnerable to the development
of eye motility disorders that are highly
resistant to surgery. Parbhu et al.8 found
that CT evidence for soft tissue entrapment
in children is easily missed or underesti-
mated by radiologists because of the
trapdoor mechanism. Minor muscle entrap-
ment in children may rapidly result in
muscle fibrosis followed by persistent dip-
lopia, and requires intervention within 2–4
days. In addition, the oculocardiac reflex,
due to orbital wall fractures and vagal
stimulation in children, causes serious bra-
dycardia with potential life-threatening
complications.6,9,10,11
Indications for early intervention within
2 weeks have also been reported in the
literature, and include enophthalmos larg-
er than 2 mm with significant hypoglobus
or diplopia.12 Large displaced fracture
defects generally require surgery within
2 weeks, since the development of
enophthalmos is anticipated. Enophthal-
mos may be obvious at the time of presen-
tation, but may be masked by oedema or
haematoma. However, if surgery is
delayed until enophthalmos is apparent,
fibrosis may develop between orbital soft
tissues, the sinus mucosa, and bone frag-
ments. To prevent fibrosis of the injured
orbital tissue, early repair within 2 weeks
has been proposed for patients who
have clinically unimproved diplopia with
radiological evidence of orbital tissue
compression.13 Delaying the operation
further may increase the complexity of
the reconstruction14 and introduce the risk
of additional complications, such as sinus-
itis, dacryocystitis, late ptosis, and func-
tional deficits (e.g. enophthalmos,
hypoglobus, and diplopia).12
Delayed reconstructions are commonly
indicated in patients who have developed
aesthetically disturbing enophthalmos or
persistent diplopia 2 weeks after trauma.
In these patients, the indication for surgical
intervention may be uncertain in the early
stages after trauma. This uncertainty
applies specifically to small orbital defects,
e.g. in patients with orbital fractures who
have good ocular motility and only slight
displacement of the orbital content. In a
retrospective study, Dal Canto and Linberg
14 found similar complication rates be-
tween orbital floor and/or medial wall frac-
ture repairs conducted within 14 days and
those performed 15–29 days after trauma.
However, the majority of studies10,11,15–18
support early reconstruction because of the
better postoperative results and a decreased
incidence of diplopia and enophthalmos.
These outcomes are thought to result from
reduced scarring of soft tissue.10,11,15–18
The initial contusion, shearing, and lacera-
tion cannot be prevented; however, early
reversal of an ongoing tissue crush or
severe stretch might limit late fibrosis, es-
pecially in cases of fractures with dispro-
portionate soft tissue displacement.11
If an orbital wall defect needs recon-
struction, several decisions need to be
made on the timing of surgery. The aim
of the present study was to systematically
review all the available controlled clinical
trials on post-traumatic orbital reconstruc-
tion with a focus on the timing, or delay of
surgery.
Methods
A systematic literature search in PubMed
(updated 14 September 2013; all indexed
years) with multiple search terms was per-
formed, combining the subjects ‘orbital
fracture’, ‘timing’, and ‘delay’. The search
excluded case series with 10 or fewer sub-
jects, and the language was restricted to
English, German, and Dutch. All prospec-
tive and retrospective human clinical stud-
ies reporting comparative data regarding
the interval between the injury and the
reconstructive orbital surgery and also the
outcome of the orbital fracture treatment
met our entry criteria; these studies could
include either adults or children. During
the primary review process (performed in
accordance with the PRISMA criteria,
(preferred reporting items for systematic
reviews and meta-analyses) for systematic
reviews19), two authors (SS and LD)
assessed the relevance of the retrieved arti-
cles based on the abstracts. In a secondary
review, full articles were retrieved and
relevant articles were included. Any dis-
agreements were resolved through discus-
sions with a third person (PG). Fig. 1 shows
a flow diagram of the inclusion process.
The PubMed search terms (all indexed
years) were as follows: ((((‘‘Orbital Frac-
tures’’[Mesh] OR orbital fracture*[tiab]
OR orbit fracture*[tiab] OR orbital trau-
ma*[tiab] OR orbit trauma*[tiab] OR or-
bital injur*[tiab] OR orbit injur*[tiab] OR
orbital wall fracture*[tiab] OR orbital wall
injur*[tiab] OR orbital wall trauma*[tiab]
OR orbital floor fracture*[tiab] OR orbital
floor injur*[tiab] OR orbital floor trau-
ma*[tiab] OR blow-out fracture*[tiab]
OR blowout fracture*[tiab] OR supraor-
bital fracture*[tiab] OR trapdoor frac-
ture*[tiab] OR malar fracture*[tiab] OR
tripod fracture*[tiab] OR orbitozygomatic
fracture*[tiab] OR orbito-zygomatic frac-
ture*[tiab] OR zygomatico-orbital frac-
ture*[tiab] OR tripartite fracture*[tiab]
OR (le fort[tiab] AND fracture*[tiab])
OR (lefort[tiab] AND fracture*[tiab])))
AND (‘‘Time’’[Mesh] OR time[tiab]
OR timing[tiab] OR delay*[tiab] OR
moment[tiab] OR wait*[tiab] OR early[-
tiab] OR late[tiab] OR week*[tiab] OR
day[tiab] OR days[tiab])) NOT (case
reports[pt] NOT (cases[tiab] OR series[-
tiab] OR group[tiab] OR patients[tiab] OR
review[tiab] OR retrospective[tiab])))
AND (English[la] OR Dutch[la] OR Ger-
man[la]).
Results
In the systematic search, a total of 17
studies including 1579 patients with orbit-
al injuries were identified (Tables 1–3).
Prospective studies
Several prospective studies on orbital frac-
ture surgery specified the timing of the
reconstruction. The timeframe reported typ-
ically ranged from immediate repair
to repair within 1 month after the inju-
ry,20,21,22,23,24,25 with the exception of one
study in which the maximum interval ran-
ged up to 3 months after trauma.26 Nonethe-
less, only two of these studies analysed the
 Controversies in orbital reconstruction—II. Timing of post-traumatic orbital reconstruction
Initial PubMed search
792 Hits (all indexed years)
After primary review (reading
abstracts)
23 Articles
After secondary review (reading full-text
articles)
2 Prospective studies
1 RCT
1 Cohort study
15 Retrospective studies
9 Adult population studies
4 Paediatric population studies
2 Studies involving all ages
Fig. 1. Flow diagram of the present review performed in accordance with the PRISMA criteria.
actual effect of timing as a variable in the
clinical outcome measures (Table 1).20,21
One randomized controlled trial by
Bayat et al.20 compared the effects of nasal
septal cartilage (n = 11) with conchal car-
tilage (n = 11) for orbital blowout fracture
reconstruction, and found that timing the
reconstruction to <4 weeks after the injury
had a significant positive effect on postop-
erative enophthalmos. However in this
study, the timing of the operation was not
randomized over the groups, and it was not
specified why the subjects were treated ear-
lier or to which groups they were allocated.
In addition, a cohort study by Kontio
et al.21 followed 24 subjects with orbital
floor fractures (of whom 13 had associated
facial fractures) for a mean 234 days
(range 146–406 days), and found no cor-
relation between the timing of the opera-
tion (mean 7 days, range 0–26 days) and
the outcome of postoperative diplopia.
Collectively, the results suggest that the
prospective studies have not provided
Excluded after primary
review: 769 articles
722 Off-topic
27 Animal studies
20 Cadaver studies
Excluded after secondary
review: 6 articles
Did not analyse the timing of
repair as a variable in the
surgical outcome
evidence on whether to perform early,
delayed, or late orbital reconstruction.
Retrospective studies
There are numerous retrospective studies
in the literature providing descriptive data
on the timing of orbital reconstruction.
However, only 15 studies were found that
reported comparative analyses on the ef-
fect of surgical timing on various clinical
outcome measures (Tables 2 and 3). Nine
of these studies included only adult
patients,14,27–34 four studies only paediat-
ric patients,7,35–37 and two included both
adults and children.38,39
With regard to adult orbital fractures,
four studies found a statistically signifi-
cant positive effect of the earlier timing of
surgery on clinical outcome measures
(enophthalmos and ocular motility),27,31,
33,34
whereas five studies were inconclu-
sive (Table 2).14,28–30,32
435
With regard to paediatric orbital frac-
tures, one study with paediatric patients
found a statistically significant correlation
between surgery performed within 3
weeks and diplopia at long-term follow-
up,36 while five studies were inconclusive
(Table 3).7,35,37–39
In summary, two retrospective studies
found some advantageous effects for
surgery performed at <2 weeks for
adults, although six studies found no
significant differences, and one of six
studies in paediatric patients provided
evidence for a correlation between ear-
lier repair and the occurrence of diplopia
and extraocular motility disorders.
Discussion
This review identified two prospective and
15 retrospective trials concerning the
effects of surgical timing on post-traumatic
orbital reconstruction outcomes. Although
most authors agree on the indications for
immediate intervention, no randomized
controlled trials have evaluated the effects
of surgical timing as an independent vari-
able on clinical outcome measures. A
strong limitation to the majority of studies
is that the reasons for the different time
intervals between trauma and reconstruc-
tion chosen by the clinicians and institu-
tions are rarely specified. It has been
proposed that early surgical intervention
may improve the ultimate outcome, but
identifying patients at risk of late compli-
cations remains challenging.40 Although
there is strong consensus on the indications
for immediate repair, current available data
are insufficient to provide a solid base for
guidelines on optimal timing of orbital
fracture reduction.
Quantification and analysis of orbital
trauma is highly complex due to the het-
erogeneous nature of the injuries. First,
orbital volume is dependent on soft tissue
components, which tend to change over
time (e.g. post-traumatic oedema, incar-
ceration of peri-orbital tissue, late fibrosis,
and late atrophy). Second, the size and
location of the bony defect and volumetric
changes can be critical factors with regard
to the clinical outcome.41 Differences in
results between studies must thus be inter-
preted with caution.
Orbital wall fracture reconstruction it-
self may produce dissatisfactory results,27
such as persistent diplopia or enophthal-
mos. For the development of evidence-
based treatment guidelines, it is necessary
to review and investigate all variables that
influence these outcomes.41 Some logisti-
cal factors such as patient delay, doctor’s
delay, and the availability of operating
436 Dubois et al.
Table 1. Overview of prospective studies on the timing of surgical orbital fracture repair, 2006–2010.
Study Fracture
[Ref.] Design type
Bayat Randomized Blowout
et al.20 controlled fractures
clinical trial
Kontio Cohort study Isolated floor
et al.21 (11) and floor
with associated
facial fracture
(13)
NS, not significant; SD, standard deviation; N/A, not available.
rooms may influence the timing of
surgery. Recent studies have shown that
technological advancements such as pre-
operative planning, rapid prototyping,
customized implants, and intraoperative
navigation may influence the predictabili-
ty of the orbital reconstruction.42–45 How-
ever, additional unwanted effects of new
technologies can include the need for extra
time and manpower for planning, prepar-
ing, and performing surgery. It has been
reported that the surgeon’s experience
may also be an important factor in the
outcome of complex reconstructions.46,47
After 1–2 weeks, most swelling has dis-
appeared, which allows a more cosmetic
assessment. Extra time may therefore
prove to be a co-variable positively influ-
encing the outcome of reconstruction.
A minimally displaced orbital fracture
is generally referred to as a ‘small frac-
ture’. However, a significant transient dis-
placement of bone fragments at the time of
injury may remain unnoticed after the
entrapped soft tissues have snapped back
into position. In these cases, motility rath-
er than volume is the primary concern, and
surgery is usually advised only if there is
clinically significant diplopia that does not
resolve within 2 weeks, when most of the
acute swelling has disappeared. Putterman
et al.3 were the first to evaluate this con-
servative approach. Some years later, the
Amsterdam-Korneef group found that
Number Interval from
Surgical of injury to surgery
technique patients (delay)
Nasal septal 22 <4 weeks: n = 8
cartilage (11) >4 weeks: n = 13
vs. conchal
cartilage (11)
Autogenous 24 7 Days
iliac cortical (range 0–26)
graft
diplopia in blowout fractures due to oede-
ma, haematoma, or oculomotor nerve pal-
sy (n = 17) recovered spontaneously
within 1 year after injury in all patients.48
Since it has been shown that entrapment is
easily missed or underestimated in CT
scans of younger patients (<16 years of
age) who present with diplopia and/or
motility disturbances after trauma, the
conservative approach applied to children
may lead to eye motility disorders highly
resistant to surgery.7,8 These patients are
likely to benefit from immediate or early
intervention.
Entrapment of peri-orbital tissue may
lead to early fibrosis followed by persis-
tent diplopia.8 Nowinski et al.36 have
shown an association between early recon-
struction and the prevention of fibrosis.
However, five other studies on paediatric
patients found no differences between
groups.7,35,37–39 Everhard-Halm et al.48
demonstrated a complex network of fi-
brous septa that functionally unite the
sheath of the inferior rectus muscle, the
fibro-fatty tissues, and the periosteum of
the orbital floor. In orbital fractures, mo-
tility may be limited by displacement of
this entire complex, or by entrapment of
any of its components. It is unclear which
tissue types (peri-orbital content such as
fat, septa, periosteum, or muscle) are re-
sponsible for late motility disorders, and it
should be specified whether the inferior
Follow-up Results
3–6 At baseline, differences
Months in the mean values of
the enophthalmos
between patients
treated within or after 4
weeks of injury were
non-significant (mean
(SD), 4.8 (0.89) vs. 5.1
(0.8) mm, respectively;
P = NS). However, the
mean correction of the
enophthalmos (and
residual enophthalmos)
was significantly
higher (and lower) at
each follow-up visit in
patients who were
treated within 4 weeks
of injury (P = N/A)
5–13 Timing of the operation
Months did not affect the
occurrence of diplopia
(P = N/A)
rectus muscle or the inferior oblique mus-
cle contributes most to motility limita-
tions.
Enophthalmos related to shredding of the
fat of the peri-orbit due to trauma or surgery
is difficult to predict. Overcorrection in
reconstructive surgery is sometimes recom-
mended, but it is unknown to what extent. A
core benefit of early intervention is the
reduction of fat atrophy. A recent consen-
sus is that early reconstruction results in
less enophthalmos because of minimal soft
tissue scarring.10,11,15–18 The initial haema-
toma with contusion, shearing, and lacera-
tion of the orbital content cannot be
prevented, but early reconstruction may
limit damage to the fatty tissue.11 This
theory states that late reconstruction leads
to novel haematoma formation and may
therefore subsequently cause even more
fatty tissue atrophy. However, supporting
evidence remains limited.
It should be noted that in rare cases,
surgery may also be delayed because of
contraindications such as the patient’s
general condition not allowing surgery,
an orbital fracture near the only seeing
eye, or severe ocular injury (e.g. retinal
detachment, ruptured globe, hyphema, or
traumatic optic nerve lesions).
Orbital reconstruction is challenging
because of the high level of unpredict-
ability. A perfect anatomical reconstruc-
tion does not guarantee a perfect
Table 2. Overview of retrospective studies on the timing of surgical orbital fracture repair in adults, 1983–2013.
Number Interval from injury to
Study [Ref.] Design Fracture type of patients surgery (delay) Follow-up Results
Hawes and Consecutive Orbital floor fractures 51 <2 Months (n = 43) >6 weeks ‘Early’ vs. ‘late’ repair
Dortzbach31 case series (either with diplopia or vs. >2 months (n = 8) Enophthalmos postoperative: 7% vs. 50%
enophthalmos) (P < 0.002)
Motility ‘satisfactorily’ corrected: 88% vs.
40% (P < 0.02)

