Microsoft Word - 4CostanVV_Multidisciplinary


 
 
 
 
 
552 | Costan et al - Multidisciplinary approach to orbital fracture repair 

 

 
 
 
 
 
 

DOI: 10.2478/romneu-2018-0071   

Multidisciplinary approach to orbital fracture repair 

V.V. Costan1, M. Dabija2 

“Grigore T. Popa” University of Medicine and Pharmacy Iasi, ROMANIA 
1Faculty of Dental Medicine, Department of Surgery, Oral and Maxillofacial Surgery 
2Faculty of Medicine, Department of Surgery II, Neurosurgery 

 
Abstract: The orbit is a frequent location for fracture occurrence, often in association 
with other fractures of the facial skeleton. Due to the anatomical situation of the orbit at 
the crossroads of multiple specialties, including maxillofacial surgery, ophthalmology, 
neurosurgery and otolaryngology, this territory must be managed by multidisciplinary 
teams for an accurate diagnosis and treatment. This paper focuses on reviewing the main 
types of orbital fractures, the indication for surgical repair and the contribution of 
different specialties in the management of various orbital fracture patterns. 
Key words: orbit, fracture, multidisciplinary, blow-out, blow-in 

 
Introduction 

Fractures of the orbit are often 
encountered in the context of facial trauma, 
either isolated or in association with other 
fractures of the facial skeleton. Over 40% of all 
facial fractures have an associated orbital 
involvement (1). The most frequent patterns 
of fractures including the orbit are orbito-
zygomatic fractures and naso-orbito-
ethmoidal fractures. Isolated fractures of the 
orbital walls are reported in between 4-16% of 
facial fractures cases (2). With such a high 
occurrence and potential for important 
functional and morphologic impairment, it is 
important to accurately diagnose and treat 
orbital fractures. 

The orbit pathology is situated at the 
intersection of multiple medical specialties 
due to the anatomical location, the 

neighboring anterior skull base and paranasal 
sinuses, but also due to its contents consisting 
of the globe and optic nerve. In a traumatic 
setting, all the named structures can be 
damaged to various degrees, necessitating a 
collaboration between the maxillofacial 
surgeon, the neurosurgeon, ophthalmologist 
and otolaryngologist for an accurate diagnosis, 
treatment and follow-up, aiming for minimal 
complications.  

The anatomic characteristics of the orbital 
region explain the various fracture patterns 
and the frequent association of fractures 
involving multiple facial bones. The orbits and 
the anterior skull base form a guarding 
ensemble, in the biomechanical context of the 
naso-ethmoido-maxillo-fronto-orbital 
complex. The whole architecture of the nose, 
paranasal sinuses, the orbits and the anterior 



 
 
 
 
 

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skull base comprises an anterior strength zone 
(the glabella, the naso-maxillary suture, the 
nasal process of the frontal bone, the orbital 
rims) absorbing the impact and a posterior 
fragile complex (the cribriform plate, the 
ethmoidal labyrinth, the perpendicular plate of 
the ethmoid bone, the sinus cavities) 
dissipating the forces (1, 3).  

The design of the orbit is well adapted to 
soften any traumatic impact on its fragile 
contents. The orbital rims are thickened bone 
structures forming horizontal and vertical 
buttresses of the facial skeleton absorbing and 
resisting the direct force of the impact (4). The 
orbital fat behaves like a cushion dissipating 
forces to protect the globe and optic nerve. The 
thin orbital walls allow for pressure to escape 
the orbit by fracturing in case of important 
traumatism, thus avoiding crushing of the 
intraorbital structures. Similarly, the orbital 
roof also serves as a pressure release for 
superior traumatisms, impacting the skull and 
brain. Its down-fracture dissipates the 
crushing force directed on the brain substance. 
In addition to these protective features, the 
surrounding paranasal sinuses act as air-bags 
consuming the strength of the traumatism (5, 
6, 7). Their role is emphasized by the increased 
frequency of orbital blow-in fractures in 
children due to the absence of frontal sinus 
pneumatization (8).  

In relation to the anatomical 
characteristics, the impact point, strength and 
direction, the fracture trajectory may interest 
to various degrees the orbital rims, the walls of 
the orbit, as well as the adjacent bones of the 
facial skeleton translating into the frequently 
encountered clinical forms: naso-ethmoido-
maxillo-fronto-orbital complex (CNEMFO) 

fractures (3), more commonly named NOE 
complex (naso-orbito-ethmoidal) fractures, 
orbito-zygomatic fractures, isolated orbital 
walls fractures including blow-in and blow-
out types, and combined orbital fractures 
comprising the orbital frame and walls (1). 
Less frequent, but with a high morbidity, is the 
association of orbital fractures with skull and 
skull base fractures in high-velocity 
traumatisms. 

