orbital-fractures- ANIMATION

Incisions

• Existing lacerations
• LowerEyelid –

1)Subciliary
2)Subtarsal
3) Infraorbital approaches

• Transconjuctival Approach – Lower Eyelid

Both approaches allow easy elevation of the periorbita along
the floor and release of entrapped orbital contents

Orbicularis Oris Muscle

 Innervated by Cranial Nerve VII

 Upper Eyelid – Levator
Palpebral Superioris – Cranial
Nerve III

 Orbicularis Oculi -

 Orbital and
 Palpebral Portions

Palpebral Portion is divided into
fibers -

 Pretarsal Portion - in front of the tarsus.
 Preseptal Portion - in front of orbital septum

SAGITAL SECTION THROUGH ORBIT & GLOBE

 C- Palpebral Conjuntiva
 IO- Inferior Oblique muscle
 IR- Inferior Rectus Muscle
 OO- Orbicularis Oculi
 OS – Orbital Septum
 P - Periosteum/ Periorbita
 TP- Tarsal Plate.

Surgical approach – principles for orbital #

01 02

Surgical approach – principles for orbital #

Anterior

01 02

Posterior

Surgical approach – principles for orbital #

periosteum Anterior

subperiosteal dissection of the
anterior maxilla and orbital floor.

01 Trans cutaneous 02

Sub cutaneous Posterior

Subcutaneous dissection of skin, leaving
pretarsal portion of orbicularis muscle
attached to tarsus

Surgical approach – principles for orbital #

periosteum Anterior periosteum

subperiosteal dissection of the traction suture placed through the
anterior maxilla and orbital floor. cut end of the conjunctiva, which
assists in retracting the conjunctiva..

01 Trans cutaneous Trans conjunctival 02

Sub cutaneous Posterior Sub conjunctival

Subcutaneous dissection of skin, leaving orbit and globe demonstrating level
pretarsal portion of orbicularis muscle and plane of incision. The
attached to tarsus conjunctiva and lower lid retractors
are incised with scissors..





Orbital Implants

• Use of implants based on degree of comminution
and size of fracture

• Various implant material used

– Autogenous bone and cartilage
– Alloplastic material

Orbital implants for floor fractures

08 3d reconstruction 3d reconstruction 07
Composite materials
porous
Preformed implants 05
06 3d reconstruction
Porous & non porous.
Non porous.
Synthetic/
04 Composite materials Artificial Implants- 03

02 Synthetic/ B) Porous-. MEDPOR
Artificial Implants-
Natural bone & 01
A) Non Porous-(titanium, cartilage grafts
Supramid, silicone).
a) Autografts
b) Allografts-.

Implants & Bone Grafts- Multiple implant options - the repair of orbital floor fractures.
An implant is placed over the fracture site.

1. Natural bone & cartilage grafts – a) Autografts ( calvarial bone,), autogenous bone
grafts from clavicle, mandible, iliac crest etc, are considered as the best.

Autogenous materials provide rigidity & moulding capacity, vascularity, biocompatibility &
minimal immune reactivity.
They have osteo conductive and Osteo inductive properties.
Apart from bone grafts, cartilage grafts from auricular concha & nasal septum can also
be used

b) Allografts- Alloplastic cancellous bone 'Genesis Sponge’ - demineralized cancellous bone
to induce proliferation of mesenchymal cells & osteoblast differentiation to help normal bone
formation.
It has high osteo conduction and osteo induction properties.

split-thickness calvarium for an implant -lengthens the surgical time and increases the potential
complications.
Then, the periorbita is closed over the implant along the orbital rim.

Bone Graft https://youtu.be/icDZye4Pf2Y

OUR INSTITUTION VIDEO POSTED IN YOU TUBE- 2010

Disadvantages :
•Additional Donor site needed
•Possible contour and dimensional changes due to
remodeling
•Difficult to shape according to patients anatomy

2. Synthetic/ Artificial Implants- A) Non Porous- Osteo Conductive Materials (titanium,
Supramid, silicone)-
Allograft materials, such as Supramid or silicone sheets, - commonly used and easy to work
with.
However, these implants can migrate or form capsules and may need to be removed later.
Surgical intervention for orbital fractures involving the medial wall and floor can be
done with synthetic implants like silastic sheeting, and Titanium .