Controversies in orbital reconstruction—II. Timing of post-traumatic orbital reconstruction

Verhoeff et al.30 Chart review Orbital trauma with 28 <2 Weeks vs. >2 weeks >6 months Higher complete recovery rate in earlier
subsequent motility <2 Months vs. >2 months repair (73% <2 weeks vs. 40% <2 months
disorders needing repair vs. 25% >6 months); P = N/A
Harris et al.33 Cohort study Orbital floor fracture with 30 Mean 16/24 days 4–10 weeks Higher than median ocular motility outcome
or without medial wall Range 1–2920 days postop. in patients treated < 1 week; P = N/A
extension, and diplopia
Matteini et al.28 Chart review Pure orbital fractures 108 <2 h, 2–24 h, 1–3 Days, 2–6 months ‘Strong relation’ between timing of surgery
3–7 days, 7–12 days (mean 4 months) and the variables ‘functional impairment or
muscle entrapment’ and ‘serious conditions
of compression or ischaemia’; P = N/A
Dal Canto and Chart review Orbital fractures (floor 58 <14 Days (n = 36) vs. >3 weeks No significant difference between ocular
Lindberg14 and/or medial wall) 15–29 days (n = 22) motility (preop. and postop.), self-reported
diplopia, and strabismus between ‘early’
and ‘delayed’ groups. Time to resolution or
stability of diplopia postop. independent of
the time to surgery
Simon et al.32 Consecutive Orbital floor fracture with 50 <2 Weeks vs. >2 weeks No apparent difference between early and
case series entrapment or late repair. Repair <2 weeks was associated
enophthalmos with less improvement in enophthalmos vs.
>2 weeks (delta 0.2 ! 1.1 vs.
1.3 ! 1.9 mm, P = 0.02)
Shin et al.29 Chart review Orbital fractures with 233 <14 Days vs. 15–30 days >6 months No significant difference in degree of preop.
diplopia or motility and postop. diplopia, motility restriction,
restriction and enophthalmos between the two groups
Brucoli et al.27 Chart review Blowout fractures without 51 <2 Weeks vs. >2 weeks 6–81 months Timing of surgery at <2 weeks vs. >2
orbital rim involvement (mean 39 months) weeks was significantly associated with a
positive influence on diplopia at long-term
follow-up (P < 0.05), on postop.
enophthalmos (P < 0.05), and on
infraorbital hypaesthesia (P < 0.05)
Shin et al.34 Chart review Pure blowout fractures 952 <3 Days, 4–7 days, 8–14 There was no significant difference in the
days, 15–30 days, >1 month improvement of diplopia according to
timing of surgery (P < 0.05, McNemar test),
but timing of surgery (operated after 1 week)
was significantly related to postoperative
extraocular movement limitation and
enophthalmos (P > 0.05, McNemar test)
N/A, not available.

437
 438
Table 3. Overview of retrospective studies on the timing of surgical orbital fracture repair in children, 1998–2011.
Number Interval from injury
Study [Refs.] Design Fracture type Age, years of patients to surgery (delay) Follow-up Results

Dubois et al.
Jordan et al.7 Chart review Post-traumatic 4–18 20 Range 48 h–40 days 4 Weeks to 1 year In patients who had surgery
enophthalmos or <48 h: n = 5 within 4 days (n = 5), symptoms
diplopia with >48 h to <4 days: n = 1 resolved between 3 and 6 weeks
motility disorder; >14 to <40 days: n = 14 postop
‘white-eyed blowout’ Patients who had surgery at 2–3
weeks tended to show slower
symptom resolution (over
months); 3 patients had
permanent restriction (P = N/A)
Gerbino et al.35 Chart review Trapdoor fractures 6–16 24 Range <24 h–192 h Average 36 months A correlation was found between
<24 h: n = 12 (‘urgent’) timing (<24 h vs. >24 to <96 h
>24 to <96 h: n = 8 (‘early’) vs. >96 h) with regard to residual
>96 h: n = 4 (‘delayed’) diplopia (8.3% vs. 37.5% vs.
100%) at follow-up (P = N/A)
Wang et al.37 Chart review Blowout fracture 5–18 41 0–2 Days: n = 4 (‘immediate’) Mean 6.5 months Higher mean changes in
(Mean 12.7) 3–14 Days: n = 18 (‘early’) (range 0.3–59) supraduction limitation when
15–30 Days: n = 11 (‘delayed’) operated after 3–14 days vs. <2
>30 Days: n = 8 (‘late’) days (P = 0.47). Surgery at <1
month: 60% complete resolution
of preop. motility restriction and
51.6% complete resolution of
diplopia at follow-up, vs. 0%
improvement of diplopia and
motility when operated at >1
month (P = N/A)
Ethunandan Case series Blowout fracture 4–53 10 Range 0–41 days Mean 5.1 months No diplopia at follow-up in
and Evans39 with painful gaze (Mean 19.6) (mean 12.3 days) (range 1–12) patients who had surgery within 7
restriction days. One patient treated at 20
days had troublesome diplopia
that required extraocular muscle
surgery. None of the other
patients, including one treated 41
days after injury, had any relevant
residual diplopia (P = N/A)
Amrith et al.38 Consecutive Blowout fracture 7–76 63 (13 <1 Week, >1 week >6 Months (53%) Children had earlier surgery than
case series (Median 27) Children) <6 Months (47%) adults (P < 0.001) and tended to
have better motility outcomes
than adults (however, P = 0.684).
Surgery at <1 week showed a
trend towards better motility
outcomes (P = 0.231)
Nowinski et al.36 Chart review Complex orbital 5–15 14 <3 Week: n = 11 (‘early’) 4.7 Years Correlation between surgery at
fractures in (Mean 9.4) >3 Week: n = 3 (‘postponed’) (range 1.2–13.1) >3 weeks and diplopia at long-
combination with term follow-up (P = 0.04,
traumatic brain injury Fisher’s exact test)
N/A, not available.
 Controversies in orbital reconstruction—II. Timing of post-traumatic orbital reconstruction 439

Table 4. Criteria for orbital fractures.

