**3.3. Orbital fractures**

### *3.3.1. Classification*

**Figure 5.** Classification of palatal fractures.

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into two subcategories of anterior and posterolateral fractures. Anterior type I palatal fracture involves the incisor teeth and involving the posterior teeth it is defined as type 1b palatal fracture. Type II palatal fracture is defined as sagittal fracture which is less common in adults. Type III and IV fractures are the most common palatal fractures in adults [11]. Type III is also According to the involved orbital walls there are five fracture patterns. The most common fracture of the orbit is the orbital floor fracture mostly detected as a blow-out fracture [6] (**Figure 7**).

**Figure 6.** (A) Gunning for closed treatment of simultaneous mandibular and palatal fractures in an edentulous patient and (B) Maxillomandibular fixation for closed treatment of the patient.

**Figure 7.** Coronal CT view indicating orbital floor (blow out) fracture.

Orbital roof fracture is the most common fracture in pediatric population [12]. Other less common orbital fractures involve medial or lateral wall. Combined orbital fracture especially involving all four orbital walls are the least common orbital fracture [6] patterns whilst the leading functional and esthetic problems of this pattern are much more serious than former fracture types.

**Figure 8.** The patient is not able to look upward concurrently by both eyes due to left orbital floor fracture lead to inferior

Maxillofacial Fractures: From Diagnosis to Treatment http://dx.doi.org/10.5772/intechopen.76166 61

**Figure 9.** Periorbital ecchymosis and subconjuctival hemorrhage following orbital fracture.

rectus muscle entrapment.

### *3.3.2. Signs and symptoms*

Entrapment of extraocular muscles should be assessed when there is suspected orbital wall fracture (**Figure 8**). Forced duction test is helpful in distancing between muscle entrapment and neurologic disturbance although this test is sometimes falsely negative due to post-injury edema. Diplopia is a common sign of orbital fracture, especially medial fracture pattern due to rectus muscle entrapment [13]. Infraorbital nerve hypoesthesia is a symptom of orbital fracture especially when the infraorbital rim is involved [14]. Subconjunctival hemorrhage and periorbital ecchymosis are useful signs of an underlying orbital fracture [15] (**Figure 9**). Enophthalmus is an important sign of orbital fracture and also a significant indication of orbital reconstruction [16]. Enophthalmus usually occurs as a result of increased orbital volume or loss of orbital content especially orbital fat.

### *3.3.3. Management*

Orbital fracture cases are non- or minimally displaced should just observe. No intervention is needed when Orbital fractures do not result in any ocular problems including diplopia or enophthalmus. Orbital fracture treatment is a controversial issue among maxillofacial and oculoplastic surgeons. Fracture size, timing of the reconstruction, and biomaterials for reconstructions are all important issues which should be considered in orbital fracture repair. The debate still is present in deciding on whether to treat an orbital fracture or not. The investigations are insufficient with high heterogeneity in this field. As a general rule it is almost acceptable that defects more than 50% of the orbital wall or 2 cm length should be treated [17]. Enophthalmus and positive-forced duction tests are two indications for management of orbital wall fractures.

Orbital roof fracture is the most common fracture in pediatric population [12]. Other less common orbital fractures involve medial or lateral wall. Combined orbital fracture especially involving all four orbital walls are the least common orbital fracture [6] patterns whilst the leading functional and esthetic problems of this pattern are much more serious than former

Entrapment of extraocular muscles should be assessed when there is suspected orbital wall fracture (**Figure 8**). Forced duction test is helpful in distancing between muscle entrapment and neurologic disturbance although this test is sometimes falsely negative due to post-injury edema. Diplopia is a common sign of orbital fracture, especially medial fracture pattern due to rectus muscle entrapment [13]. Infraorbital nerve hypoesthesia is a symptom of orbital fracture especially when the infraorbital rim is involved [14]. Subconjunctival hemorrhage and periorbital ecchymosis are useful signs of an underlying orbital fracture [15] (**Figure 9**). Enophthalmus is an important sign of orbital fracture and also a significant indication of orbital reconstruction [16]. Enophthalmus usually occurs as a result of increased orbital vol-

Orbital fracture cases are non- or minimally displaced should just observe. No intervention is needed when Orbital fractures do not result in any ocular problems including diplopia or enophthalmus. Orbital fracture treatment is a controversial issue among maxillofacial and oculoplastic surgeons. Fracture size, timing of the reconstruction, and biomaterials for reconstructions are all important issues which should be considered in orbital fracture repair. The debate still is present in deciding on whether to treat an orbital fracture or not. The investigations are insufficient with high heterogeneity in this field. As a general rule it is almost acceptable that defects more than 50% of the orbital wall or 2 cm length should be treated [17]. Enophthalmus and positive-forced duction tests are two indications for management of

fracture types.

60 Trauma Surgery

*3.3.3. Management*

orbital wall fractures.

*3.3.2. Signs and symptoms*

ume or loss of orbital content especially orbital fat.

**Figure 7.** Coronal CT view indicating orbital floor (blow out) fracture.

**Figure 8.** The patient is not able to look upward concurrently by both eyes due to left orbital floor fracture lead to inferior rectus muscle entrapment.

**Figure 9.** Periorbital ecchymosis and subconjuctival hemorrhage following orbital fracture.

Timing of orbital reconstruction is categorized into three groups of immediate categories: within 24 h, early (between first and day 14), and delayed (after 2 weeks) [18]. When the reason of diplopia is muscle entrapment immediate reconstruction of the orbit is advocated by the investigators. Blow-out fracture in young patients is the other indication for immediate repair. Early orbital reconstruction is advocated by some surgeons in cases of early enophthalmus and symptomatic diplopia with positive forced duction test. Early reconstruction should also be considered in cases with large orbital wall defects (more than 50% defects). Symptomatic diplopia with negative force duction test and late-onset enophthalmus are indications for delayed orbital reconstructions [18].

**Materials Examples Advantages Disadvantages Indications**

Biocompatibility, cost effective, variability in thickness, radio opacity

Replacement with bone

High stability, easy fixation, availability, no donor site defect

**Figure 11.** Naso-orbital-ethmoid fracture types. A, type I Naso-orbital-ethmoid fracture. B, type II naso-orbital-ethmoid

**Figure 12.** Signs in a patient with naso-orbital-ethmoid fracture. Rounding of the left medial canthus (arrow) and

formation

Donor site morbidity, difficult to shape, high resorption rate

High cost, radiolucency, low stability

High cost, increased infection rate

Large defects, immature orbits, secondary defect reconstruction

63

Small defects

Maxillofacial Fractures: From Diagnosis to Treatment http://dx.doi.org/10.5772/intechopen.76166

> Medium size defects with medium complexity

Autogenous bone grafts

Resorbable materials

Non-resorbable materials

Iliac bone graft, caldaria grafts

poly-l-lactic acid (PLLA),

Titanium mesh, Porous polyethylene sheets

**Table 1.** Materials available for orbital reconstruction.

fracture. C, type III naso-orbital-ethmoid fracture.

traumatic telecanthus is obvious in this patient.

Decision-making on the ideal material for orbital reconstruction is based on the surgeon's experience, cost, defect size, and medical history (**Figure 10**) [19]. The available material and their pros and cons are categorized in **Table 1**.
