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Purpose: To evaluate clinical presentations, computed tomography (CT) findings, and various prognostic factors affecting the surgical outcomes of trapdoor fractures., Methods: This retrospective multi-center study reviewed medical records and orbital CT scans of patients under 21 years old, diagnosed with isolated trapdoor fractures. The study was conducted across multiple medical centers, including emergency and clinical departments in Isfahan, Shiraz, and Tehran-Iran. The characteristics and outcomes following surgical intervention were assessed., Results: 45 patients with isolated trapdoor fractures were included in the study, with a mean age of 11.67 ± 4.69 years, predominantly male (84.4%). Vehicle accidents was the major cause of fractures (31.1%). 44 patients (97.8%) had orbital floor fracture, and one patient (2.2%) had medial wall involvement. Nausea/vomiting were reported in 41 patients (91.1%). Surgical intervention within 2 days, resulted in 85.0% of patients experiencing no postoperative diplopia. Delayed surgery beyond 2 days showed increased odds of diplopia, although not statistically significant. CT scan findings suggested a lower risk of diplopia in patients with soft tissue entrapment compared to muscle involvement (OR: 0.336, 95% CI: 0.077-1.462, p = 0.146). Shorter time to surgery (within 2 days) was significantly associated with normal postoperative eye movements (p = 0.002). Nausea/vomiting were more prevalent in patients with muscle entrapment (p < 0.05)., Conclusion: Surgical intervention within 48 h is crucial for improving ocular motility following trapdoor fractures. Extraocular symptoms, including nausea/vomiting, should raise suspicion for trapdoor fractures in cases of orbital trauma associated with ocular movement impairment., Clinical Trial Number: Not applicable., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Purpose: No definitive procedures have been proposed for orbital floor fractures extending to the slope of the posterior end, which is a challenging problem. This study demonstrates the effectiveness of an orbital reconstruction procedure based on anatomical landmarks that we developed, called the three landmarks procedure (TLP)., Methods: This study is a single-center retrospective cohort study conducted by the Department of Otorhinolaryngology, Japanese Red Cross Asahikawa Hospital. Data were collected from April 2000 to December 2023. The effect of TLP and the balloon procedure (BP) on ocular movement was compared. The prevalence of postoperative enophthalmos after TLP was examined., Results: The study included 17 patients who underwent TLP and 25 patients who underwent BP. Postoperative mean Hess area ratio (HAR%) was 98.3 (95% confidence interval (CI), 97.0-99.6) in the TLP group and 88.6 (95% CI 83.2-94.0) in the BP group. Among study patients with fractures extending to the posterior slope, 14 underwent TLP and 16 underwent BP. Postoperative mean HAR% was 98.5 (95% CI 97.3-99.7) in the TLP group and 89.2 (95% CI 82.4-95.8) in the BP group. Among all patients who underwent TLP, mean postoperative enophthalmos was 0.06 mm (95% CI - 0.32 to 0.44). It was 0.14 mm (95% CI - 0.31 to 0.59) among patients with fractures extending to the posterior slope., Conclusion: TLP resulted in better postoperative ocular movements than BP. Furthermore, TLP is an effective technique for treating fractures extending to the posterior slope, which are challenging to reconstruct., (© 2024. The Author(s).)

Background: Midfacial fractures are among the most frequent facial fractures. Surgery is recommended within 2 weeks of injury, but this time frame is often extended because the fracture is missed on diagnostic imaging in the busy emergency medicine setting. Using deep learning technology, which has progressed markedly in various fields, we attempted to develop a system for the automatic detection of midfacial fractures. The purpose of this study was to use this system to diagnose fractures accurately and rapidly, with the intention of benefiting both patients and emergency room physicians., Methods: One hundred computed tomography images that included midfacial fractures (e.g., maxillary, zygomatic, nasal, and orbital fractures) were prepared. In each axial image, the fracture area was surrounded by a rectangular region to create the annotation data. Eighty images were randomly classified as the training dataset (3736 slices) and 20 as the validation dataset (883 slices). Training and validation were performed using Single Shot MultiBox Detector (SSD) and version 8 of You Only Look Once (YOLOv8), which are object detection algorithms., Results: The performance indicators for SSD and YOLOv8 were respectively: precision, 0.872 and 0.871; recall, 0.823 and 0.775; F1 score, 0.846 and 0.82; average precision, 0.899 and 0.769., Conclusions: The use of deep learning techniques allowed the automatic detection of midfacial fractures with good accuracy and high speed. The system developed in this study is promising for automated detection of midfacial fractures and may provide a quick and accurate solution for emergency medical care and other settings., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Masson SAS. All rights reserved.)

