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Review

Controversies and Contemporary Management of Orbital Floor Fractures

by
Shivam Patel
1,
Tom Shokri
2,
Kasra Ziai
1 and
Jessyka G. Lighthall
3,*
1
Department of Otolaryngology-Head and Neck Surgery, College of Medicine, The Pennsylvania State University, Hershey, PA, USA
2
Department of Otolaryngology-Head and Neck Surgery, Otolaryngology and Facial Plastic Surgery Associates, Fort Worth, TX, USA
3
Facial Plastic and Reconstructive Surgery, Department of Otolaryngology-Head and Neck Surgery, College of Medicine, The Pennsylvania State University, 500 University Drive, H091, Hershey, PA 17033-0850, USA
*
Author to whom correspondence should be addressed.
Craniomaxillofac. Trauma Reconstr. 2022, 15(3), 237-245; https://doi.org/10.1177/19433875211026430
Submission received: 1 November 2020 / Revised: 1 December 2020 / Accepted: 1 January 2021 / Published: 24 June 2021
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Abstract

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

Introduction

Orbital floor fractures are a common outcome of trauma sustained to the midface. They are most commonly seen in the first 30 years of life.[1,2,3,4] The complex anatomy and proximity to vital structures present a reconstructive challenge to the surgeon. Furthermore, the approach to the management of these fractures is a source of continued controversy. Recent advances in computer-aided technology, including 3-dimensional printing, implementation of planning software, intraoperative navigational imaging, endoscopic guidance, and novel implants, have allowed for improvement in prospective management modalities. However, these innovations have also spurred further deliberation for the optimal approach and surgical correction of these complex injuries.[3,4]

Methods

A Pubmed and Cochrane search was performed with no date restrictions for literature on management of orbital floor fractures. The search terms used were “orbital floor fractures,” “management,” and various combinations of the terms. Articles not written in the English language were excluded.