The extrusion rates - silastic sheeting is minimal as a capsule forms around the implant
-chances of diplopia post operatively is decreased due to less fibrovascular ingrowth.
Pliability, ease of shaping and conforming to the fracture site is an advantage
with these implants. They are cost effective and biocompatible as well.

1. For fractures not involving the orbital rim and that lesser than 2.5cm square,
silastic sheeting and Titanium/ porous polyethylene gives good result.

2. For fractures involving orbital rim and greater than 2.5 cm square, titanium mesh
is advocated , the disadvantages of which are the sharp edges that need to be burred down
and tissue ingrowth through the holes.

3. For very large reconstructions, titanium mesh covered with porous polyethylene can be
used.

Reconstruction Material

B) Porous- Osteo inductive grafts- eg, MEDPOR- -allogeneic materials like hydroxyapatite,
porous polyethylene (MEDPOR), because of its ease of use (mouldable and easily shaped)
and its ability to become incorporated in the soft tissue.

Its porosity, like other integrated implants such as hydroxyapatite, allows this material to
remain firmly fixated in the position that the surgeon places it.

Osteo inductive bioabsorbable copolymer Hydroxyapatite Poly Lactide Caprolactone
can assist good bone formation for bone defects <15mm with linear or trapdoor types
of fracture.

Resorbable meshed plate implant 'Osteomesh' made of Poly caprolactone which will
degrade & resorb fully in vivo by hydrolysis supports bone In growth.

It degrades as new bone regenerates & is replaced by autologous bone.

Porous Polyethylene Sheet (PPE)

Disadvantages :
• Not Radiopaque (Not visble on Post Operative
Radiographs
•Lack of Rigidity when very thin wafer of PPE is used.
When a more thick rigid wafer is used there is a risk
of causing dystopia

RESORBABLE MATERIALS –

Hydroxyapatite Poly Lactide Caprolactone /Osteomesh

❖ Thermoplastic and
❖ Non Thermoplastic Materials

1.ADVANTAGES :
▪ Availability Handling/
▪ Contourability (only for

thermoplastics)
▪ Smooth surface and smooth edges

2.Disadvantages:
-No radio opacity
-Degradation of material with possible contour
loss Sterile infection / inflammatory response

-Difficult to shape according to patients
anatomy (only for non- thermoplastics)

- Less drainage from the orbit than

POLYETHYLENE & TITANIUM MESH-composite

 By combining titanium mesh
with porous polyethylene –

 Material becomes radio opaque

 More rigid than porous PPE.

 ADVANTAGE :

 Stability
 Contouring
 Adequate in large three wall

fractures
 Radiopacity
 No Donor Site Needed

 DISADVANTAGES : Less
Drainage from orbit than with

Bone Growth Process for orbital fractures

01 02 03 04

TITANIUM, MEDPOR A) AUTOGRAFTS Osteomesh
SUPRAMID,
Porous- osteo inductive B) ALLOGRAFTS- osteo conductive and
SILICONE
osteo conductive and Osteo inductive properties

Non Porous- osteo conductive Osteo inductive properties

Dis advantages of conventional implants & its placement- conventionally size and

shape of defect of orbital floor blow out fracture was estimated from
1.the two dimensional CT scan images.

And with the small trans-conjunctival incision,
2.the bony defect especially the posterior landing zone will be difficult to be visualized
clearly during the operation.

3.The implant had to be repeatedly retrieved from the subperiosteal plane after insertion
for trimming and moulding for more precise placement which could theoretically
increase implant fatigue, increase soft tissue handling, worsen tissue oedema and
prolong operative time.