The potential benefits to surgical outcomes of intraoperative and/or same-day computed tomography (CT) during isolated orbital fracture reconstruction are debatable, and previous research on this topic is limited by small sample size. This retrospective IBM MarketScan Commercial and Medicare Supplemental research database study examined patients undergoing isolated orbital reconstruction from January 1, 2012 to December 31, 2018, to assess whether same-day CT affected postoperative outcomes. The average age of the 5,023 participants was 37 (standard deviation [SD]: 16) years and 63% were males. The data revealed that 16.2% (815 of 5,023) patients underwent a same-day CT. Those who underwent a same-day CT scan exhibited reduced odds of postoperative enophthalmos (adjusted odds ratio [aOR]: 0.269; 95% confidence interval [CI]: 0.167-0.433) and diplopia (aOR: 0.670; 95% CI: 0.495-906). Interestingly, these patients also displayed a higher rate of revision surgeries (aOR: 2.721; 95% CI: 1.893-3.912). In summary, while same-day CT scans diminish certain postoperative complications of orbital fracture repair, they are also associated with an increased likelihood of subsequent surgical revision., Competing Interests: None declared., (Thieme. All rights reserved.)

Importance: Create validated criteria to identify orbital fracture patients at higher risk for significant ocular injuries. Objective: Determine history and physical examination findings in orbital fracture patients who are associated with ocular injury and warrant urgent assessment by an ophthalmologist. Design, Setting, and Participants: Retrospective chart review of 535 adult orbital fracture patients evaluated at a Level I emergency department between 2014 and 2017, without prior history of orbital fracture, ocular injury, or ocular/orbital surgery. Main Outcomes and Measure: Presence of ocular injury. Results: In total, 195 (36%) patients had an ocular injury. Those with and without ocular injury were compared in a multivariate logistic regression model including demographics, fracture characteristics, injury mechanism, and physical examination findings. Visual acuity change, radiographic retrobulbar hemorrhage, abnormal pupillary reaction, and inability to open the injured eye all had significant associations with ocular injury when other findings were controlled. Conclusion: This study shows a significant association between ocular injury and visual acuity change, retrobulbar hemorrhage, abnormal pupillary reaction, and inability to open the injured eye. These factors can help triage when to obtain an urgent ophthalmology consult.

Purpose: Our aim was to determine if intraoperative navigation (ION) improved radiographic outcomes in patients undergoing delayed primary/secondary orbital reconstruction for inferomedial defects, as measured by volume restoration, enophthalmos correction, and positional accuracy of implants. Patients and Methods: A prospective quasiexperimental study was performed to compare two groups of patients requiring orbital reconstruction. Use of ION was the exposure evaluated. Outcome measures were (i) intraorbital volume and enophthalmos evaluated radiologically, (ii) implant position accuracy, and (iii) procedural duration. Data were analyzed statistically to compare variance between groups. Results: Forty patients (6 females and 34 males) were recruited into the study with a mean age of 27.3 years. The study group demonstrated a greater reduction of intraorbital volume (0.49 cu.cm; p  = 0.02) and enophthalmos (0.72 mm; p  = 0.001). Implant positioning was more accurate using ION, with less mediolateral ( p  = 0.006) and yaw ( p  = 0.04) deviations. Surgical time for implant positioning was shorter by 17 min, with navigation ( p  < 0.001). Conclusion: The use of ION demonstrated radiographic improvements in volume restoration, enophthalmos correction, as well as accuracy of implant positioning, in patients requiring delayed primary/secondary orbital reconstruction.

A 37-year-old scuba diver developed sudden severe headache, mid-facial pressure/pain and diplopia while diving. Upon examination, he had signs and symptoms consistent with silent sinus syndrome (SSS), including bilateral enophthalmos, hypoglobus, and diplopia/strabismus in conjunction with CT findings of occluded maxillary sinus ostia, atrophic/collapsed maxillary sinuses, and bilateral orbital floor fractures with fat herniation. As there was no history of trauma or chronic sinusitis, this rare case of bilateral SSS was deemed the cause of the spontaneous fractures (i.e. barotrauma secondary to a lack of equalization to ambient surrounding pressure). Transconjunctival repair of the fractures was successful and maxillary sinus antrostomies re-established aeration of the sinuses. We present this case and its management, as well as review the literature concerning sinus barotrauma as a result of diving and SSS. There have been no reports of orbital fractures primarily caused by scuba diving, nor secondarily from diving with the rare entity, SSS.