The complex shape of the orbit, as well as 
the anatomical situation in areas of high risk of 
injury to important structures, make the 
reconstruction of the orbital cavity a difficult 
task, often requiring multidisciplinary 
evaluation, diagnosis and management. 

Multidisciplinary evaluation and 
management  

A facial trauma patient is habitually 
evaluated by a multidisciplinary team in the 
emergency setting, including maxillofacial, 
neurosurgical, ophthalmological and 
otolaryngology consultations together with 
other necessary consultations for excluding 
serious injuries in other body parts. Common 
emergency procedures include maintenance of 
a patent airway, management of epistaxis and 
hemostasis for bleeding in soft tissue 
lacerations, drainage of retrobulbar 
hematoma, management of persistent oculo-
cardiac reflex, and intracranial vascular 
lesions. The initial consultation is usually 
determined by the predominant emergency in 
each case. Diagnostic imaging is 
recommended in hemodynamically stable 
patients. Facial fracture repair is performed 
after the resolution of acute life-threatening 
injuries.  



 
 
 
 
 
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Clinical examination is often indicative of 
the type of fracture, but a thin slice CT 
(Computer Tomography) evaluation is 
cardinal for the assessment of orbital injuries 
(9, 10) that may otherwise be missed due to the 
presence of edema and masked clinical signs 
and symptoms. Even more so, CT is necessary 
due to the possible presence of skull base 
fractures, dura tears, posttraumatic 
intracranial lesions, possible occurrence of 
orbital apex syndrome, extraocular muscle 
incarceration, globe injuries. The three-
dimensional reconstruction of the CT images 
aids the greater understanding of the fracture 
characteristics and assists in deciding the 
treatment plan (11, 12). Stereolithic models 
obtained by mirroring techniques and three-
dimensional printing are useful for the choice 
and modelling of the reconstruction material, 
particularly in cases of comminuted fracture 
repair (13). 

There is controversy on the indication for 
surgery and particularly regarding the most 
appropriate timing for performing surgical 
repair in orbital fracture cases. The indications 
for immediate surgery, performed within 24 
hours, are less of a subject for debate. 
Consensus has been achieved regarding 
emergency interventions in cases of diplopia, 
incarcerated extraocular muscle and persistent 
oculo-cardiac reflex (syncope, bradycardia, 
heart block, nausea, vomiting), emergency 
intervention for “white-eyed” blowout 
fracture (patient under 18, minimal clinical 
signs, superior gaze restriction, muscle 
entrapment, trap-door mechanism), and also 
in cases with severe displacement of the globe, 
orbital apex syndrome, optic nerve 
compression and high risk of vision loss (14). 

The debate is ongoing regarding the 
indications for early (within two weeks) and 
late surgery (beyond two weeks). 
Consideration is given to the amount of 
fracture displacement, orbital volume changes, 
the comminution of the fracture, the degree of 
functional and esthetic impairment, the 
presence of priming neurosurgical lesions, and 
to the existence of important comorbidities as 
contraindications for surgery.  

It is most difficult to determine the 
indication for the surgical repair or 
conservative management in minimally 
displaced fractures, in the absence of initial 
symptoms, since posttraumatic changes in the 
orbital soft tissues could progress with the 
apparition of late enophthalmos. Most authors 
agree that in the absence of contraindication, 
the best functional and cosmetic results are 
obtained by performing the primary repair of 
volume modifying orbital fractures, with 
primary grafting when necessary, or 
reconstruction using alloplastic materials (15, 
16). This is true for the majority of inferior 
wall, medial and lateral wall orbital fractures. 
Orbital roof fractures, however, are commonly 
managed conservatively in almost 90% of cases 
comprising minimally displaced fractures 
(12). Possible complications include the onset 
of pulsatile exophthalmos and orbital 
encephalocele that has been reported to also 
occur late after the conservative management 
of minimally displaced fractures of the 
superior orbital wall (12). Blow- in fractures 
with severe displacement, as well as orbital 
roof fractures with a surface greater than 2 cm2 
must be closely monitored since there is a high 
risk of encephalocele development and orbital 
dystopia (8). For severely and moderately 



 
 
 
 
 

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displaced orbital roof fractures the surgery 
indication is maintained. The presence of an 
orbital encephalocele is a surgical indication 
for the removal of the herniated tissue with 
closure of the dura and orbital reconstruction 
(17). Surgery is also performed in the presence 
of superior orbital wall fractures in association 
with dural tears and cerebrospinal fluid (CSF) 
leaks (18). Other situations in which surgery is 
necessary encompass the presence of 
intraorbital foreign bodies, or impingent bone 
fragments causing the compression and lesion 
of the optic nerve, or of the extraocular 
muscles.  