Results

Indications and Timing of Repair

Indications for orbital floor fracture repair remain controversial as many of these fractures heal without intervention or adverse sequelae. Putterman et al. [2] recommended observation of all fractures for 4-6 months with late intervention if necessary for the development of enophthalmos or diplopia. On the contrary, other studies noted a significant increase in poor outcomes with the late repair of the fractures (>2 months).[3] In 2002, Burnstine[4] published recommendations for repair, which are widely employed by reconstructive surgeons but are primarily based on expert opinion. Despite these recommendations, there is still no consensus about which patients would benefit from surgical intervention, nor is there agreement about when the repair should be performed. Nevertheless, in all cases, a thorough history, clinical exam, and review of imaging are required to identify patients that may warrant urgent surgical exploration.
Urgent surgical repair is described as operative interventions in the first 24-48 hours after injury. Immediate intervention should be considered for early enophthalmos and hypoglobus, diplopia with evidence of muscle entrapment, hemorrhage, non-resolving oculocardiac reflex, and white-eyed blowout fractures in patients <18 years old (restriction of ocular mobility, entrapped soft tissue on imaging, and minimal periorbital ecchymosis or edema on the exam).[4] The oculocardiac reflex (OCR), though rare, results from pressure on the globe due to entrapped periorbital soft tissues and subsequent increase in efferent vagal tone causing syncope, bradycardia, potential heart block, nausea, and vomiting. The incidence of OCR varies widely in the literature depending on the clinical scenario, with a reported fatality risk of 1 in 3,500 cases.[5] Therefore, an immediate surgical exploration is indicated to prevent fatal cardiac arrhythmia.[5,6] Immediate repair has been shown to improve ocular motility in patients with signs of muscle entrapment due to the prevention of ischemic necrosis, resultant fibrosis, and strabismus. Delayed treatment of muscle entrapment has been shown to correlate with a higher incidence of persistent postoperative diplopia.[7,8,9] Several studies have shown that repair within 48 hours of injury significantly reduces this risk.[4,10,11,12,13]
Except for cases requiring urgent intervention, substantial controversy exists regarding the timing of treatment and identification of patients requiring surgical correction rather than observation. Bansagi and Meyer[10] evaluated 34 patients <18 years old with orbital floor fractures and found that early surgical intervention, defined as less than 2 weeks, resulted in a complete return of ocular motility compared with late intervention groups. Egbert et al.[11] observed a median time for improvement of preoperative duction deficits of 4 days for patients who underwent surgery within 7 days of the initial injury and 10.5 days for those who underwent repair after 14 days (P = 0.030). However, the timing of surgery did not affect the complete resolution of duction deficits or diplopia. Therefore, the authors concluded that early surgical repair resulted in more rapid improvement than a conservative delayed approach.[11]
Children tend to have greater bone elasticity allowing the orbital floor to bend and form a trapdoor (“white-eyed” fracture), where a bone fragment often hinged medially is transiently displaced inferiorly, allowing herniation of orbital contents into the maxillary sinus, thereby resulting in entrapment as the fragment returns to its prior position.[7,14,15] The blood flow to the entrapped tissue is compromised, resulting in muscle or fat ischemia, fibrosis, and diplopia. In contrast, adult patients have more brittle bones, which are more likely to break, resulting in tissue prolapse and an increase in orbital volume, which place the patient at risk for the development of enophthalmos hypoglobus, and diplopia.
In an attempt to better stratify patients, investigators have attempted to establish parameters to predict patients at high risk of late complications that may benefit from earlier intervention. These studies are largely based on CT findings evaluating the size (area) of the floor defect, the calculated change in orbital volume, or the degree of soft tissue herniation. Conventionally, defect size has been used as an indication for surgical repair, with fractures larger than 2 cm2 or defects greater than 50% of the orbital floor being the standard criteria for intervention.[3,16] Notably, studies have found that as little as a 5% increase in total orbital volume (~1.25 mL) is a predictor of clinically significant enophthalmos (>2 mm)[16,17,18,19] while others note that volume changes up to 1.5-2 mL or more can be observed.[16,20,21] Also, a linear association between an increase in orbital volume and enophthalmos has been demonstrated.[22]
Despite the criteria for early surgical intervention mentioned above, 7-10% of patients treated nonoperatively develop late enophthalmos.[3,23] Late correction of established enophthalmos has been associated with poor functional and cosmetic results due to fat atrophy and orbital fat scarring to the maxillary antrum.[3,24] However, in a study by Chen et al.,[25] authors conducted a study to evaluate the long-term enophthalmos outcomes following surgical management of different types of orbital fractures at various time intervals (<2 weeks, 2-4 weeks, and >4 weeks). The authors found no statistically significant differences in the enophthalmos improvement rates with surgical intervention at these various time intervals.
Diplopia secondary to muscle contusion or edema is also common after orbital injury and should continue to improve 2 weeks after injury. Patients with persistent diplopia associated with evidence of soft-tissue entrapment on computed tomographic (CT) imaging or positive forced duction test require surgical exploration and possible repair.[4] A study by Hawes and Dortzbach[3] showed a correlation between the time of repair and increased postoperative diplopia. Authors found 38% of patients undergoing surgery 2 months or longer after injury experienced persistent diplopia compared to only 7% who had surgery within 2 months. Similarly, Yu et al.[26] evaluated the impact of fracture type and timing of surgical intervention on diplopia outcomes and demonstrated that patients treated within 2 weeks of orbital injury exhibit a higher rate of diplopia resolution compared to those treated between 2-4 and more than 4 weeks.
Several studies have described rounding of the inferior rectus (IR) muscle as a relative indication for operative management. Matic and colleagues[27] found that a height-to-width ratio >1 in the inferior rectus muscle is predictive of late enophthalmos but not persistent diplopia (Figure 1). The authors postulate that the shape of the inferior rectus muscle may be a better predictor of post-traumatic enophthalmos than orbital floor defect size or orbital volume measurements as these values are only reflective of the status of osseous support while the former is representative of both bony and soft-tissue support.[27,28] A recent retrospective study by Gabrick et al.[29] correlated radiographic features of non-surgically managed orbital floor fractures with long-term patient-reported outcome measures (FACE-Q). They found a significant association between rounding the IR muscle and the appearancerelated psychosocial distress (P = 0.006). This factor should be considered when making decisions regarding the repair of orbital floor fractures.