Background: Orbital floor fractures result in critical changes in the shape and inferior rectus muscle (IRM) position. Radiological imaging of IRM changes can be used for surgical decision making or prediction of ocular symptoms. Studies with a systematic consideration of the orbital floor defect ratio in this context are missing in the literature. Accordingly, this study on human cadavers aimed to systematically investigate the impact of the orbital floor defect ratio on changes in the IRM and the prediction of posttraumatic enophthalmos., Methods: Seventy-two orbital floor defects were placed in cadaver specimens using piezosurgical removal. The orbital defect area (ODA), orbital floor area (OFA), position and IRM shape, and enophthalmos were measured using computed tomography (CT) scans., Results: The ODA/OFA ratio correlated significantly (p < 0.001) with the shape (Spearman's rho: 0.558) and position (Spearman's rho: 0.511) of the IRM, and with enophthalmos (Spearman's rho: 0.673). Increases in the ODA/OFA ratio significantly rounded the shape of the IRM (ß: 0.667; p < 0.001) and made a lower position of the IRM more likely (OR: 1.093; p = 0.003). In addition, increases in the ODA/OFA ratio were significantly associated with the development of relevant enophthalmos (OR: 1.159; p = 0.008), adjusted for the defect localization and shape of the IRM. According to receiver operating characteristics analysis (AUC: 0.876; p < 0.001), a threshold of ODA/OFA ratio ≥ 32.691 for prediction of the risk of development of enophthalmos yielded a sensitivity of 0.809 and a specificity of 0.842., Conclusion: The ODA/OFA ratio is a relevant parameter in the radiological evaluation of orbital floor fractures, as it increases the risk of relevant enophthalmos, regardless of fracture localization and shape of the IRM. Therefore, changes in the shape and position of the IRM should be considered in surgical treatment planning. A better understanding of the correlates of isolated orbital floor fractures may help to develop diagnostic scores and standardize therapeutic algorithms in the future., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Authors. Published by Elsevier GmbH.. All rights reserved.)

Orbital walls are one of the most common sites of midface fractures and account for ~40% of traumatic injuries in this region. These fractures are often associated with changes in the anatomy of the orbital cavity and frequently affect the orbital inferior wall, infraorbital groove and canal, and medial orbital wall, which leads to changes in its pattern and volume as well. Generally, the forces required for brake superior and lateral walls are greater than those required for thin medial and inferior walls. Disruption of any of these structures leads to the expansion of orbital volume that brings to the appearance of enophthalmos, diplopia, and impaired ocular mobility. The gold standard in the treatment of orbital wall fractures is surgical reconstruction, that includes fracture site exposure, freeing tissue prolapsed into the fracture site, and re-approximating the orbital wall support, usually with an orbital implant. It usually could be achieved by the usage of such as transconjunctival, subciliary, and coronal approaches and implementation of graft and reconstructive materials, including bones, cartilage, titanium, and resorbable mesh. Today, the gold standard in orbital floor reconstruction is the application of titanium mesh orbital plates. However, their implementation could be associated with a number of postoperative complications, such as mispositioning and orbital adherence syndrome. Orbital adherence syndrome is a poorly described and understood phenomenon and appears to occur after the use of large-pored titanium mesh for orbital reconstruction. It usually appears as limited eye movement that appears 1 to 2 weeks after reconstructive procedure. Prevention is possible through careful patient selection and the placement of a smooth interface medium in the initial surgery. The aim of the current study is to present the outcomes of orbital reconstruction done by both orbital mesh and customized ​​smooth-surfaced titanium orbital implants., Competing Interests: The authors report no conflicts of interest., (Copyright © 2024 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of Mutaz B. Habal, MD.)

Gillies temporal approach has been widely used to reduce zygoma fractures. Traditionally, it is the preferred method to reduce the isolated zygomatic arch fracture. It can be combined with other approaches, such as subciliary and intraoral incisions for more complex zygomatic fractures, so-called tripod fractures. In this study, the author hypothesized that complex zygomaticomaxillary bone fracture reduction can successfully be achieved without Gillies temporal incision. The author retrospectively analyzed the medical records and 3D facial Computed Tomography (CT) scans of 80 patients who had orbitozygomaticomaxillary fractures that affected >3 sites among the frontozygomatic suture, zygomaticomaxillary buttress, zygomatic arch, and orbital walls from May 2021 to August 2023. A single surgeon performed all surgical operations. All fractures were reduced with 2 incisions, lower eyelid incisions (subciliary or subconjunctival) and intraoral incisions (gingivobuccal approach), within a week of the initial traumatic event. After sufficient exposure to fractured sites using 2 incisions, the author reduced the fracture with a bony hook at the inferior orbital rim, lateral wall, or Boise elevator at the intraoral incision. All cases were successfully corrected without any complications. In conclusion, the author can successfully reduce complex zygomaticomaxillary fracture combined with orbital wall fractures without temporal Gillies approach., Competing Interests: The author reports no conflicts of interest., (Copyright © 2024 by Mutaz B. Habal, MD.)