Pre-formed Orbital Implant

ADVANTAGES :
•Radiopacity
•Smooth Surface
•Minimal or no countouring necessary

DISADVANTAGE : •Cost

3D Printed Grafts
www.presentationgo.com

3D Printed Grafts
www.presentationgo.com

3D Printed Grafts

computer & robust 3D
modelling software

enables 3D models to be created at
ease with typical desktop workstations.

www.presentationgo.com

3D Printed Grafts

Digital-3d Design- skull model computer & robust 3D
modelling software
3D skull model was created in standard
triangle language (STL) format and enables 3D models to be created at
refined with 3D modelling software . ease with typical desktop workstations.

www.presentationgo.com

3D Printed Grafts Area Specific Mesh
Optimization
Digital-3d Design- skull model
orbital floor defect and the contralateral
3D skull model was created in standard intact orbital floor was cropped from
triangle language (STL) format and the skull.
refined with 3D modelling software . reducing the computational burden and
time required for printing.

computer & robust 3D
modelling software

enables 3D models to be created at
ease with typical desktop workstations.

www.presentationgo.com

3D Printed Grafts Area Specific Mesh
Optimization
3D Print Models
orbital floor defect and the contralateral
medically designated Acrylonitrile intact orbital floor was cropped from
Butadiene Styrene (ABS) the skull.
using an Industrial Grade fused reducing the computational burden and
deposition modelling (FDM) printer. time required for printing.

Digital-3d Design- skull model computer & robust 3D
modelling software
3D skull model was created in standard
triangle language (STL) format and enables 3D models to be created at
refined with 3D modelling software . ease with typical desktop workstations.

www.presentationgo.com

3D Printed Grafts Area Specific Mesh
Optimization
Actual Custom Implant-
orbital floor defect and the contralateral
porous polyethylene sheet (0.85mm intact orbital floor was cropped from
thick) is trimmed and moulded to fit the the skull.
size of defect according to the sterilized reducing the computational burden and
3D printed model . time required for printing.

3D Print Models computer & robust 3D
modelling software
medically designated Acrylonitrile
Butadiene Styrene (ABS) enables 3D models to be created at
using an Industrial Grade fused ease with typical desktop workstations.
deposition modelling (FDM) printer.

Digital-3d Design- skull model

3D skull model was created in standard
triangle language (STL) format and
refined with 3D modelling software .

www.presentationgo.com

3D CT-reconstruction of Orbital Implant Custom composite - Orbital Implant

3-5
days

Pre-formed
NON POROUS-Orbital Implant

Advantages- 1) implants (porous polyethylene) can be precisely shaped with ease using
a 3DP orbital floor bone model under direct visualization.

2) the technique has considerably shortened the operative time and the duration of
anaesthesia and could potentially decrease implant fatigue.

3) 3DP models are effectively being used in patient education and communication where
surgeons can better explain the patho anatomy and the surgical procedure.

Patients benefit from a deeper understanding via visual and tactile feedback using their
own anatomical model.
.

Materials used:
1)Titanium mesh
2)Medpor-Titanium composite mesh with additional effects of the porous structure for

better tissue in growth
3)Porous polyethylene
4)Poly ether ether ketone(PEEK)

Titanium vs polymer implant- 3DP patient specific titanium implants as an alternative
in craniofacial bone defect reconstruction.

Advantges of 3DP template shaped polymer implant over titanium metal are

1) its porosity allows for fibrovascular tissue in-growth and very low extrusion rate
2) the current FDM printed ABS polymer model remains far more economical than 3DP

titanium implants.
3) metallic implants placed critically near the eye are unnecessary hazards that preclude

any future MRI studies.

c. orbital rim involvement- If the orbital rim is involved and unstable, microplates may
be screwed directly into the floating bone segment to anchor it to stable bone.

Evolution Road Map – Orbital implants

Evolution Road Map – Orbital implants

Autografts & Allografts

PROS- Biocompatible, mesenchymal osteoblast
differentiation
CONS- Donor Site, Poor Shape & Contour

Evolution Road Map – Orbital implants

Autografts & Allografts Alloplast- non porous

PROS- Biocompatible, mesenchymal osteoblast PROS- Pliability, ease of shaping and conforming
differentiation CONS- Extrusion, Capsule Formation, sharp edges &
CONS- Donor Site, Poor Shape & Contour tissue ingrowth
.