Immediate Early Delayed
Time frame Within 24 h 1–14 Days >14 Days
Indications " Diplopia with CT evidence of an " Early enophthalmos/hypoglobus " Symptomatic diplopia without
entrapped muscle or peri-orbital causing facial asymmetry proven entrapment on CT
tissue associated with a " Symptomatic diplopia with positive examination, negative forced
non-resolving oculocardiac reflex: forced duction, evidence of an duction, and minimal clinical
bradycardia, heart block, nausea, entrapped muscle or peri-muscular improvement over time
vomiting, or syncope soft tissue on " Late-onset enophthalmos/hypoglobus
" ‘White-eyed blowout fracture’, CT examination
young patient (<18 years), history " Large floor fracture (<50% surface
of peri-ocular trauma, little displaced) causing latent enophthalmos
ecchymosis or oedema (white eye),
marked extraocular motility vertical
restriction, and CT examination
revealing an orbital floor fracture
with entrapped muscle or
peri-muscular soft tissue
Significant globe displacement with
vision threatening emergency
CT, computed tomography.

aesthetic and functional outcome, be-
cause soft tissue involvement poses dif-
ficulties in predicting the long-term
effect on function and aesthetics .41 Dif-
ferent aspects of timing are believed to
influence surgical outcome both posi-
tively and negatively. Based on this
systematic review, it is our opinion that
the Burnstine criteria must be critically
revisited (Table 4).
In conclusion, this systematic review
has analysed currently available data
and it is concluded that insufficient data
are available to provide a robust basis for
guidelines on the best timing of orbital
reconstruction. The evidence for early
post-traumatic orbital reconstruction is
limited to expert opinions and retrospec-
tive analyses. Several confounders, such
as local standards, available operating
room time, legal matters, and insurance,
may influence the clinician’s decision with
regard to the timing of reconstruction.
Prospective studies are required, and
should evaluate the extent of bony orbital
trauma, whether soft tissue entrapment is
present, the origin of the tissue involved,
and how much time has elapsed between
the trauma and diagnosis. Age has been
shown to play an important role in the
timing of surgical intervention. Adequate
follow-up to record potential postopera-
tive complications is essential. Future re-
search must strive to establish a
relationship between the extent of the
trauma, the time between trauma and in-
tervention, and age.
Funding
None.
Conflict of interest statement
None declared.
Ethical approval
Not required.
Patient consent
Not required.
Acknowledgement. We would like to thank
Ingeborg M. Nagel, clinical librarian, for
assistance in identifying appropriate
search terms.
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Corresponding author
Tel.: +31 20 5661364
fax: +31 20 5669032
E-mail: L.Dubois@amc.uva.nl
YIJOM-3206; No of Pages 10

Int. J. Oral Maxillofac. Surg. 2015; xxx: xxx–xxx

http://dx.doi.org/10.1016/j.ijom.2015.06.024, available online at http://www.sciencedirect.com

Review
Trauma

Controversies in orbital L. Dubois1, S. A. Steenen1,

P. J. J. Gooris1, R. R. M. Bos2 ,
A. G. Becking1

reconstruction—III.
1
Department of Oral and Maxillofacial
Surgery, Orbital Unit, Academic Medical
Centre and Academic Centre for Dentistry
Amsterdam, University of Amsterdam,

Biomaterials for orbital Amsterdam, The Netherlands; 2Department

of Oral and Maxillofacial Surgery, University
Medical Centre Groningen, Groningen, The

reconstruction: a review with

Netherlands

clinical recommendations
L. Dubois, S.A. Steenen, P.J.J. Gooris, R.R.M. Bos, A.G. Becking: Controversies in
orbital reconstruction—III. Biomaterials for orbital reconstruction: a review with
clinical recommendations. Int. J. Oral Maxillofac. Surg. 2015; xxx: xxx–xxx. # 2015
International Association of Oral and Maxillofacial Surgeons. Published by Elsevier
Ltd. All rights reserved.

Abstract. The goal of orbital reconstruction is to repair trauma defects, to correct the
position of the eye anatomically, avoiding enophthalmos, and to restore ocular
function. For the reconstruction of (trauma) defects, many surgeons recommend
materials that can be bent into an anatomical shape and that possess the properties of
radiopacity and long-term stability. However, apart from these desired properties,
the ideal material for orbital reconstruction remains controversial. Autologous bone
is often mentioned as the ‘gold standard,’ likely because of its mechanical
properties, revascularization potential, and its adaptation to the orbital tissue with
minimal acute and chronic immune reactivity. However, autologous bone can show
unpredictable resorption rates and suboptimal volume correction. In recent years, an
increasing interest in the use of alloplasts for orbital reconstruction has become
apparent in the literature. Modern technological advantages, such as preoperative
planning, navigation, and perioperative imaging, can be beneficial in the decision to
Key words: orbit; trauma; blowout fractures;
choose a certain implant. The aim of this review is to give a comprehensive classification of facial fractures; orbital fractures;
overview of the advantages and disadvantages of materials used to reconstruct orbital reconstruction; biomaterials.
traumatic orbital defects and to provide a practical, evidence-based, complexity-
driven set of guidelines. Accepted for publication 29 June 2015

In the reconstruction of orbital fractures, the traumatic defect and bringing the as described in previous reviews,2,3 a third
the purpose of an implant in orbital wall globe into its correct position, thereby pivotal factor in orbital fracture surgery
reconstruction is to restore function avoiding enophthalmos.1 In addition to is the choice of reconstruction material.
and aesthetic appearance by repairing the timing and methods of reconstruction, Numerous studies describing orbital

0901-5027/000001+010 # 2015 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

Please cite this article in press as: Dubois L, et al. Controversies in orbital reconstruction—III. Biomaterials for orbital reconstruction: a
review with clinical recommendations, Int J Oral Maxillofac Surg (2015), http://dx.doi.org/10.1016/j.ijom.2015.06.024
YIJOM-3206; No of Pages 10

2 Dubois et al.

fracture repair with a variety of materials clinical findings and radiological informa- strength to support the orbital contents
that offer various advantages and disad- tion.4 However, among 55 studies per- and restore the contour of the orbit.4
vantages have been reported in the liter- formed on orbital reconstruction, it was In defining the ideal characteristics of
ature.2,3 For many decades, biological found that the indication for surgery was an orbital implant, many surgeons prefer
transplants derived from human or animal based on diplopia in only 18.3% of cases materials that (1) allow bending to an
tissues, polymers, and metals have been and on preoperative enophthalmos in only anatomical shape, (2) are radiopaque,
used. With the development of biocom- 29.8% of cases.4 The other two most and (3) remain stable over time. The
patible alloplastic implants, new options frequently reported indications for orbital key question is what specific characteris-
(polymers, biological ceramics, and com- reconstruction are defect size (<50% of tics orbital implants should have to be
posites) have been added to the surgeon’s surface) and incarcerated tissue, with both beneficial for the different types of orbital
armamentarium (Table 1). Within this identified on computed tomography (CT) fracture. While an increasing body of evi-
context, controversy exists regarding the scans. If an indication for surgery is pres- dence is pointing to the importance of
best material features, which can be de- ent, the next dilemma is the selection of differentiated and complexity-based treat-
fined broadly by the following parameters: the correct implant. This choice could be ment models in general trauma surgery,
(1) autogenous versus allogeneic, (2) non- based on an algorithm for the defect size, this approach seems to fail for orbital
resorbable versus resorbable material, (3) the anatomical location, or the remaining fractures. For smaller defects (types I
malleable versus preformed anatomical structural support.5 Small defects may and II), the strength of the reconstruction
plates, and (4) pre-fabricated versus cus- heal solely by the formation of scar tissue, material holds limited relevance for a
tom-made implants. whereas larger defects, especially those successful outcome.6 Rather, the choice
The indication for repair of orbital wall associated with enophthalmos and hypo- of material is more dependent on biocom-
fractures is based on a combination of globus, need material of a sufficient patibility.5 In larger fractures (types III
and IV), mechanical properties and the
contour or form factor needs special con-
Table 1. Types of materials used for orbital reconstruction. sideration, as well as biocompatibility.
Biological materials The orbit remains a controversial entity
Autografts/autogenous materials in the human body with respect to the
Autologous bone
appropriate material for fracture repair.
Calvarium; iliac crest; rib, anterior sinus maxillary wall; mandibular symphysis
Maxillary sinus wall Today, the search for a material with ideal
Autologous cartilage characteristics is ongoing (Table 2).
Nasal septum or concha; auricle; rib The aims of this study were (1) to
Autologous fascia provide a comprehensive overview of
Tensor fascia lata; temporal fascia the advantages and disadvantages of both
Autologous periosteum traditional and new materials for the re-
Allografts construction of traumatic orbital defects,
Lyophilized dura mater; demineralized human bone; lyophilized cartilage; irradiated fascia (2) to define the ideal characteristics of
lata implant materials for future research, and
Xenografts and animal-derived materials
Collagen membrane; porcine sclera; porcine skin gelatin/Gelfilm; bovine bone or sclera
(3) to offer evidence-based clinical recom-
Biological ceramics (inorganic, non-metallic) mendations regarding the best suitable
Porous hydroxyapatite (HA) and other calcium phosphates material available.
Bioactive glasses (BAG)
Metals
Titanium Advantages and disadvantages of
Cobalt alloys currently available reconstruction
Polymers (plastics) materials
Non-porous non-resorbable (permanent) implants
Silicone; nylon (SupraFOIL; Supramid); polytetrafluoroethylene (PTFE; Teflon, Gore-Tex); Biological materials
hydrogels, PEEK, PEKK
Biological materials are defined as grafts
Non-porous resorbable implants
Hyaluronate/carboxymethylcellulose (HA/CMC; Seprafilm) harvested from the same or another human
Porous non-resorbable implants or animal and include autografts, allo-
Porous polyethylene (PE; Medpor) grafts, and xenografts. Autologous grafts
Porous resorbable (absorbable) implants are characterized by cost-effectiveness but
Poly(lactic acid) (PLA); poly(glycolic acid) (PGA); PLA/PGA implants limited availability, variable resorption
Polydioxanone (PDS); polyglactin 910/PDS implants (Ethisorb) rates leading to unpredictable (orbital)
Composites volume, associated donor site morbidity
HA-reinforced high density composite (HAPEX) (pain, scarring, infection, haematoma),
Titanium/PE composite implant (Medpor Titan) and an increased surgical time. In the past,
HA/PLLA/polycaprolactone (PCL) sheet
Bone morphogenetic protein-loaded gelatin hydrogel
viral infections and other diseases (e.g.
PLA-based polymer sheet bovine spongiform encephalopathy and
Periosteum/polymer complex Creutzfeldt–Jakob disease) originating
Gelatin hydrogel (dogs) from the donor tissue have been reported
HA nanoparticles/cyclic acetal hydrogels for allografts and xenografts.
Bone marrow-coated PCL scaffolds (pigs) Since the 18th century, autologous bone
PEEK, poly(aryl ether ether ketone); PEKK, poly(aryl ether ketone ketone); PLLA, poly-L-lactic has been the ‘gold standard’ biomaterial
acid. for the reconstruction of bony defects in