This study aimed to compare the accuracy of inferomedial orbital fracture restoration using customized orbital implant versus 3D preformed titanium mesh. Patients were divided into two groups. Group 1 underwent surgery with customized orbital implants and intraoperative navigation, while group 2 was treated using 3D preformed titanium meshes with preoperative virtual surgical planning (VSP) and intraoperative navigation. Reconstruction accuracy was assessed by: (1) comparing the postoperative reconstruction mesh position with the preoperative VSP; and (2) measuring the difference between the reconstructed and unaffected orbital volume. Pre- and postoperative diplopia and enophthalmos were also evaluated. Fifty-two patients were enrolled (25 in group 1 vs 27 in group 2). The mean difference between final plate position and ideal digital plan was 0.62 mm (SD = 0.235) in group 1 and 0.69 mm (SD = 0.246) in group 2, with no statistical difference between the groups (p = 0.282). The mean volume differences between the reconstructed and unaffected orbits were 0.95 ml and 1.02 ml in group 1 and group 2, respectively, with no significant difference between the groups (p = 0.860). Overall clinical improvements, as well as complications, were similar. 3D preformed titanium meshes can reconstruct inferomedial fractures with the same accuracy as customized implants. Therefore, in clinical practice, it is recommended to use 3D preformed meshes for this type of fracture due to their excellent results and the potential for reducing time and costs., Competing Interests: Declaration of competing interest None declared., (Copyright © 2024 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

To clinically and radiographically evaluate patient-specific titanium meshes via a trans-antral approach for correction of enophthalmos and orbital volume in patients with recent unilateral orbital floor fracture. Seven patients with unilateral orbital floor fractures received patient-specific titanium meshes that were designed based on a mirror-image of the contralateral intact orbit. The patient-specific implants (PSIs) were inserted via a trans-antral approach without endoscopic assistance. The patients were evaluated clinically for signs of diplopia and restricted gaze as well as radiographically for enophthalmos and orbital volume correction. Diplopia was totally resolved in two of the three patients who reported diplopia in the upward gaze. Whereas enophthalmos significantly improved in all but two patients, with a mean value of 0.2229 mm postoperatively compared to 0.9914 mm preoperatively. CT scans showed excellent adaptation of the PSIs to the orbital floor with a mean reduction of the orbital volume from 29.59 cc to 27.21 cc, a mean of 0.6% smaller than the intact orbit. It can be concluded that the proposed PSI can offer good reconstruction of the orbital floor through an isolated intraoral transantral approach with minimal complications. It could of special benefit in extensive orbital floor fractures., Competing Interests: Declaration of competing interest No conflict of interest declared., (Copyright © 2024 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

To compare the reconstruction of orbital fractures using patient-specific implants (PSI) and conventional pre-formed titanium mesh; to develop a method of three-dimensional (3D) superimposition and analysis of the reconstructed orbits; and to present the pitfalls in 3D planning of orbital PSI and how to avoid them. This was a retrospective study of patients with orbital fractures who were treated in our institution between the years 2022 and 2023 using PSI or conservative prefabricated titanium mesh. Three different methods for virtual reconstruction of orbital fractures were used and are detailed with advantages, disadvantages and indications. Data acquired included age, gender, method of reconstruction, functional outcomes and aesthetic outcomes. 3D analysis for accuracy of reconstruction was performed. A total of 23 patients were included; 12 were treated using PSI and 11 using prefabricated titanium meshes. There were 8 male and 4 female patients in the PSI group comparted to 5 and 6 in the prefabricated group. All three virtual methods for reconstruction were used successfully, each with the proper indications. When comparing PSI reconstruction to conventional mesh, a significant difference in accuracy was observed; PSI cases showed an inaccuracy of 0.58 mm compared to 1.54 mm with the conventional method. Complications are presented, and tips for avoiding them are detailed. Three different methods for virtual reconstruction were used successfully; automated computerized reconstruction is used for small defects, repositioning is the superior method for non-comminuted cases while mirroring is the method of choice in comminuted fractures. 3D analysis can be performed using a novel method detailed in this report. PSI reconstruction showed superior results, indicating it should be the method of choice when possible. Pitfalls are presented and approaches to prevent them are discussed. Orbital reconstruction is a very important entity in maxillofacial surgery with crucial functional and esthetical implications, and one should use virtual planning and PSI implants, as they significantly improve outcomes., Competing Interests: Declaration of competing interest None., (Copyright © 2024 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