There is no agreement regarding the best 
reconstructive material, with some authors 
advocating for the use of autologous bone 
grafts (16), while others have obtained good 
outcomes by titanium mesh reconstruction 
and thus avoidance of donor site morbidity 
and associated complications (15, 19). In the 
absence of treatment due to late presentation, 
missed diagnosis or delayed surgery due to 
contraindication, the resulting orbital sequelae 
can be addressed in late correction procedures, 
performed after six months from the initial 
injury, for the maturation of the scar tissue (20, 
21). Common orbital sequelae include the 
presence of enophthalmos, exophthalmos, 
orbital dystopia, hypoglobus, diplopia, orbital 
contour changes and facial asymmetry, eyelid 
malpositioning, epiphora, restriction of eye 
movements and soft tissue contraction. 
Following orbital roof fractures in the 
pediatric population that were managed non-
operatively, and other skull and skull base 
fractures, there is concern for the development 
of “growing skull fractures” with enlargement 
of existing communications with the 

intracranial space, dural tears and brain 
herniation (22, 23). Timely diagnosis 
facilitates early intervention and prevention of 
complications. 

Maxillofacial surgery contribution 
Fractures of the inferior, medial and lateral 

orbital walls and rims, in the absence of 
associated skull and skull base fractures, in 
conjunction or not with other fractures of the 
facial skeleton, are managed by the 
maxillofacial surgeon, after the initial 
emergency multidisciplinary evaluation. 
Other fractures that comprise neurosurgical 
lesions, such as orbital roof fractures, or 
panfacial and skull fractures, are often 
managed in mixed surgical teams. Isolated 
blow-out fractures of the inferior orbital wall 
account for 22-47% of orbital injuries (24, 25, 
26). Orbital floor fractures are often found in 
association with fractures of the medial orbital 
wall. Most remaining orbital fractures are 
found in the context of other facial fractures, 
mainly orbito-zygomatic fractures, or naso-
orbito-ethmoid fractures (1, 3) (Fig. 1-6). 

The recognition of emergency situations is 
key for preserving unaltered visual function. 
Retrobulbar hematomas in the context of 
orbital fractures is encountered in 0.45–0.6% 
of cases. The key to avoiding permanent injury 
to the optic nerve and posttraumatic blindness 
is the early recognition of the condition, with 
the help of the ophthalmologist and adequate 
imaging, followed by the drainage of the 
hematoma by lateral canthotomy. It is 
recommended to perform the drainage within 
one hour from onset, and under 24 hours, 
since studies showed that function 
preservation is better when the interval from 



 
 
 
 
 
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onset to treatment is shorter (27). Careful 
monitoring for retrobulbar hematomas must 
also be performed in the postoperative period. 
Compression of the optic nerve by displaced 
bone fragments or intraorbital foreign bodies 
are also indications for emergency surgery, 
just like the un-resolving oculo-cardiac reflex. 
Other lesions indicating the need for 
immediate surgical treatment are related to the 
entrapment of the extraocular muscles and 
orbital fat (trap-door fracture) especially in 
children, when the thick periosteum causes 
more pressure on the entrapped tissues (14). 
The early and late treatment indications vary 
on the presence of clinical signs, the amount of 
fracture displacement and orbital volume 
change, the presence of comorbidities and 
associated traumatic lesions (19).  

The maxillofacial surgeon is familiar with 
several types of access for repairing orbital 
fractures and complex midfacial fractures, 
such as the superior eyelid, inferior eyelid, 
transconjunctival, intraoral approaches, and 
the coronal flap offering exposure for the 
frontal skull, temporal regions, the superior, 
medial and lateral orbit (28, 4). The coronal 
flap is often used in mixed approaches for 
repairing skull fractures, frontal sinus 
fractures, superior orbital rim fractures, NOE 
fractures, and fractures of the orbital roof, 
particularly the blow-out type. The blow-in 
type of orbital roof fracture can be adequately 
accessed and repaired through an upper lid 
approach, in mixed surgical teams (29). 
Additionally, the closure of large CSF fistulas 
associated with tissue loss may be performed 
in mixed surgical teams, by using various types 
of pedicled or free flaps. 