Please cite this article in press as: Dubois L, et al. Controversies in orbital reconstruction—III. Biomaterials for orbital reconstruction: a
review with clinical recommendations, Int J Oral Maxillofac Surg (2015), http://dx.doi.org/10.1016/j.ijom.2015.06.024
YIJOM-3206; No of Pages 10
Controversies in orbital reconstruction—III
Table 2. Ideal orbital reconstruction material characteristics.
1. Stability and fixation Strong enough to support the orbital content and related forces
Ability to be stable and retain its shape once manipulated
No deformation (sagging of material into maxillary sinus)
under pressure load
Stable over time
Possibility of being fixed to surrounding structures
2. Contouring and handling Restores adequate volume to treat enophthalmos, diplopia,
and motility disorders
Easy to shape to fit the orbital defect and regional anatomy/
malleability
Adequate in three-wall fractures
No sharp edges and smooth surface
3. Biological behaviour Biocompatibility: no infection/extrusion/migration/foreign
body reaction
Chemically inert, non-allergenic, non-carcinogenic
Durable with minimal resorption
Osteoinductive/osteoconductive
High tissue incorporation but readily dissected in implant
removal during secondary reconstruction
4. Drainage Spaces within the implant to allow drainage of orbital fluids
5. Donor site morbidity Does not increase surgical complication rate/donor site
morbidity (pain, swelling, etc.)
6. Radiopacity Radiopaque to enable radiographic evaluation without
artefacts
7. Availability and Readily available in sufficient quantities
cost-effectiveness Acceptable costs
the craniofacial area.7,8 Autologous bone latter is in contrast to calvarial bone,
grafts are used in orbital surgery because which is intramembranous in origin and
of their strength, rigidity, vascularization is more stable. Resorption rates of 80%
potential, and incorporation into the orbit- have been observed in iliac crest bone
al tissues with minimal acute and chronic grafting.11 Resorption may be decreased
immune reactivity (i.e. infection, extru- by fixating of the graft, which promotes
sion, collagenous capsule formation, and revascularization and osteoconduction.13
ocular tethering).9 Calvarial bone appears Despite the popularity of autologous
to be a superior option in orbital recon- bone, cartilage is easier to harvest and
struction because of its accessibility, the much more malleable, and the relative
various graft sizes that can be harvested, avascularity of this tissue allows survival
the hidden nature of the scar as a result of with minimal oxygen perfusion and less
its location in a hair-bearing area, and the resorption.14 The nasal septum is particu-
occurrence of little or no postoperative larly advantageous because of the rapid
pain.10 Donor site morbidity remains a harvest time and the minimal cosmetic and
general drawback for autologous bone functional morbidity.15 Bayat et al.16 per-
harvesting. In full-thickness calvarial har- formed a randomized clinical trial (RCT)
vesting, care has to be taken not to tear the and found a superior effect for nasal carti-
dura, since this injury carries the risk of lage versus conchal cartilage with respect
iatrogenic subarachnoid haemorrhage or to the occurrence of enophthalmos at the
even intracerebral haemorrhage10 and 3–6-month follow-up. A second RCT
might require reconstruction itself. Iliac found no significant differences in the
crest grafting carries an associated risk of clinical outcomes of orbital fractures
peritonitis, haemorrhage, pain, anterior repaired with either a cartilage graft or
spine fracture, lateral femoral cutaneous an absorbable polyacid co-polymer.17 In
nerve damage, increased hospitalization cartilage grafting, limited donor site mor-
time, and possibly thrombo-embolism.11 bidity is involved. The major drawback of
Additional disadvantages of autologous cartilage use is acquiring sufficient tissue
bone are the difficulty that can occur in for large orbital defects.
contouring the bone to the perfect shape Allografts (syn. homografts) are trans-
(e.g. because of fracturing of the graft with planted tissues (e.g. lyophilized dura ma-
bending). In addition, autologous bone ter or banked (demineralized) bone) from
grafting is associated with unpredictable another human being. Their advantages
resorption, especially rib and iliac bone, include a decreased surgical time, preop-
which are of endochondral origin.12 The erative customizability, absence of donor
Please cite this article in press as: Dubois L, et al. Controversies in orbital reconstruction—III. Biomaterials for orbital reconstruction: a
review with clinical recommendations, Int J Oral Maxillofac Surg (2015), http://dx.doi.org/10.1016/j.ijom.2015.06.024
3
site morbidity (only in cadavers), and
abundant availability of banked (deminer-
alized) bone.1 Lyophilized dura (Lyodura)
was a standard in the past for the recon-
struction of smaller orbital defects because
of its strength and absence of tissue reac-
tions.18 However, it became controversial
following a case of Creutzfeldt–Jakob pri-
on disease in a patient who received dura
originating from a cadaver.19 Consequent
to this report, lyophilized dura sterilization
was no longer performed with gamma
irradiation but with sodium hydroxide.20
The disadvantages of allografts include a
resorption rate substantially higher than
that of autologous tissue,9 the need for
immunosuppressive pharmacotherapy,
and the alleged risk of viral transmission,
such as hepatitis C virus21 and HIV.22
Demineralized bone sheets of 100–300-
mm thickness have been shown to be too
weak to support orbital prolapse in cases
with enophthalmos.23
The use of xenografts in bone recon-
struction is generally not encouraged be-
cause it is associated with disease
transmission, immunological transplant
rejection, and unpredictable and high
resorption rates.1 In contrast to biological
materials, the use of manufactured
implants saves operative time and avoids
donor site morbidity.
Metals
Titanium has been used extensively in
craniofacial surgery and dentistry in the
form of implants, plates, and screws.24
With its high biocompatibility and phy-
sico-mechanical properties, it could be
an ideal implant for covering large ana-
tomical defects (categories III–V) and
globe malposition if implant-stabilizing
surrounding bone or a distal landmark
(a ‘bony ledge’) is absent.2
An attractive feature of titanium is
its ability to be both incorporated into
the surrounding tissues and to osseointe-
grate.24 Titanium mesh seems to be
particularly suitable for reconstructing
large orbital fractures. Computer-
assisted designed and manufactured
(CAD/CAM) titanium implants have en-
abled optimal reconstructive surgery,
with the protection of vital structures
such as the optic nerve.25 Titanium is
strong, rigidly fixable, widely available,
and is subject to osseointegration with
minimal foreign body reaction.26 How-
ever, titanium is costly and may have
irregular edges if not cut properly, which
may impinge soft tissue. Furthermore,
fibrous tissue will incorporate the
mesh-holes, which can make implant
YIJOM-3206; No of Pages 10
4 Dubois et al.
replacement technically complex.26 Late
unwanted effects such as infection, cor-
rosion, and toxic metal ion release have
been reported with the use of titanium
implants.24 One RCT has evaluated the
effects of titanium implants as compared
to perforated polydioxanone (PDS) foil
for small orbital floor fracture recon-
struction, and found no significant differ-
ences in the clinical outcomes.27 A pilot
study without controls used a low-profile
0.25-mm titanium plate in large defects
(categories II and III) and found success-
ful clinical outcomes without complica-
tions in 93% of the cases; at the 6-month
follow-up, no functional or aesthetic con-
cerns were observed.28
Cobalt-based alloys such as vitallium
are used widely in dentistry for their high
resistance to corrosion. These alloys pro-
duce large artefacts on CT and magnetic
resonance imaging (MRI) and have rarely
been used in orbital surgery.29 These
materials have been replaced by titanium
in general prosthesiology.
Polymers
Polymers (or plastics) are large molecules
comprising multiple repeated subunits and
can be categorized into absorbable and
non-absorbable (permanent) types.
Non-absorbable permanent polymer
implants
Porous ultra-high density polyethylene
(PE; Medpor) sheets of various sizes
and thicknesses (0.4–1.5 mm) have been
used widely to cover smaller floor defects
since the 1990s. This widespread use is a
product of the ability to easily cut the
sheets into various shapes and the ability
of orbital tissue to move freely over the
smooth surface.30 Connective tissue and
vascular components grow into the pores
with minimal foreign body reaction.29 In a
prospective cohort study of floor recon-
structions, PE sheets showed satisfactory
surgical outcomes and infection rates sim-
ilar to autografts.5
Silicone is flexible, easy to handle,
chemically inert, and relatively cheap.1
Silicone implants are substantially less
palpable than non-silicone implants (auto-
grafts, titanium, or resorbable plates).31
However, unacceptably high rates of im-
plant extrusion, cyst formation, and infec-
tions have been found, especially in the
early postoperative period.32 Indeed, 12%
of orbital silicone implants require remov-
al within 1 month after placement.33
Polytetrafluoroethylene (PTFE; Tef-
lon) is biologically and chemically inert,
Please cite this article in press as: Dubois L, et al. Controversies in orbital reconstruction—III. Biomaterials for orbital reconstruction: a
review with clinical recommendations, Int J Oral Maxillofac Surg (2015), http://dx.doi.org/10.1016/j.ijom.2015.06.024
non-antigenic with minimal foreign body
reaction, sterilizable, and easily mould-
able. However, this polymer has not
yet been subject to comparative clinical
studies.
Relatively new in orbital floor repair is
the use of nylon foil, a non-porous poly-
amide. Nylon foil has provided favourable
results in preliminary non-comparative
studies.34,35
Hydrogels are a network of hydrophilic
polymer chains in a watery gel, and pos-
sess flexibility similar to natural tissue.
Hydrogels have shown promising results
in animal research in delivering bone mor-
phogenetic protein type 2 (BMP-2) local-
ly, significantly stimulating local bone
growth.36
Absorbable polymer implants
These materials have been used widely
for over 30 years in many fields of surgi-
cal practice,37 and are of interest because
of their more predictable absorption rates
than biological grafts, as well as their
high level of customizability and con-
trol.38 Resorbable materials provide tem-
porary support, leaving fibrous
granulation tissue during their degrada-
tion.39 These materials do not necessarily
require rigid fixation, can be applied in
multiple layers in larger orbital volume
displacement, and can be radiolucent on
postoperative imaging.
In an RCT, the administration of an
absorbable copolymer of poly(lactic acid)