Objective: For analyzing the mechanical properties of 2 cranio-orbital repair materials under distinct external impacts by finite element analysis and evaluating the stability of various repair materials., Methods: Based on the computed tomography images of the patients with cranio-orbital fractures, three-dimensional models of the normal craniomaxillofacial models were established by segmenting them with Mimics 19.0, Geomagic Studio 12.0, and UG 12.0, respectively, to build the finite element models of titanium repair fixation and the poly-ether-ether-ketone repair fixation. The models were then simulated by Ansys 19.2, with divergent impact forces to analyze the stresses and displacements of the repair materials, as well as the internal fixation system, and to make a comparison on the stability of the distinct repair materials., Results: The titanium mesh is stable at impact forces ≤1500 N. Furthermore, the poly-ether-ether-ketone mesh and the internal fixation system are resistant to fracture and displacement at impact forces of up to 3000 N., Conclusion: By simulating distinct mechanical environments, the biomechanical finite element analysis method can digitally assess the mechanical properties of cranio-orbital repair materials and objectively evaluate the stability of the repair materials and the internal fixation system., Competing Interests: The authors report no conflicts of interest., (Copyright © 2023 by Mutaz B. Habal, MD.)

Orbital trauma can occur independently or in conjunction with other craniofacial trauma and can cause damage to bony and neurovascular structures as well as soft tissues. Appropriate interdisciplinary treatment of patients is essential to prevent long-term damage such as blindness or muscle dysfunction. Even complex fractures and soft tissue damage can be visualized using modern thin-layer computed tomography (CT), which is necessary for proper treatment., (© 2024. The Author(s), under exclusive licence to Springer Medizin Verlag GmbH, ein Teil von Springer Nature.)

A frontoorbitozygomaticomaxillary fracture, also known as a complex midface fracture or "quadripod fracture," is a type of facial fracture involving multiple midface region bones. This includes the frontal bone (forehead), orbitozygomatic complex (which includes the zygomatic bone or cheekbone and the orbital bones around the eye), and the maxillary bone (upper jaw). These complex midface fractures associated with temporoparietal bone fractures can occur in clinical practice. However, a single-piece fracture of these has not been reported before. This study reports a 44-year-old male patient with a significant frontoorbitozygomaticomaxillary fracture associated with a temporoparietal bone fracture combined with epidural hematoma at the superior aspect of unilateral frontoparietotemporal convexity. Surgical treatment was performed 3 weeks after the traumatic event. Despite craniotomy of the parietal bone fragment, the reduction was not possible. The facial bone reduction was finally achieved following an additional single osteotomy at the unilateral zygomaticomaxillary buttress. The follow-up CT scan taken immediately and 3 weeks postoperatively showed successful realignment of craniofacial bone fracture. In conclusion, a single-piece fracture of frontoorbitozygomaticomaxillary bone connected to a temporoparietal bone can require additional osteotomy to achieve successful outcomes in an acute setting., Competing Interests: The authors declare no conflicts of interests., (Copyright © 2023 by Mutaz B. Habal, MD.)

One of the greatest challenges in orbital reconstruction is to obtain adequate orbital volume and globe projection after traumatic injury. Autologous bone graft has been considered the gold standard for orbital floor reconstruction, but the harvesting yields many possible complications, such as donor site morbidity. Bone resorption is a frequent problem that can lead to insufficient volume after graft placement. There is a theoretically lower resorption rate of skull bone grafts, even though the exact amount is not known yet. This study is the first to evaluate bone volume and density changes of calvarial split bone grafts after orbital floor reconstruction with a 2-year follow-up. Bone volume and density of calvarial split grafts were determined using computed tomography scans and the software program RadiAnt Dicom Viewer in a total of 10 patients with orbital floor fracture reconstruction. Computed tomography scans taken immediately after surgery (T0) and after a postoperative period of 2 years (T1) were evaluated. The authors found a mean bone volume reduction of 34.25% after 2 years. Bone density was still high after 2 years (over 850 HU), with a mean reduction of 8%. Based on these findings, calvarial split bone grafts represent the ideal reconstruction material for orbital floor fractures., Competing Interests: The authors report no conflicts of interest., (Copyright © 2023 by Mutaz B. Habal, MD.)