Delayed Repair

Proponents of the delayed approach to the treatment of orbital fractures suggest that this allows for the resolution of traumatic edema before the repair allowing for proper identification of enophthalmos not initially appreciated on the exam and facilitating surgical exposure.[30] The goal of orbital fracture repair is not to achieve bone healing or prevent malunion like other fracture repairs but to reconstitute orbital volume allowing for the resolution of symptoms and intact vision. Patients that do not present with findings necessitating immediate intervention are routinely seen at a 2-week follow-up, at which time they are evaluated for unresolved or progressive symptoms such as infraorbital nerve hypoesthesia, diplopia, delayed enophthalmos, change in visual acuity, or hypoglobus. The development of these signs within the first 5-6 weeks after an injury should be considered a strong relative indication for surgery.[31] Progressive hypoesthesia of the V2 distribution of the infraorbital nerve has been demonstrated as a relative indication for surgical repair in patients with orbital floor fracture.[32,33]

Approach

The controversy surrounding the management of orbital floor fractures extends to the surgical approach as well. Unfortunately, there is still an insufficient level of evidence coupled with an inconsistency in outcome measures that has resulted in difficulty establishing a definitive evidence-based approach. Traditionally, external transorbital approaches have been used to repair orbital fractures, which provide exposure of the orbital floor and inferior orbital rim by one of several incisions: subciliary, subtarsal, transconjunctival, or transcaruncular.
The subciliary incision has been associated with a higher risk of cicatricial ectropion and may lead to significant scarring.[34] The subtarsal incision is generally considered the least technically demanding and provides the most direct access to the orbital rim and floor but has been noted to leave substantial visible scarring.[35,36,37] This remains a point of contention, as prior studies had shown that a subtarsal incision within a skin crease of the lower lid produced a superior aesthetic result compared to the options mentioned above.[38,39] The transconjunctival approach is the most extensively investigated method. This approach avoids scar formation and risk of ectropion; however, it is technically more advanced and does come with a risk of entropion. Complication rates in one meta-analysis were found to be the highest in the subciliary approach (19.1%) followed by the subtarsal approach (9.7%), and the lowest rate of complications was with transconjunctival access (2.1%).[40]
An alternative method to orbital floor management is a transantral approach under endoscopic guidance that is well-described in the literature.[41,42] This approach has been associated with minor complications such as transient infraorbital hypoesthesia or anesthesia; however, it allows successful reconstruction of orbital floor defects while minimizing manipulation of the globe and eliminating a lower eyelid incision. The transantral endoscopic approach has also shown efficacy in repairing complex orbital fractures beyond an isolated floor fracture.[42] Certainly, a surgeon’s familiarity with a particular technique and the patient’s distinct presentation are important factors in decision-making regarding the most appropriate approach.

Reconstruction of the Orbital Floor—Orbital Implants

Many materials have been described in the literature for orbital floor repair and may be divided into biological or alloplastic composition. The findings in the literature have been inconsistent and are largely retrospective case series with limited subjects without conclusive data.[43,44,45] Additionally, individual surgeon preferences vary on the type of orbital implant.[46] The choice of material is dependent on biocompatibility instead of the strength of graft material.[47] Biological materials offer several potential advantages, including improved biocompatibility but are limited by their donor site morbidity.[48,49] Synthetic, or alloplastic grafts, have been associated with higher rates of complications in the literature, including infection and extrusion of the material, but have the advantage of being readily obtainable, avoiding donor site complications.[50] Generally, rates of complications remain low and are attributed to the state of the orbital soft tissue at the time of repair. Regardless of the type of implant chosen, key factors to consider include assuring implants are placed on stable bony ledges, normal orbital volume is restored, soft-tissue contents are adequately reduced, and the normal orbital floor shape is restored. Rather than being a straight line and conical, the anatomic orbital floor is S-shaped (Figure 2).