(PLA) and poly(glycolic acid) (PGA) had
functional and aesthetic outcomes and
complications similar to auricular carti-
lage implants in orbital blowout fractures
with or without medial wall involve-
ment.17 In addition, PLA 70/30 plates
were studied in a controlled clinical trial
and showed similar surgical outcomes and
complications as compared to autografts
in category II and III floor defects, without
MRI evidence of foreign body reaction.40
Polydioxanone (PDO, PDS) is used
widely in surgery for resorbable sutures,
which degrade completely in approxi-
mately 6 months. In a multi-centre RCT,
perforated PDS foils of 0.15-mm thickness
were found to have surgical outcomes
similar to 0.3-mm titanium meshes in
orbital floor reconstructions, although
PDS foil was considered to be more con-
venient to handle.27 Another RCT com-
pared the use of a porcine collagen
membrane to a 0.15-mm PDS foil and
observed that complications and clinical
symptoms remained absent for 6 months
after orbital floor surgery.41 In one pro-
spective case series, PDS implants were
suggested as inadvisable because of un-
satisfactory orbital reconstructions and
high complication rates.11
In a retrospective cohort study, recon-
structions with polyglactin 910/PDS
(Ethisorb) flexible patches showed a simi-
lar postoperative orbital geometry as com-
pared to 0.25-mm PDS foil in floor
reconstructions.42 In contrast to reports
that polyglactin 910/PDS implants have
high infection rates,43 a retrospective
study of 87 patients treated with this ma-
terial found no postoperative infections
during a 3-month follow-up.39
Biological ceramics
Hydroxyapatite (HA), which is chemical-
ly and crystallographically similar to
bone mineral, has been available for cra-
niofacial surgery since the 1990s.44 How-
ever, in orbital surgery, it has been found
to be inferior to porous PE sheets with
regard to the postoperative outcomes of
enophthalmos.45
Bioactive glasses (BAGs) are synthetic
blocks or granules that bond chemically to
bone. The disadvantages of BAGs include
their rather brittle nature and the lack of
ease in moulding, shaping, and fixing
them.46 Nonetheless, these materials have
been demonstrated to be osteoinductive
and osteoconductive as implants,47 and
to cause minimal foreign body reaction,
infection, extrusion, displacement, and
resorption.46,48 The benefits of preformed
bioglass implants need further research.
Composites
An interesting group of orbital implants is
the composites because of the potential to
utilize the advantages of a selected mate-
rial while reducing its disadvantages
through hybridization with a second ma-
terial. A reciprocal process can allow the
strengths of both materials to be used. A
clinical example is titanium-reinforced
PE. Titanium mesh offers the advantages
of high strength and stability, easy con-
touring, and radiopacity in postoperative
imaging, while PE implants have a smooth
surface allowing the free movement of
orbital tissue. In recent years, a composite
material (titanium-reinforced porous PE)
has become available for maintaining oc-
ular function and facilitating a secondary
surgery if necessary.49 A retrospective
chart review found no significant differ-
ences in the clinical outcome measures
between PE channel implants versus PE-
reinforced titanium implants. Kim et al.50
suggested that reinforced titanium PE
implants do not require screw fixation.
YIJOM-3206; No of Pages 10
A promising addition to polymers may
be an extra coating. Heparinized bone
marrow-coated polycaprolactone (PCL)
scaffolds have shown promising potential
in animal research, showing significantly
greater bone induction in comparison to
non-coated PCL scaffolds.51
To conclude, the predominant material
investigated in the literature in the 1990s
was autologous bone (45% bone versus
32% Medpor or titanium). A global trend
towards the use of alloplastic material for
orbital reconstruction can be identified.
This trend is reflected in more recent
publications, in which alloplastic materi-
als have been chosen increasingly for
orbital reconstruction (30% bone graft
versus 46% alloplastic implants). This
increasing preference for alloplastic mate-
rials is likely the result of their ease of use,
technological advancements, absence of
donor site morbidity, and an increasing
level of evidence of the safety and efficacy
of synthetic materials for this indication.52
The ideal implant material
Introduction
In the search for the best material for
orbital reconstruction, the most conve-
nient approach may involve searching
for the optimal material with reference
to the fracture characteristics (e.g. fracture
complexity, medical history, experience
of the surgeon, costs). This approach could
support a decision-making process for
selecting an implant type based on typical
fracture patterns. Seven material charac-
teristics that would necessarily influence
this clinical decision-making process are
discussed (Table 3): (1) stability and fixa-
tion, (2) contouring abilities, (3) biological
behaviour, (4) drainage, (5) donor site
morbidity, (6) radiopacity, and (7) avail-
ability and cost-effectiveness. Future
developments and new technologies are
discussed as well.
Stability and fixation
Restoring the original orbital volume
is essential for recovering ocular
function.53,54 To accomplish this, a reli-
able material that can reconstruct proper
orbital volume and reposition the support-
ing tissues without significant resorption is
required. Numerous materials have been
used to achieve anatomical reconstruction
and these differ with respect to their sta-
bility. Van Leeuwen et al.6 have devel-
oped a mathematical model to judge
preoperatively whether a material is suit-
able based on four variables that influence
Please cite this article in press as: Dubois L, et al. Controversies in orbital reconstruction—III. Biomaterials for orbital reconstruction: a
review with clinical recommendations, Int J Oral Maxillofac Surg (2015), http://dx.doi.org/10.1016/j.ijom.2015.06.024
Controversies in orbital reconstruction—III
deformation: (1) the size of the orbital
defect, (2) the mechanical properties of
the reconstruction material, (3) the thick-
ness of the reconstruction material, and (4)
the pressure load of the orbital content.
Based on the properties of various bioma-
terials, the authors concluded that not all
materials were suitable when varying de-
fect sizes were considered.6 In particular,
Jaquiéry category I and II defects can be
treated safely with titanium, bone, PLA,
and PE (see Table 4).6 For these small
defects, a flexible material may generally
be sufficient, whereas for the reconstruc-
tion of larger defects (Jaquiéry III and IV),
a more rigid material (e.g. titanium) is
required. Gross soft tissue prolapse, orbit-
al pressure, and the absence of a posterior
bony ledge are decisive factors.3,6
Autologous bone is prone to resorption,
possibly leading to loss of stability and
contour over time. Resorption rates of up
to 80% have been observed in iliac crest
bone grafting.11 Resorption may be de-
creased by fixation of the graft, facilitating
subsequent revascularization and osteo-
conduction.13
Resorbable implants are of interest be-
cause of their predictable resorption rates,
high levels of customizability, and con-
trol.38 Resorbable materials provide tem-
porary support, producing fibrous tissue
during degradation.39 Van Leeuwen et al.6
showed that the material properties of
some resorbables are stable enough to
support the orbital content. In contrast,
others have demonstrated an increase in
orbital volume as a late complication.11,55
For all orbital implants, fixation is re-
quired to prevent migration, which may
lead to infections, fibrosis, and scarring,
and may incidentally result in diplopia and
even blindness.56–60 With the exception of
bioglass, most orbital implant materials
can be fixed easily to the surrounding
tissue, mostly the bone. If the orbital
rim is comminuted, fixation may be more
complex. Titanium mesh may help to
secure (or replace) the bony pieces.
Contouring
The size of the bony defect is important in
choosing the alloplast material for recon-
struction. Larger fractures have more var-
iability in the defect shape, and failure to
place the implant in a correct position
might lead to atrophy, contractions, and
herniated tissue.61 In most situations, un-
less pre-bent plates are used, the restora-
tion of the complex anatomy of the orbit
requires a significant effort in contouring
the implant. Bony orbital walls are often
comminuted, and bone fragments are
5
often displaced into the maxillary sinus.
In this context, reconstruction of the ab-
sent pieces of bone is essential to support
the globe and restore orbital shape. CT is
the single best method for imaging in
orbital fractures and planning orbital re-
construction.62 Intraoperative and postop-
erative CT scanning aids the surgeon in
evaluating the result of reconstruction.
Suboptimal alignment of the implant does
not necessarily lead to clinically relevant
enophthalmos or diplopia.63 Nevertheless,
anatomical reconstruction of the bony or-
bit is an important prerequisite for predict-
able reconstruction.2
Among the materials available, titanium
mesh is the easiest material to shape an-
atomically, especially when an intraoper-
ative skull model is used for adaptation of
the implant. Ellis and Tan64 demonstrated
that titanium mesh is architectonically
more accurate in form than bone grafts.
However, controversy exists in the use of
preformed titanium mesh versus intraop-
erative bending of titanium meshes. A
cadaver-based study found no significant
differences in volume restoration between
patient-specific implants (PSI) moulded
on a pre-injury stereolithographic model,
self-bent titanium meshes, and preformed
titanium meshes.65 Preformed implants
may be more advantageous because of
versatility and costs.65 Andrades et al.63
concluded that pre-bent titanium implants
are superior in terms of optimal recon-
struction in comparison to other implants.
In large defects (Jaquiéry III–VI), the
implant contour becomes an increasingly
important factor for repositioning the
globe into a correct position.66
Biological behaviour
In addition to being perfectly accepted by
the acceptor area, autografts are both
osteoconductive and osteoinductive if
fixed properly, and elicit minimal foreign
body reactions.9 However, autografts are
associated with high resorption rates.13
Despite the popularity of autologous
bone, cartilage is easier to harvest and
much more malleable. Additionally, its
hypovascularity allows survival with min-
imal oxygen perfusion, and this might
explain why this tissue is less subject to
resorption.14
The role of resorbable materials is to
provide temporary support, leaving fibrous
tissue during and after their degradation.39
Late inflammation reactions may occur
even up to 3 years after surgery,67 and
incomplete degradation and thick scar for-
mation have been described. In particular,
animal studies found that poly-L-lactic acid
 6