Evolution Road Map – Orbital implants

Autografts & Allografts Alloplast- non porous

PROS- Biocompatible, mesenchymal osteoblast PROS- Pliability, ease of shaping and conforming
differentiation CONS- Extrusion, Capsule Formation, sharp edges &
CONS- Donor Site, Poor Shape & Contour tissue ingrowth
.

Alloplast- porous

PROS- incorporated , firmly
Fixated & Resorbable
CONS- Brittle, Dystopia-thick
rigid wafer & Less drainage .

Evolution Road Map – Orbital implants

Autografts & Allografts Alloplast- non porous

PROS- Biocompatible, mesenchymal osteoblast PROS- Pliability, ease of shaping and conforming
differentiation CONS- Extrusion, Capsule Formation, sharp edges &
CONS- Donor Site, Poor Shape & Contour tissue ingrowth
.
3D Print- Non Porous
Alloplast- porous
PROS- precisely shaped
CONS-Donor Site, Poor Shape & Contour PROS- incorporated , firmly
Fixated & Resorbable
CONS- Brittle, Dystopia-thick
rigid wafer & Less drainage .

Evolution Road Map – Orbital implants

Autografts & Allografts Alloplast- non porous

PROS- Biocompatible, mesenchymal osteoblast PROS- Pliability, ease of shaping and conforming
differentiation CONS- Extrusion, Capsule Formation, sharp edges &
CONS- Donor Site, Poor Shape & Contour tissue ingrowth
.
3D Print- Non Porous
Alloplast- porous
PROS- precisely shaped
CONS-Donor Site, Poor Shape & Contour PROS- incorporated , firmly
Fixated & Resorbable
CONS- Brittle, Dystopia-thick
rigid wafer & Less drainage .

3D Print - Porous

PROS- fibrovascular tissue in-growth and very low extrusion
rate & ABS polymer model -economical
CONS- Donor Site, Poor Shape & Contour & Less drainage

Evolution Road Map – Orbital implants

Autografts & Allografts Alloplast- non porous

PROS- Biocompatible, mesenchymal osteoblast PROS- Pliability, ease of shaping and conforming
differentiation CONS- Extrusion, Capsule Formation, sharp edges &
CONS- Donor Site, Poor Shape & Contour tissue ingrowth
.
3D Print- Non Porous
Alloplast- porous
PROS- precisely shaped
CONS-Donor Site, Poor Shape & Contour PROS- incorporated , firmly
Fixated & Resorbable
CONS- Brittle, Dystopia-thick
rigid wafer & Less drainage .

3D Print - Porous 3D Composite

PROS- fibrovascular tissue in-growth and very low extrusion PROS- More rigid , Stability Contouring
rate & ABS polymer model -economical & three wall fractures
CONS- Donor Site, Poor Shape & Contour & Less drainage CONS- Radiopacity & Less Drainage.

Evolution Road Map – Orbital implants

Autografts & Allografts Alloplast- non porous

PROS- Biocompatible, mesenchymal osteoblast PROS- Pliability, ease of shaping and conforming
differentiation CONS- Extrusion, Capsule Formation, sharp edges &
CONS- Donor Site, Poor Shape & Contour tissue ingrowth
.
3D Print- Non Porous
Alloplast- porous
PROS- precisely shaped
CONS-Donor Site, Poor Shape & Contour PROS- incorporated , firmly
Fixated & Resorbable
CONS- Brittle, Dystopia-thick
rigid wafer & Less drainage .

3D Print - Porous 3D Composite

PROS- fibrovascular tissue in-growth and very low extrusion PROS- More rigid , Stability Contouring
rate & ABS polymer model -economical & three wall fractures
CONS- Donor Site, Poor Shape & Contour & Less drainage CONS- Radiopacity & Less Drainage.

Evolution Road Map – Orbital implants









Stages for Orbital Fractures Mgmt

www.presentationgo.com

Stages for Orbital Fractures Mgmt

1

Per op &
Immediate
post op Care

www.presentationgo.com

Stages for Orbital Fractures Mgmt

1 2

Per op & Post op &
Immediate Rehab Care
post op Care

www.presentationgo.com

Stages for Orbital Fractures Mgmt

1 2 3

Per op & Post op & Complications
Immediate Rehab Care
post op Care

www.presentationgo.com