The zygomaticomaxillary complex and the orbital floor are commonly affected by mid-face fractures; their fractures pose challenges in reconstruction and can result in complications, such as enophthalmos. This study explores an intraoral approach with the help of a customized balloon technique and a contrast agent as an alternative to the conventional methods. A case report of a 67-year-old man with complex midfacial trauma is presented. The surgical process involved open reduction through an intraoral approach along with a transantral approach with the customized balloon technique. The procedure aimed to achieve reduction, fixation, and reconstruction of a complex mid-face fracture., Competing Interests: The authors report no conflicts of interest., (Copyright © 2024 by Mutaz B. Habal, MD.)

Objective: Three-dimensional (3D) modeling technology aids the reconstructive surgeon in designing and tailoring individualized implants for the reconstruction of complex craniofacial fractures. Three-dimensional modeling and printing have traditionally been outsourced to commercial vendors but can now be incorporated into both private and academic craniomaxillofacial practices. The goal of this report is to present a low-cost, standardized office-based workflow for restoring bony orbital volume in traumatic orbital fractures., Methods: Patients with internal orbital fractures requiring open repair were identified. After the virtual 3D models were created by iPlan 3.0 Cranial CMF software (Brainlab), the models were printed using an office-based 3D printer to shape and modify orbital plates to correctly fit the fracture defect. The accuracy of the anatomic reduction and the restored bony orbital volume measurements were determined using postoperative computed tomography images and iPlan software., Results: Nine patients fulfilled the inclusion criteria: 8 patients had unilateral fractures and 1 patient had bilateral fractures. Average image processing and print time were 1.5 hours and 3 hours, respectively. The cost of the 3D printer was $2500 and the average material cost to print a single orbital model was $2. When compared with the uninjured side, the mean preoperative orbital volume increase and percent difference were 2.7 ± 1.3 mL and 10.9 ± 5.3%, respectively. Postoperative absolute volume and percent volume difference between the orbits were -0.2 ± 0.4 mL and -0.8 ± 1.7%, respectively., Conclusions: Office-based 3D printing can be routinely used in the repair of internal orbital fractures in an efficient and cost-effective manner to design the implant with satisfactory patient outcomes., Competing Interests: The authors report no conflicts of interest., (Copyright © 2024 by Mutaz B. Habal, MD.)

Craniomaxillofacial trauma is primarily diagnosed and managed by oral and maxillofacial surgeons. Among the cases encountered, midface fractures involving orbital walls are highly prevalent. In these fractures, involvement of the orbital walls, particularly floor of the orbit, can lead to considerable aesthetic and functional limitations. From a maxillofacial perspective, indications for surgical repair of orbital floor encompass marked decrease in ocular motility, fracture affecting more than 50% of surface area, an increase in orbital volume exceeding 18% and enophthalmos greater than 2 mm. In the absence of these discernible signs, surgical intervention is not generally indicated. However, in this case, an early adolescent with a history of midface trauma and minimal orbital floor fracture 8 months earlier presented with progressively delayed onset enophthalmos and hypoglobus closely resembling features of silent sinus syndrome. The enophthalmos and hypoglobus were corrected by placing custom-made non-resorbable high-density polyethylene implant in the orbital floor. Postoperative follow-up demonstrated aesthetically and functionally satisfactory outcomes., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Prompt diagnosis and management of orbital entrapment fractures in the pediatric patient have been advocated. This retrospective study analyzed a cohort of orbital entrapment fractures in pediatric patients with regard to diagnostic pitfalls, treatment and outcomes in a Level I trauma center in Germany. Based on medical records and radiological imaging, patients under the age of 18 years who presented with orbital fractures during 2009-2021 were analyzed. Overall, 125 patients presented with orbital fractures, of whom 29 patients (23.2%) had orbital entrapment fractures. The majority of patients presented with monocle hematoma (n = 23), diplopia (n = 20), and/or restricted extraocular eye movement (n = 14). While all patients with orbital entrapment fractures underwent three-dimensional imaging, 10 radiological reports (34.5%) did not include findings on orbital entrapment fractures. All patients underwent surgical exploration in less than 24 h. In 12 patients, clinical symptoms such as diplopia and restricted ocular elevation were documented upon postoperative evaluation before discharge. Considering the significant proportion of orbital entrapment fractures that are not noted on radiological imaging, prompt clinical examination should be initiated in pediatric patients at risk for orbital fractures. Urgent surgical intervention should be recommended in entrapment fractures., Competing Interests: Declaration of competing interest The authors declare no conflict of interest., (Copyright © 2023 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