YIJOM-3206; No of Pages 10
Table 3 . Advantages and disadvantages of commonly used biomaterials.
review with clinical recommendations, Int J Oral Maxillofac Surg (2015), http://dx.doi.org/10.1016/j.ijom.2015.06.024
Please cite this article in press as: Dubois L, et al. Controversies in orbital reconstruction—III. Biomaterials for orbital reconstruction: a

Biological Donor site

Dubois et al.
Stability Contouring behaviour Drainage morbidity Radiopacity Availability Cost-effectiveness
Titanium meshes (flat)
Stability +++ ++ contouring ++ allows tissue + permeable + + + +
ingrowth
Fixation ++ ! possible sharp ! poor dissection
edges of peri-orbita in
secondary
reconstruction
Bone graft
Stability ++ + variability in +++ maximal ! ! donor site + +/! +/!
thickness/smooth biocompatibility/ needed: harvest
surface adequate peri-orbita time/pain/
in three-wall readily dissects scarring/
fractures off bone in complications
Fixation + ! remodelling/ secondary
difficult to shape reconstruction
Porous polyethylene sheets
Stability+! + eased by ++ allows tissue ! + ! not visible on + +
Lack of rigidity when thin artificial sterile ingrowth postoperative
Fixation+/! skull/smooth imaging
edges
Composite of porous polyethylene and titanium mesh
Stability ++ + eased by ++ allows tissue ! + + + +/!
Fixation ++ artificial sterile ingrowth
skull, adequate in
three-wall
fractures
Resorbable materials
Stability+/! + smooth surface +/! sterile ! in case non- + ! not visible on + +
and edges/ infection/ perforated: less postoperative
handling inflammatory drainage than imaging
(thermoplastics) response uncovered
Stable over time? ! non- titanium mesh
thermoplastics
Fixation+/! ! degradation of
material with risk
of contour loss
Preformed orbital implant
Stability +++ +++ minimal ++ allows tissue + permeable + + + +/!
Fixation ++ contouring ingrowth
necessary/
smooth surface
YIJOM-3206; No of Pages 10

Controversies in orbital reconstruction—III 7

Table 4 . Modified classification of orbital wall defect size.
Category Complexity Description Note
Category I Low Isolated defect of the orbital floor
or the medial wall, 1–2 cm2, within
zones 1 and 2
Category II Medium Defect of the orbital floor and/or of Bony ledge preserved
the medial wall, >2 cm2, within at the medial margin of
zones 1 and 2 the infraorbital fissure
Category III High Defect of the orbital floor and/or of Missing bony ledge
the medial wall, >2 cm2, within medial to the
zones 1 and 2 infraorbital fissure
Category IV High Defect of the entire orbital floor and Missing bony ledge
the medial wall, extending into the medial to the
posterior third (zone 3) infraorbital fissure
(PLLA) had not fully degraded within 5 are likely to increase the risk of traumatic
years,68 while PDS degradation was asso- haemorrhage.77 Maurer et al.78 found that
ciated with thick scar formation.11 PDS is anticoagulant therapy was associated with
not approved for orbital reconstruction in a significantly increased risk of retrobul-
the USA because of the significant postop- bar haematoma. In this previous study, the
erative sequelae, including sensory distur- incidence of retrobulbar haematoma in
bances (59%), restriction of motility (38%), patients on anticoagulant therapy with
and enophthalmos (24%).69 orbital fractures was 2.4%; this percentage
The stability of the position of non- increased to 8.8% in the geriatric group.
resorbable implants is dependent on the Anti-platelet therapy alone (e.g. aspirin)
degree of acute (e.g. sterile inflammation did not increase the risk.79
or infection) and chronic (capsulation, mi- No study has been published in the
gration, extrusion) peri-orbital tissue reac- literature on the advantages of a perme-
tion. Early integration in the acceptor area able material that could drain a possible
is advantageous for implant stability, but intra-orbital haemorrhage into the maxil-
might decrease the possibility of removal in lary sinus or ethmoids. Perforations in an
secondary reconstruction and replacement orbital implant can be beneficial in these
(e.g. if a fibrous capsule is present). cases. Titanium mesh probably has the
Hence, the reconstruction may become best implant design because of its perfora-
increasingly technically complex.26 tions, and it is suitable for large orbital
Bioactive glasses exhibit both osteoin- wall defects, where most haemorrhage is
ductive and osteoconductive properties seen.
with little overall resorption.46–48 Exces-
sively large implants can alter the nutri-
Donor site morbidity
tional supply to the adjacent structures.70
The physical form of a material can in- By choosing an autogenous graft for or-
crease the host response.70–72 bital reconstruction, the consequence is a
Titanium is highly biocompatible and second surgical site with its own specific
the rate of postoperative infection is mini- after effects. There is the initial extra
mal.23,64 However, late unwanted effects surgical time needed for the procedure,
such as corrosion and toxic metal ion which can be reduced if the surgeons can
release have been described.73,74 Current- work in two teams.
ly, no allogeneic implant material exerts
the ideal biological behaviour.
If the anterior iliac crest is selected,
various complications can be encountered,
including sensory disturbances, vascular
injuries (e.g. bleeding or haematoma),
seroma, fracture of the iliac crest, and
accidental perforation of the lower abdo-
men. Postoperatively, gait disturbance
together with pain at the donor site can
occur. The pain experienced during mo-
bilization can result in restricted activity
and thereby lead to extra costs for both the
patient and community.
Some surgeons prefer calvarial bone
harvesting for orbital reconstructions be-
cause of the lower resorption rates and
decreased postoperative pain.80 Compli-
cations encountered with calvarial bone
grafts are alopecia along the incision line,
bleeding from the incision site, and inner
table perforations with or without dural
tear. In the presence of damage to the dura,
leakage of the cerebrospinal fluid will
occur. In the worst case scenario, brain
injury may occur.
Autologous cartilage grafts from the
auricle are considered a relatively safe
procedure with minor complication rates
and favourable aesthetic outcomes. Com-
plications can include the formation of
haematoma and sensory impairment con-
fined to the concha (donor site). In terms of
anthropometric measurements, resultant
differences in the length and width of
the affected ear, in the tragus–lateral can-
thus distance, and in the protrusion angle
of the involved ear may occur. Overall,
these findings are minor and are not con-
sidered a contraindication to harvesting
ear cartilage.
Radiopacity
The accuracy of an anatomical reconstruc-
tion can be evaluated by peri- or postop-
erative imaging. Visibility of the implant
material (bone or titanium) on CT scans is
of immense importance in challenging

Drainage
Retrobulbar haematoma is one of the most
serious complications after orbital recon-
struction. The reported incidence of retro-
bulbar haematoma in the literature is about
0.6%.75 If postoperative impairment of
vision due to retrobulbar haematoma
becomes evident, an immediate surgical
intervention is essential. It is more likely
to occur in heavily traumatized patients
with comminuted fractures and in patients
taking anticoagulant medication.76 Both Fig. 1. The orbital implant (titanium mesh) is positioned below the ledge, resulting in an
anticoagulant and anti-platelet therapies increased orbital volume.