Biological Materials

Autologous bone grafts have historically been considered the “gold standard” for orbital floor reconstruction as they offer both short and long-term viability by providing rigidity, molding capacity, minimal immune reactivity, vascularity, and biocompatibility.[45] Calvarial bone grafts can be used as full-thickness, split-thickness, bone chips, bone shavings, and dust.[44] The parietal bone has been described as being the most suitable, with regard to shape, for use in facial reconstruction.[50] Autologous cartilaginous grafts have also been shown to have utility in orbital reconstruction due to their ease of harvesting, malleability, reliable support without resorption, and fewer postoperative complications.[51,52] The primary sources for cartilaginous grafting are auricular concha, rib, and nasal septum.[53] Cartilage grafts are unique in that they have low anaerobic metabolism and are relatively avascular, which is thought to improve graft viability and reduce resorption rates compared to bone grafts.[51]

Allografts and Xenografts

Allografts used to reconstruct orbital floor fractures include lyophilized dura mater (LyoDura) and banked demineralized human bone (DHB). Lyodura is digested by macrophages and eventually replaced with endogenous collagenous connective tissue post-operatively.[54] Allogenic human or animal dura grafts undergo sterilization to decrease disease transmission; however, evidence in the literature has demonstrated that allografts are associated with increased donor-to-patient disease transmission risks.[55,56,57] DHB grafts are produced in biocompatible, resorbable sheets and are both osteoconductive and osteoinductive due to their ability to provide type 1 collagen; however, the utility of DHB implants in orbital floor reconstruction remains undetermined. Sallam Ahmed et al.[58] demonstrated that DHB sheets used in the setting of enophthalmos provided inadequate structural support and were an insufficient form of repair due to an elevated rate of resorption of DHB compared to the autologous bone.

Alloplastic Implants

Alloplasts can be subdivided into resorbable and non-resorbable plates. Resorbable alloplastic grafts include polymers composed of poly-L-lactic acid, polydioxanone, polyglycolic acid, or composite polymers.[55,59,60,61,62,63] These materials have been associated with delayed enophthalmos and severe inflammatory reactions resulting in ocular muscle adhesions and diplopia. Resorbable grafts provide temporary support and are replaced by fibrous granulation tissue as the material degrades, thereby providing resistance against herniation forces during the initial healing phase and maintaining orbital contents.[55,60,61]
Permanent, non-resorbable, alloplastic implants offer a longer-term rigid option for reconstruction and are commonly used in orbital floor fracture repair but have higher risks of implant-associated infections. Porous polyethylene is malleable while also allowing rigid fixation and vascular ingrowth due to open pore structure. However, if placed in close proximity to extraocular muscles, it may form adhesions.[64,65,66,67,68] Titanium mesh implants are easily contoured and biocompatible but may be difficult to position in deep orbital fractures and have also been shown to be associated with fibrosis, scar formation, and orbital adherence syndrome.[68,69,70] A systematic review by Avashia et al.[43] evaluated implant material for orbital reconstruction, concluding that the evidence supporting one material’s superiority over another is inadequate. Therefore, the surgeon must rely on his or her operative expertise in conjunction with the implant type’s unique characteristics to develop an individualized surgical approach that fits the patient’s specific needs.

Contemporary Adjuncts to Repair: Virtual Surgical Planning, Intra-Operative Imaging, and Navigation