Background: Growing skull fracture (GSF) of the orbital roof is a rare complication of head injury in infancy and early childhood. Analysis of the Medline database between 1983 and 2023 identified 17 articles describing 63 children after surgical treatment of GSF of the orbital roof., Material and Methods: We present a 2-year-old child with moderate traumatic brain injury (TBI) complicated by GSF of the orbital roof. Neuroimaging and literature data are described., Results: Severe ophthalmological symptoms in acute period of TBI subsequently partially regressed with persistent swelling of the upper eyelid and hypophthalmos. CT and MRI revealed a linear fracture of the frontal bone extending to superior orbital wall and intraorbital collection of cerebrospinal fluid (pseudomeningocele) mixed with blood. MR signs of GSF of the orbital roof with pseudomeningocele shrinkage were found in 5 weeks after injury. After 6 months, CT and MRI revealed signs of more severe GSF. Surgical treatment implied craniotomy, excision of scars, arachnoid membrane and abnormal brain matter, resection of deformed fracture edges, dura mater sealing and orbital roof reconstruction with bone autograft. Ophthalmological symptoms regressed after 6 months. The follow-up period was 6 years. There were no signs of fracture recurrence., Conclusion: In this case, acute intraorbital pseudomeningocele led to GSF of the orbital roof in 5 weeks after injury. Incomplete regression of ophthalmological symptoms, their aggravation or delayed appearance in children with orbital roof fracture requires a thorough examination including high-resolution CT and MRI, and orbital roof GSF should be considered in the differential diagnosis.

Purpose: Orbital floor fractures can cause functional disorders such as limitation of ocular motility. The dysfunction of the extrinsic muscles was studied with the Hess-Lancaster test; although we expected a large percentage of inferior rectus muscle dysfunction, the results showed 52% superior rectus muscle dysfunction., Methods: In light of these results, we began testing five patients with functional deficits evidenced by the Hess-Lancaster test with magnetic resonance imaging to assess the change in thickness of the affected muscle compared to the contralateral healthy muscle during standardized eye movements., Results: This investigation showed an increase in the size of the inferior rectus muscle on the affected side during the fraction of time when the patient was asked to look up, probably due to post-traumatic fibrosis. According to our hypothesis, muscle thickness would condition the correct release of the inferior rectus muscle to such an extent that it would also influence the contraction of the superior rectus muscle, which would then be deficient., Conclusions: Based on our experience, a multidisciplinary approach and longer follow-up with thorough investigations should be considered for patients with orbital floor fractures. Furthermore, our results suggest the need for early surgical treatment, in contrast to current guidelines that aim to delay restorative surgery.

Craniomaxillofacial trauma is a challenging entity to manage effectively and often necessitates serial evaluation and treatment. A multidisciplinary team is best served to evaluate and treat these complex injury patterns with the use of necessary adjuncts, such as neuronavigation, intraoperative imaging, custom implant use, and virtual surgical planning. Complications of facial trauma can present at a spectrum of time points and manifest in a variety of manners and as such patients should be observed closely and longitudinally. Although not all complications and secondary deformities can be avoided, this article highlights some common pitfalls and our unique management strategies., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Purpose: This retrospective study aims to define the optimal timing of the surgical treatment of orbital floor trapdoor fractures (OFTFs) in adults according to clinical and radiological findings., Methods: From January 2006 to December 2020, 382 patients with isolated orbital floor fracture were admitted to the Division of Maxillofacial Surgery of Turin, Italy. The criteria for inclusion were age ≥ 16 years, preoperative computed tomography showing a linear (1a) or medial hinge fracture (1b), diplopia, and 6 months of follow-up data. Aetiology and mechanism of injury, presence of post-traumatic enophthalmos and oculocardiac reflex, time between trauma occurrence and surgery [stratified as < 24 h (urgent treatment), 24-96 h (early treatment), and > 96 h (late treatment)], days of hospitalisation, and clinical outcomes were examinated., Results: Twenty-four patients (18 males; mean age, 23.2 years) presented with OFTFs. The most common cause was sport injury (50%). Type 1a fracture was observed in eight patients (mean age, 19.5 years), type 1b fracture in 16 patients (mean age, 23.6 years). Urgent, early, and late treatments were performed in eight patients each. The mean time between trauma occurrence and surgery was 3,8 days (range: 0-17 days). Resolution of diplopia was observed 1 week after surgery in 10 patients, 1 month in 12. Diplopia persisted in 2 patient, both treated > 96 h after trauma., Conclusion: Although the number of patients was too small to define a standard protocol, the authors recommend early treatment of adult OFTFs to promote complete resolution of diplopia., (© 2022. The Author(s).)