Please cite this article in press as: Dubois L, et al. Controversies in orbital reconstruction—III. Biomaterials for orbital reconstruction: a
review with clinical recommendations, Int J Oral Maxillofac Surg (2015), http://dx.doi.org/10.1016/j.ijom.2015.06.024
YIJOM-3206; No of Pages 10
8 Dubois et al.
injuries with severe dislocation of the
orbital walls, e.g. in orbits with an absent
posterior bony ledge. In these cases, lim-
ited visibility of the deep surgical field and
the absence of a palpable ledge may cause
the distal end of the plates to be placed too
low (see Fig. 1). A good implant in a bad
position will lead to a suboptimal result.63
To prevent poor implant positioning, ac-
curate preoperative planning by mirroring
a defined three-dimensional segment from
the unaffected side onto the deformed/
traumatized side with computer-assisted
techniques is an important aid for precise
and predictable results.81 Navigation can
be beneficial, but imaging is the gold
standard for peri- and postoperative eval-
uation of the position of the implant.
Evaluation of the postoperative results is
equally important for the learning curve of
the surgeon and might help to predict
postoperative enophthalmos.
Availability and cost-effectiveness
Availability is a relative parameter related
to economic and local circumstances and
hospital interest and availability. Stocks of
alloplasts can be limited in some parts of
the world. Under these circumstances, the
harvesting of bone grafts may be prefera-
ble, and in the case of orbital reconstruc-
tion, several options are available for the
donor site. However, alloplasts reduce
both the operation time and hospitaliza-
tion because of the lack of donor site
morbidity.
Pre-bent or preformed alloplastic mate-
rials are even more advantageous and have
shortened the operating time compared to
other alloplasts.65
Technological advantages
Computer-assisted surgery (CAS) may be
beneficial to the outcome of orbital recon-
struction. The use of three-dimensional
reconstruction in CT imaging and virtual
planning offers accurate and individual-
ized assessment and planning for the res-
toration of orbital walls and orbital
volume.82,83 Since more complex preop-
erative planning and intraoperative navi-
gation have become available, it has been
demonstrated repeatedly that CAS is help-
ful in achieving more predictability in
orbital reconstruction.83,84 One of the
greatest advantages of CAS is the possi-
bility of checking the implant fit preoper-
atively in a digital environment. With
stereolithographic files (stl) of pre-shaped
implants, the best possible anatomical fit
can be targeted. These digital stereolitho-
graphs may be pre-shaped or individually
Please cite this article in press as: Dubois L, et al. Controversies in orbital reconstruction—III. Biomaterials for orbital reconstruction: a
review with clinical recommendations, Int J Oral Maxillofac Surg (2015), http://dx.doi.org/10.1016/j.ijom.2015.06.024
designed (PSI). This digital planning is not
material-specific: the only prerequisite is
that the material has rigidity such that the
digitally formed shape is coherent with the
actual shape of the implant, even after
manipulation. To date, titanium mesh is
most in concordance with this prerequi-
site. In the future, other modern materials
such as bioglass, hydrogels, and poly-
ether-ether cones and composites may
be fabricated as custom implants or pre-
formed scaffolds using new techniques for
rapid prototyping.85,86
Clinical recommendations
The debate on the clinical recommenda-
tions for orbital reconstruction material
will likely continue because of the absence
of RCTs and best practice clinical studies.
The predominant factor regarding the
most suitable material characteristic may
be the defect size and to a lesser extent the
defect location. Availability is also an
important variable and is dependent on
geographic and economic backgrounds.
Nonetheless, based on the literature and
material characteristics of the different
types of orbital implants, it is possible
to derive clinical recommendations for
materials in specific cases.
Treatment algorithm for orbital wall
fractures
1. Small-sized, low-complexity defects
(class I): Most materials are suitable;
biological behaviour is most important
and resorbables may be used in these
cases.
2. Medium-sized, medium-complexity
defects (class II): Apart from the bio-
logical behaviour of an implant, the
experience of the surgeon with specific
types of orbital implants will benefit
the outcome. Various materials can be
used, from autologous materials to
alloplasts (e.g. PE or titanium).
3. Large-sized, high-complexity defects
(classes III–VI): Stability and contour
become more significant, and pre-bent
or patient-specific titanium mesh is the
preferred reconstruction material.
Further additional factors of influence
are: (1) the chosen surgical approach (skin
versus transconjunctival), (2) the need for
simultaneous orbital rim reconstruction,
which favours titanium, (3) costs, (4) op-
erating time availability, with effective
use of operating room time favouring
the use of alloplasts, (5) patients on anti-
coagulant therapy will favour the use of
mesh for drainage reasons, (6) experience
of the surgeon in dealing with certain
materials or in harvesting grafts, (7) the
availability of modern planning tools (e.g.
for PSI fabrication), (8) the availability of
navigational surgery for stereolitho-
graphic virtual planning for .stl based on
preformed titanium implants, and (9) the
availability of intraoperative CT scanning.
Funding
None.
Competing interests
None declared.
Ethical approval
Not required.
Patient consent
Not required.
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Address:
Leander Dubois
Department of Oral and Maxillofacial
Surgery
Academic Medical Centre
Academic Centre for Dentistry Amsterdam
University of Amsterdam
Meibergdreef 9
1105 AZ Amsterdam ZO
The Netherlands
Tel: +31 20 5661364;
Fax: +31 20 5669032
E-mail: L.Dubois@amc.uva.nl
Int. ~ Oral Maxillofac. Surg. 2000; 29:264 267 Copyright © Munksgaard 2000
Printed in Denmark. All rights reserved
InternadonalJoumd of
Oral &
MaxillofacialSurgery
ISSN 0901-5027

Trauma; oral surgery; implantology

Transcaruncular approach for

Arnulf Baumann, Rolf Ewers
Clinic of Oral and Maxillofacial Surgery,
Medical School, University of Vienna, Austria

reconstruction of medial
orbital wall fracture
A. Baumann, R. Ewers: Transcaruncular approach for reconstruction o f medial
orbital wall fracture. Int. J. Oral Maxillofac. Surg. 2000; 29: 264-267.
© Munksgaard, 2000

Abstract. Medial orbital wall fractures can cause horizontal diplopia and
enophthalmos. Therefore, reconstruction of displaced medial wall fractures
should be considered. We used a transcaruncular approach in five male patients
to reconstruct the medial orbital wall after acute injuries and also as a secondary
procedure for enophthalmos correction. Four of these patients had a concomitant
orbital floor fracture. The incision was made in the caruncule and extended in the
conjunctiva superior and inferior into the fornices for 10-12 mm. The tissue was
bluntly dissected in an anteroposterior direction. The periosteum was incised
dorsal of the posterior lacrimal crest and after elevation of the periosteum, the
fractured orbital wall was visible. Transplants up to a height of 2 cm could be
inserted for reconstruction of the medial orbital wall. In the cases of acute
trauma, the medial wall was reconstructed using a resorbable polydioxanone Key words: transcaruncular approach; medial
orbital wall fracture; enophthalmos;
plate. Cortical bone was used for the reconstruction of late enophthalmos. No
reconstruction.
postoperative complications were found. The transcaruncular approach gave a
rapid entry to the fractured medial orbital wall without a visible scar. Accepted for publication 19 April 2000

The medial orbital wall fracture has
been described but, unlike the classical
blow-out fracture of the orbital floor,
has not received a great deal of atten-
tion. A medial orbital wall fracture can
easily be overlooked because there are
clinical symptoms in only a few in-
stances. Suggestive symptoms of a me-
dial orbital wall fracture may be sub-
cutaneous emphysema, epistaxis, peri-
orbital oedema, ecchymosis, and nar-
rowing of the palpebral fissure. Eye
symptoms like horizontal diplopia with
limitation of adduction, restriction of
abduction, and globe retraction are
seldom found. These eye symptoms are
explained by muscle entrapment and
are indications for operative treatment
of a medial orbital wall fracture 1I'14.
However, if a medial orbital wall frac-
ture is left untreated, enophthalmos
may develop. Volumetric CT-scan
studies in orbital blow-out fractures
showed a major effect of the medial
orbital wall in the degree of en-
ophthalmos is. Therefore it seems ap-
propriate to reconstruct fractures of
the medial orbital wall. Evaluation of
suspected medial wall fractures war-
rant a CT-scan in both an axial and a
coronal view 16.
The various cutaneous approaches
for reconstruction of the medial orbital
wall are not always satisfactory. They
may leave noticeable scars or provide a
limited overview of the medial wall.
With these problems in mind, we
started to use the transcaruncular ap-
proach for reconstruction of the frac-
tured medial orbital wall.
Material and methods
Patients
Since 1998 we have used the transcaruncular
approach in 5 men with fractures of the me-
dial orbital wall. Four of these had an ad-
ditional orbital floor fracture. The mean age
of these 5 patients was 39.8 years. The cause
of the fracture was a personal altercation in
3 patients and a car accident in 2 patients.
All patients had vertical diplopia preopera-
tively.
Two patients had a medial orbital wall
fracture and were treated on the 3rd day after
the trauma. The medial wall was recon-
structed by a PDS ® plate (p-dioxanone). One
of these 2 patients had an additional orbital
floor fracture, which also was reconstructed
with a PDS ® plate.
The 3 other patients developed en-
ophthalmos after a combined orbital floor
and medial wall fracture. The enophthalmos
 Transcaruncular approach for medial orbital wall fracture 265

Orbital septum
Puncture [acrimale

Lacrimal sa,
.~ral
thai
Homer's muscle ]on

Posterior lacrimal crest

~! U~Puneturn lacrimaLe
Incision of periosteur

Fibrous sep

Fig. 1. Incision in the caruncle and extension Medial rectus mt

in the conjunctiva inferiorly and superiorly
(dotted line).
Ethmoid si

was mainly caused by the medial orbital wall,

which was not treated in the first procedure.
The enophthalmos measured 3 to 4 mm and
was corrected 8-12 months after the first
treatment. The reconstruction of the orbital
walls was done with cortical bone grafts from
the mandibular angle.
In the 4 patients with complex orbital frac-
tures, an additional transconjunctival in- Fig. 2. Axial view of the transcaruncular dissection plane to the medial orbital wall. Perios-
cision was used for orbital floor reconstruc- teum is incised posterior to the posterior lacrimal crest.
tion. Pre- and postoperative axial and co-
ronal CT-scans were obtained. All patients
were followed by an ophthalmologist for lac-
rimal, conjunctival injuries and visual con-
trol. The mean follow-up was 12 months.