 

 
Figure 1 - Three-dimensional CT reconstruction of a 

patient with a displaced naso-orbito-ethmoidal 
fracture managed by a multidisciplinary approach- 

soft tissue frontal view demonstrating facial 
asymmetry due to left nasal displacement and orbital 

contour change 
 

 
Figure 2 - Three-dimensional CT reconstruction of 

the same patient demonstrating the displaced 
fractures of the nasal bones and right inferior orbital 

rim, ascending process of the maxilla and anterior 
wall of the maxillary sinus  



 
 
 
 
 

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Figure 3 - Inferior view showing the inward and 

inferior displacement of the right medial fractured 
maxillary fragment comprising the inferior orbital 

rim and ascending process of the maxilla with orbital 
volume change 

 

 
Figure 4 - Transverse CT section showing the 

displacement of the right medial maxillary fragment 
with obstruction of the right nasal fossa 

 

 
Figure 5 - Coronal CT section demonstrating right 

maxillary sinus fracture and hemosinus 
 

 
Figure 6 - Transverse CT section showing the 

displacement of the nasal fracture 

Neurosurgical contribution 
Orbital roof fractures are encountered in 

less than 9% of facial fractures in most studies 
(12, 18, 30). They are reported more often in 
children under the age of seven, because of the 
anatomical characteristics with incomplete 
frontal sinus development and a more 
prominent frontal region (18, 30, 31). In 
isolated superior orbital wall fractures, the 
direction of the impact force determines the 
type of fracture, with either a “blow-out” 
mechanism, which is more common and often 
determining orbital volume enlargement and 



 
 
 
 
 
558 | Costan et al - Multidisciplinary approach to orbital fracture repair 

 

 
 
 
 
 
 

enophthalmos, or a “blow-in” mechanism 
seen in high velocity traumatisms, 
determining the diminution of the orbital 
volume and the onset of exophthalmos. As 
previously described, most orbital roof 
fractures are managed conservatively. Still, 
indications for surgery should be carefully 
revised and adequate monitoring of the patient 
must be implemented, for early diagnosis of 
possible complications. Surgical procedures 
for repairing orbital roof fractures often imply 
a collaboration between the neurosurgeon and 
maxillofacial surgeon for achieving adequate 
access. Simple blow-in orbital roof fractures 
can be surgically approached through an 
upper blepharoplasty palpebral incision, while 
blow-out fractures are more challenging, 
requiring a neurosurgical craniotomy 
approach via a coronal incision (29). 

Severe neurosurgical lesions and 
ophthalmologic injuries may be encountered 
in conjunction with orbital roof fractures, 
consisting of brain injuries, pneumocephalus, 
dura tears, CSF leaks, pulsatile exophthalmos, 
orbital meningoencephalocele, entrapment of 
the extraocular muscles, globe rupture, optic 
neuropathies, retrobulbar hematoma (18). 
The morbidity is increased when there is 
association with other fractures of the orbital 
rims (Fig. 7-10), skull, skull base and facial 
skeleton. Orbital roof fractures, skull and skull 
base fractures in children require special 
neurosurgical surveillance, especially in cases 
where there is evidence of dural tears. This is 
due to the possibility of developing “growing 
skull fractures”, needing early diagnosis and 
management for prevention of complications 
and sequelae (22, 23). 

 

 
Figure 7 - Three dimensional CT reconstruction of a 
patient with a displaced fracture of the left superior 

orbital rim that necessitated a multidisciplinary 
management including a neurosurgeon and a 

maxillofacial surgeon 
 

 
Figure 8 - Transverse CT section proving the 

intraorbital displacement of the left superior orbital 
rim fragments 



 
 
 
 
 

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Figure 9 - Coronal CT section demonstrating the 

displaced left intraorbital fractured fragment 
impinging on the left globe and the superior rectus 

muscle 
 

 
Figure 10 - Sagittal CT section showing the presence of 
the displaced intraorbital fragment causing pressure on 

the globe and on the superior rectus muscle 

Otolaringology contribution 
Otolaryngology is often the first 

examination performed in the emergency 
setting for the management of epistaxis, 
frequently encountered in facial traumatisms, 
particularly in association with midface, lateral 
face and central face fractures.  