Intra-operative navigation using preoperative imaging can improve visualization of defects mitigating implant positioning errors, thereby reducing the need for secondary corrective procedures.[69,70,71,72] This modality is beneficial in orbital fractures involving the junction of the orbital floor and medial wall or complete separation of the floor, where standard transconjunctival approaches may not provide adequate exposure and result in misplacement of reconstructive implants requiring repeat surgery.[73]
Intraoperative CT scanning is also emerging as a beneficial adjunct to improve patient outcomes. A study by Shaye et al.[74] reviewed 38 facial reconstructive procedures that implemented intra-operative CT using parameters including fracture complexity, procedure type, scan time, and subsequent revision rate. Notably, the average total scan time was approximately 14.5 minutes and did not show significant variability based on the procedure’s complexity. Immediate revision or implant position was required in 24% of patients (9 total, 8 of which were defined as complex). Therefore, the authors concluded that intraoperative imaging is an expeditious and reliable adjunct in reconstructive surgery and may be particularly useful in confirming optimal results in complex cases that would otherwise require secondary procedures for implant repositioning.
Although intraoperative CT is useful, it still requires repeated imaging after each corrective measure, increasing radiation exposure. However, final postoperative confirmative imaging is not needed. Intraoperative navigation, using optical systems wherein infrared cameras detect light waves emitted by light-emitting diodes (LED) mounted on the patient’s head, have no additional radiation exposure, and allow the surgeon to orient without interrupting the procedure. Additionally, this technique allows for more detailed visualization of the bony structures and soft tissue.[75]
Cai et al.[76] evaluated 58 patients with orbital trauma in a prospective matched-controlled trial who underwent orbital reconstruction. Half of these patients (n = 28) were reconstructed with the Kolibri navigation system (BrainLab, Munich, Germany), while the control group (n = 29) was reconstructed without the aid of a navigation system. The navigation group displayed a statistically significant decrease in implant placement variation between the preoperative and actual reconstructions. Postoperative follow-up also showed significantly fewer ophthalmologic complications in the group with navigation, including diplopia, infraorbital hypoesthesia, ophthalmoplegia, and enophthalmos. In another study by Essig et al.,[77] the authors evaluated the quality of orbital reconstruction in 94 patients. Of those reconstructed using intraoperative navigation, implant position was accurate within 1 millimeter of the contralateral unaffected orbit used for preoperative modeling with virtual surgical planning. The deviation between the reconstructed defect and preoperative virtual planning was maximal when defects were in the orbital floor’s anterior third. When comparing navigation-assisted surgery versus conventional surgery in patients with complex orbital floor fractures, a statistically significant reduction was only achieved using navigation.
Another useful adjunct that may decrease the need for navigation and repeat imaging is endoscopic-assisted surgery. The standard 2.9 or 4 mm 30-degree scopes may be used to identify walls and confirm adequate soft-tissue reduction and implant placement. Endoscopic guidance may be used transorbitally (through lid incision), transnasally, or transantrally. A novel study investigated orbital floor reconstruction performed via transantral endoscopy with the aid of virtual reality surgical planning and 3D-printed surgical guides.[78] The authors recruited 14 patients with orbital floor fractures and obtained high-resolution CT images where a virtual 3D reconstruction of the defect was developed for intraoperative guidance. Their preliminary results from postoperative CT scans showed a complete floor reconstruction resulting in the restoration of the correct globe position, barring any complications.

Three-Dimensional Printing and Implant Contouring

Three-dimensional printing has increasingly gained popularity by surgeons for presurgical planning and intra-operative guidance. Computer-aided design and printing (CAD-CAM) are used to fabricate rapid prototypes using the following techniques: stereolithography using photocurable resin, selective laser sintering (fusion of polymers such as polystyrene or titanium), and fused deposition modeling employing the extrusion of thermoplastic materials. Stereolithographic (SLA) models have been shown, although anecdotally, to increase predictability in postoperative outcomes and decrease operating times compared to treatments without the use of these models.[79]
Three widely used implant contouring techniques include template contouring using an SLA model, preformed implants, and patient-specific implants. Template contouring can be significantly facilitated, as noted above, by the fabrication of 3-dimensional rapid prototype models using preoperative CT datasets and 3-D printing. Titanium mesh can then be shaped onto the model replicating the orbital contour (Figure 3). Park et al.[80] used this technique on 104 patients and demonstrated accurate volume reconstructions with an average of <1.5 ml discrepancy from the planned volume and minimal complication rates. Preformed implants have a standardized orbital contour based on a composite of several hundred standard CT datasets. Metzger et al.[81] evaluated the use of pre-bent titanium mesh implants in cadaveric orbits and found that these contoured implants provide accurate contours within 1 mm difference for both medial and orbital floor repair.
Patient-specific implants are constructed to fit the individual patient’s anatomy using the preoperative CT dataset and mirroring the contralateral unaffected side as detailed above. Gander et al.[82] implemented CT imaging to create a virtual implant using the mirrored contralateral unaffected orbit template in 12 patients. They reported an efficient preoperative planning time ranging from 30-36 minutes, with implant manufacturing taking approximately 4-6 days. The authors reported correction of enophthalmos and diplopia resolution with no need for reoperation to reposition implants or correct ocular bulb displacement in any of the patients. Select studies detailing contemporary management techniques are further presented in Online Supplemental Table 1.[76,79,80,81,82,83,84,85,86,87,88,89,90,91]