Surgical technique
The lower and upper eyelids are retracted by
sutures in the tarsus. No adrenaline or saline
is injected. After identification of the lacrim-
al puncta, an incision is made through the
caruncle using Westcott scissors. The incision
is extended by cutting the conjunctiva su-
perior and inferior into the fornices for 10-
12 mm (Fig. 1). The tissue is bluntly dis-
sected in an anteroposterior direction to the
posterior lacrimal crest. The tissue is retrac- Fig. 3. Left medial orbital wall and floor fracture. Reconstruction of the walls was done by
ted by a malleable retractor. The periosteum polydioxane plates (PDS ®) (white arrows).
is incised at the posterior lacrimal crest in a
superior to inferior direction. The incision is
posterior to Horner's muscle, which inserts
at the posterior lacrimal crest (Fig. 2). After to a size o f 2.0 cm in height. Post- operatively (Fig. 3). One year later,
elevation of the periosteum, the medial wall operative CT-scans showed good trans- however, a b u l g i n g o f the r e c o n s t r u c t e d
is visible from the floor to the roof. The an- p l a n t position. T h e residual en- medial wall into the e t h m o i d cells was
terior ethmoid artery can be identified and o p h t h a l m o s m e a s u r e d 0-1 m m . Verti- f o u n d in the c o r o n a l CT-scan. T h e axial
ligated or easily cauterised if necessary. After cal diplopia remains in extreme up- CT-scan showed a deviation o f the optic
repositioning of the displaced periorbital ward gaze in 2 o f the 3 p a t i e n t s with nerve (Fig. 4). T h e r e was n o en-
tissue, an alloplastic material or bone trans-
enophthalmos. o p h t h a l m o s m e a s u r a b l e by Hertel
plant can be inserted to reconstruct the me-
dial orbital wall. The conjunctiva and the One o f the 2 patients, in w h o m the exophthalmometry.
caruncle incision are sutured with 6-0 fast medial wall was r e c o n s t r u c t e d by a N o n e o f the 5 p a t i e n t s h a d a n injury
absorbable suture material. p o l y d i o x a n o n e plate (PDS ®) h a d dip- o f the lacrimal system, o f the c o n j u n c -
lopia in extreme gaze to the left at 1 tiva or o f the medial c a n t h u s p o s t o p e r a -
year. There was n o diplopia at the 3 tively. We also f o u n d n o s y m b l e p h a r o n
Results
m o n t h s p o s t o p e r a t i v e visit. T h e coronal f o r m a t i o n . T h e r e were n o compli-
In spite o f the small incision, it was CT-scan showed correct p o s i t i o n i n g o f cations involving the e t h m o i d sinus in
possible to insert b o n e t r a n s p l a n t s u p the p o l y d i o x a n o n e t r a n s p l a n t post- the follow-up period.
266 Baumann and Ewers
Fig. 4..Axial and coronal CT-scan of the same patient in Fig. 3, one year later. Bulge of the
left medial orbital wall into the ethmoid cells in the coronal CT-scan. Optic nerve deviation
by scars in the axial CT-scan.
Discussion
Operative reconstruction of the medial
orbital wall is warranted for prevention
of enophthalmos and correction of dip-
lopia. True incarceration of the medial
rectus muscle is rare 13. If there are no
eye symptoms and only a displaced me-
dial wall fracture, it may be concluded
that the periorbita is intact and a recon-
struction of the orbital wall is not
necessary. One reason for non-surgical
intervention may be the poor cosmetic
results of the different cutaneous ap-
proaches to the medial orbital wall. The
other reason may be an underestima-
tion of what might occur when the me-
dial wall is not reconstructed. We found
enophthalmos in 3 of our patients,
where the medial wall was not recon-
structed primarily. The effect of the me-
dial orbital wall fracture for the devel-
opment of enophthalmos was under-
estimated. The incidence of isolated me-
dial orbital fractures (54.9%) or in com-
bination with an orbital floor fracture
(26.8%) in orbital blow-out fracture, is
much higher than formerly expected 2.
These results may change the indication
for and also the frequency of operative
reconstruction of the medial orbital
wall.
Medial orbital wall fractures usually
involve the lamina papyracea of the eth-
moid. The lamina papyracea does not
return to the original position after
fracture. It is the thinnest bone of the
orbit. The size of the defect may range
in moderate to severe fractures from 13
to 20 mm in height and from 21 to 34
mm in length2. For enophthalmos pre-
vention, the medial orbital wall should
be reconstructed by a transplant or im-
plant. We used a resorbable alloplastic
polydioxanone material (PDS ®) in the
acute trauma phase, but it seems not
stable enough in a severe medial wall
fracture, as we noted in the postopera-
tive follow-up one year later. On the co-
ronal CT-scan an enlargement of the
medial orbital wall into the ethmoid
cells was visible one year later, in spite
of a good localisation of the transplant
on CT-scan in the immediate postopera-
tive period. The polydioxanone trans-
plant is rigid in the first months and it
will be resorbed and replaced by scar.
Lactosorb ® may be an alternative to
the polydioxanone material. Lacto-
sorb ® is a biodegradable material made
of poly L-lactic acid and polyglycolic
acid (PLLA/PGA). It has a longer ini-
tial strength for 6-8 weeks and will re-
sorb 12-15 months after implantation.
We used this material for fixation of
zygomatic fractures and for reconstruc-
tion of the orbital floor 4. The follow-up
will show whether the scar in the recon-
structed orbital wall is stable enough to
support the fibrous septa with eye
movements. KOORNNEEF6 mentioned
the fibrous septa as a connective tissue
system, which has an important acces-
sory locomotor mechanism for the eye
muscles, the optic nerve and the in-
traorbital fat. There might also be scar-
ring within and around the medial rec-
tus muscle and between the fibrous
septa, which may displace the globe
mechanically to the medial wall. The
displacement of the optic nerve can be
seen in the axial CT-scan (Fig. 4). Both
effects, no stable medial orbital wall
and scarring in the muscle and between
the fibrous septa, may explain the devel-
opment of diplopia in an extreme left
gaze in this patient in the follow-up
period.
The enophthalmos correction em-
ployed cortical bone grafts from the
mandible. These transplants were still in
the same position in the CT-scan after
one year and there was no deterioration
of diplopia in the one-year follow-up.
Therefore reconstruction of the medial
wall with a cortical bone graft seems
better than using resorbable alloplastic
material.
We used the transcaruncular ap-
proach for reconstruction of the frac-
tured medial orbital wail. This ap-
proach gives an optimal and rapid view
of the medial wall without a visible fa-
cial scar. After the caruncule and the
conjunctiva are incised, a blunt and
bloodless dissection in a fatty areolar
tissue plane is done. This dissection is
undertaken between the lacrimal muscle
(Horner's muscle) and the orbital sep-
turn. The orbital septum is redundant
medially and covers the posterior aspect
of the lacrimal muscle. The periosteum
is incised dorsal to the posterior lacrim-
al crest. Therefore neither Horner's
muscle nor the lacrimal system is dis-
turbed or detached. Another advantage
of the transcaruncular approach is that
the myofascial cone and the medial rec-
tus muscle are not injured. This muscle
can be exposed using another technique
employing a conjunctival incision along
the medial limbus9. In this approach the
dissection is carried out between the
conjunctival flap and the medial rectus
muscle. By this procedure the muscle
can be injured.
Another advantage of the transcar-
uncular approach is the preservation of
the anterior ethmoid artery. It does not
need to be ligated as in the Lynch in-
cision during the approach to the me-
dial orbital wall7. Also the posterior
ethmoid artery and the dorsal medial
orbital wall can be identified by this ac-
cess. Therefore it is also useful in fron-
toethmoidal orbital processes or orbital
apex surgery 1.
In comparison to the different cu-
taneous incisions, the transcaruncular
approach offers a preparation line just
at the height of the expected fracture
and gives the possibility of inserting a
transplant/implant under direct view.
By this access we inserted transplants/
implants to the medial orbital wall up
to a height of 2 cm, which is an ade-
quate size for the reconstruction of se-
vere orbital fractures. Most cutaneous
approaches to the medial orbital frac-
ture give an aesthetically unsatisfactory
result and some of these incisions give
poor exposure of the fractured medial
orbital wall.

The traditional cutaneous approach
to the superomedial orbit is the Lynch
incision, which was primarily proposed
for frontoethmoidal sinus surgery s. For
the approach to the medial orbital wall,
the medial canthal tendon and the lacri-
mal sac have to be identified and re-
flected. This can lead to an injury of the
lacrimal system or to an iatrogenic tele-
canthus. The Lynch incision gives good
exposure to the medial orbital wall, but
frequently creates a noticeable scar. The
Lynch incision is therefore seldom used
for pure medial orbital fracture repair.
Another cutaneous approach, the lid
crease incision, avoids one of the disad-
vantages of the Lynch incision - a no-
ticeable scar 5. However, this approach
gives only a limited view of the anterior
and superior part of the medial orbital
wall because the dissection plane comes
from a cranial direction. Insertion of
bone grafts or other transplants is
limited by this approach.
Another alternative is the subciliary
incision for the treatment of medial or-
bital floor fractures. NOLASCO & MA-
THOG12 prefer this incision for recon-
struction of combined orbital floor
and medial wall fractures. This incision
gives an aesthetic scar. One disadvan-
tage of this approach is the possible
development of ectropion. Another
disadvantage is the limited exposure of
the middle part of the medial orbital
wall. By using a subciliary or a trans-
conjunctival incision in the lower for-
nix it is only possible to expose the
lower part of the medial orbital wall.
A repositioning of the herniated soft
tissue is possible, but insertion of a
transplant under direct control is dif-
ficult. Therefore, in orbital floor and
medial wall fractures, we use a com-
bined transconjunctival incision in the
lower fornix and a transcaruncular ap-
proach to get a better view of the frac-
tured orbital walls. In contrast to
B~mcn et al. 1, we do not join the two
incisions because we think it is better
to suture each of the conjunctival in-
cisions separately for prevention of a
symblepharon.
The endoscopic approach is an alter-
native to a cutaneous incision. The
endoscopically controlled endonasal
approach gives no external scar 1°. It
may be useful for repositioning of in-
carcerated tissue, but there are several
disadvantages of this procedure. One
Transcaruncular approach for medial orbital wall fracture
disadvantage is that the honeycomb
structure of the ethmoid air cells has to
be removed to get to the medial wall.
The honeycomb structure of the numer-
ous bony septa of the ethmoid air cells
gives the lamina papyracea some sup-
port, making it less easily deformed.
Thus, the fractured medial orbital wall
is additionally weakened by this ap-
proach and has to be stabilised by a
nasal packing. Another disadvantage is
the difficulty of inserting an adequately
sized transplant to the medial wall for
prevention of enophthalmos. Bleeding
is the major limiting factor for endo-
scopic surgery.
A third alternative is the indirect ap-
proach to the medial wall by a coronal
incision. This approach gives a wide ac-
cess to the medial wall, without inter-
fering with the medial canthal liga-
ment 3. This procedure has the disad-
vantages of higher blood loss, a risk of
injury to the frontal branch of the facial
nerve, and a scar in the hair line. For
isolated medial wall fractures, this tech-
nique is more time-consuming than our
proposed direct approach to the orbit.
In conclusion, the transcaruncular
approach is a better alternative to
transcutaneous incisions because it does
not produce a visible scar and gives a
better overview of the fractured medial
orbital wall. The advantages include
rapid entry into the orbit and no injury
of the medial canthal tendon, the lacri-
mal system or the muscle layer. In ad-
dition, transplants can be inserted by
this approach to reconstruct the medial
orbital wall for prevention of en-
ophthalmos. The transcaruncular ap-
proach can be performed with minimal
morbidity and should be considered in
patients with isolated medial orbital
wall fractures, especially those involving
the superior and posterior part of the
medial wall.
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Address:
Arnulf Baumann, MD, DMD
Clinic of Oral and Maxillofacial Surgery
(Head. t?. Ewers, MD, DMD, Ph.D.)
Medical School, University of Vienna
Wgihringer Cartel 18
1090 Vienna
Austria
Tel." +43 1 40400 4269
Fax: +43 1 40400 4253