Isolated naso-orbito-ethmoid fractures 
represent approximately 5% of facial fractures 

in adults, but they have a high incidence in the 
context of other facial fractures. More than 
half of all NOE fractures are associated to 
orbito-zygomatic fractures, while 20% are 
found in the context of panfacial fractures 
(32). The most challenging part in the 
treatment of central face fractures is 
management of the frontal sinus. Fractures 
located here often interest both the anterior 
and the posterior bone plates, with the possible 
occurrence of dura tears and brain herniation. 
Multidisciplinary management is important 
for minimizing the morbidity and achieving 
good functional and cosmetic outcomes. 
Complications of frontal sinus fractures 
include the formation of mucocele, sinusitis, 
osteomyelitis, meningitis, encephalocele, 
cerebrospinal fluid fistula, central face 
deformity (33). In the presence of small dural 
discontinuity and CSF leaks, conservative 
treatment may often lead to the spontaneous 
closure of the fistula, justifying the observation 
of these fractures for up to one week before 
considering surgery. Frontal sinus obliteration 
or cranialization is indicated in cases where the 
ventilation of the frontal sinus cannot be 
reestablished (33). The endoscopic 
management of central face fractures allows 
for a minimally invasive approach and 
accurate visualization (32). In skull base 
fractures with cerebrospinal fluid fistulas, local 
flaps from the nasal cavity can be utilized for 
the closure of CSF leaks using an endoscopic 
technique. 

Fractures of the medial and inferior orbit 
can also be accessed endoscopically, or by a 
combined approach comprising a 
transconjunctival and an endoscopic trans-



 
 
 
 
 
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nasal access (34, 35). There are some 
disadvantages to the entirely endoscopic 
approach consisting of difficult insertion of 
the reconstruction material, with the orbital 
contents being supported by the nasal packing, 
which predisposes to the onset of 
postoperative enophthalmos. Thus, a 
combined open and endoscopic approach 
would associate the superior endoscopic 
visualization of the posterior bone ledges, with 
the improved access for titanium mesh 
insertion (34, 35). 

Opthalmology contribution 
Careful observation and interdisciplinary 

management are mandatory in orbital 
fractures, frequently requiring multiple 
ophthalmological examinations. One in four 
patients with orbital fractures has an 
associated ocular lesion (36). It is for this 
purpose that any periorbital trauma patient 
must be initially evaluated by an 
ophthalmologist. The eye examination 
involves determination of ocular lesions in the 
anterior or posterior segments, diagnosis of a 
globe rupturing or retrobulbar hematoma. 
Evaluation of eye mobility and the degree of 
exophthalmos and enophthalmos may not be 
accurate in the presence of posttraumatic 
edema and necessitates subsequent 
examinations. Studies have shown that the 
greatest risk for posttraumatic vision loss in 
orbital fracture patients is found in the ones 
presenting with penetrating orbital lesions, in 
patients with diagnosed fractures of the 
posterior orbit, involving the orbital apex, 
patients exhibiting a decrease in visual acuity, 
or an afferent pupillary defect (36, 37).  

Ophthalmologic examinations are 
important in the perioperative period to rule 
out the occurrence of a retrobulbar hematoma, 
which represents an indication for emergency 
drainage surgery through lateral canthotomy.  
The finding of postoperative retrobulbar 
hematomas has decreased since the 
implementation of fenestration for 
reconstructive materials used in orbital 
surgery (38), but nevertheless the importance 
of periodic inquiry regarding visual acuity in 
the postoperative time remains crucial for the 
timely intervention in case of compressive 
hematoma development. 

The ectropion-related ophthalmologic 
sequelae that are frequently linked to 
periorbital traumatisms may lead to a decrease 
in the life quality of the patient and often 
necessitate repeated correction procedures. 

Conclusion 
Maxillofacial surgeons, neurosurgeons, 

otolaryngologists and ophthalmologists 
handling the acute orbital trauma patient 
should be familiar with the possible 
complications, the indications for immediate, 
early and delayed surgery, or for the 
conservative management in different patterns 
of orbital fractures. Good collaboration 
between the different specialties increases the 
chances for early diagnosis, accurate operative 
or non-operative management with proper 
follow-up and minimal complications. The 
surgical approach often requires a 
multidisciplinary participation for achieving a 
good exposure, performing a proper 
anatomical repair, resulting in favorable 
functional and aesthetic outcomes. 



 
 
 
 
 

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