Conclusion

Orbital floor fractures involve complex soft tissue and bony reconstruction. Although there has been considerable progress in the diagnosis, perioperative care, and technologically advanced approaches, insufficiency in the level of evidence still exists, preventing the development of a convincing general guideline or algorithmic approach to reconstruction. With increased data, we can hope to form evidence-based indications for the use of particular biomaterials or criteria for orbital defect characteristics, endoscopic guidance, or the use of preoperative planning and intraoperative imaging or navigation, which may be best addressed by a specific surgical approach.

Supplementary Materials

Supplemental material for this article is available online.

Author Contributions

Drs Lighthall and Patel had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Patel, Shokri, and Lighthall. Acquisition, analysis, or interpretation of data: Patel and Shokri. Drafting of the manuscript: All authors. Critical revision of the manuscript for important intellectual content: Lighthall. Administrative, technical, or material support: Patel and Ziai. Study supervision: Lighthall.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Conflicts of Interest

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Ethical Publication Statement

The authors confirm that they have read the Journal’s position on issues involved in ethical publication and affirm that this report is consistent with those guidelines.

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Figure 1. Preoperative coronal soft tissue view of the orbital floor and medial wall fracture with inferior rectus (IR) muscle herniation. Shape of the inferior rectus muscle has been shown to be a better predictor of late enophthalmos.
Figure 1. Preoperative coronal soft tissue view of the orbital floor and medial wall fracture with inferior rectus (IR) muscle herniation. Shape of the inferior rectus muscle has been shown to be a better predictor of late enophthalmos.
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Figure 2. Sagittal view of a normal orbital floor in an S-shape configuration.
Figure 2. Sagittal view of a normal orbital floor in an S-shape configuration.
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Figure 3. A, Coronal view of isolated orbital floor fracture medial to the infraorbital nerve. B, Coronal view after reduction and placement of an anatomical 3-dimensional pre-bent titanium implant.
Figure 3. A, Coronal view of isolated orbital floor fracture medial to the infraorbital nerve. B, Coronal view after reduction and placement of an anatomical 3-dimensional pre-bent titanium implant.
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MDPI and ACS Style

Patel, S.; Shokri, T.; Ziai, K.; Lighthall, J.G. Controversies and Contemporary Management of Orbital Floor Fractures. Craniomaxillofac. Trauma Reconstr. 2022, 15, 237-245. https://doi.org/10.1177/19433875211026430

AMA Style

Patel S, Shokri T, Ziai K, Lighthall JG. Controversies and Contemporary Management of Orbital Floor Fractures. Craniomaxillofacial Trauma & Reconstruction. 2022; 15(3):237-245. https://doi.org/10.1177/19433875211026430

Chicago/Turabian Style

Patel, Shivam, Tom Shokri, Kasra Ziai, and Jessyka G. Lighthall. 2022. "Controversies and Contemporary Management of Orbital Floor Fractures" Craniomaxillofacial Trauma & Reconstruction 15, no. 3: 237-245. https://doi.org/10.1177/19433875211026430

APA Style

Patel, S., Shokri, T., Ziai, K., & Lighthall, J. G. (2022). Controversies and Contemporary Management of Orbital Floor Fractures. Craniomaxillofacial Trauma & Reconstruction, 15(3), 237-245. https://doi.org/10.1177/19433875211026430

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