This study investigated the orbital morphological features that lead to fractures at different sites by comparing patients with isolated inferior wall fracture (IWF) to patients with isolated medial wall fracture (MWF). This study analyzed the orbital morphologic characteristics of all orbital fracture patients who underwent orbital computed tomography (CT) scans between January 2017 and October 2022. On CT scans, the bony structures of the orbit were measured. We investigated the bilateral symmetry of orbital. In addition, orbital morphological differences were compared between patients with fractures of the medial wall and those with fractures of the inferior wall. A total of 135 patients with orbital fractures were included in the study. Of these, 91 were isolated MWFs and 44 were isolated IWF. We confirmed the symmetry of bilateral orbits and measured the orbit of the uninjured side. No differences were found between the MWF group and the IWF group in terms of ocular prominence, horizontal orbital diameter, orbital rim angle, sagittal orbital depth, sagittal orbital depth, and angle of inferior wall inclination. The distance between the infraorbital nerve (ION) entry point and the orbital rim was significantly smaller in the inferior lateral wall fracture group than in the MWF group (11.87 ± 2.54 vs 14.90 ± 4.64, P < 0.001), and the percentage of type 1 ION was significantly lower in the IWF group than in the MWF group (40.9% vs 65.9%, P = 0.012). We demonstrated the symmetry of bilateral orbits and found that when the point where the ION enters the infraorbital canal is near the orbital rim, patients are more prone to suffering a fracture of the inferior wall after orbital trauma. It is less likely for patients with type 1 ION to suffer an IWF following an orbital fracture., (© 2023. The Author(s).)

Background: Orbital wall fractures can result in changes to the bony orbital volume and soft tissue. Restoring the bony orbital and intraconal fat volumes is crucial to prevent posttraumatic enophthalmos and hypoglobus. We aimed to establish an evidence-based medical reference point for "mirroring" in orbital wall reconstruction, which incorporates three-dimensional (3D)-printing and navigation-assisted surgery, by comparing bilateral bony orbital volumes., Methods: We retrospectively analyzed the data obtained from 100 Korean adults who did not have orbital wall fractures, categorized by age groups. The AVIEW Research software (Coreline Soft Inc., Seoul, South Korea) was used to generate 3D reformations of the bony orbital cavity, and bony orbital volumes were automatically calculated after selecting the region of interest on consecutive computed tomography slices., Results: The mean left and right orbital volume of males in their 20 s was 24.67 ± 2.58 mL and 24.70 ± 2.59 mL, respectively, with no significant difference in size (p = 0.98) and Pearson's correlation coefficient of 0.977 (p < 0.001). No significant differences were found in orbital volumes in other age groups without fractures or in patients with nasal bone fractures (p = 0.84, Pearson's correlation coefficient 0.970, p < 0.001). The interclass correlation coefficients (2,1) for inter- and intrarater reliability were 0.97 (p < 0.001) and 0.99 (p < 0.001), respectively., Conclusions: No significant differences were found in the bilateral bony orbital volumes among males of any age. Thus, the uninjured orbit can be used as a volumetric reference point for the contralateral injured orbit during orbital wall reconstruction., (© 2023. The Author(s).)

The unique anatomy and physiology of the growing craniofacial skeleton predispose children to different fracture patterns as compared to adults. Diagnosis and treatment of pediatric orbital fractures can be challenging. A thorough history and physical examination are essential for the diagnosis of pediatric orbital fractures. Physicians should be aware of symptoms and signs suggestive of trapdoor fractures with soft tissue entrapment including symptomatic diplopia with positive forced ductions, restricted ocular motility (regardless of conjunctival abnormalities), nausea/vomiting, bradycardia, vertical orbital dystopia, enophthalmos, and hypoglobus. Equivocal radiologic evidence of soft tissue entrapment should not withhold surgery. A multidisciplinary approach is recommended for the accurate diagnosis and proper management of pediatric orbital fractures., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: The use of an acellular dermal matrix (ADM) has not been reported in medial orbital wall fracture reconstruction previously. This study aimed to share our early experience with the cross-linked ADM as an allograft material for medial orbital wall reconstruction., Methods: In this study, the author evaluated the medical records and serial facial computed tomography scans of 27 patients with pure medial orbital wall fractures reconstructed by a single surgeon between May 2021 and March 2023. The author routinely approached the medial orbital wall with a retrocaruncular incision. Five out of 27 patients were reconstructed with trimmed, multiple folded, 1.0-mm-thick cross-linked ADM (MegaDerm; L&C Bio, South Korea)., Results: All cases reconstructed with cross-linked ADM improved clinically and radiologically without complications. The serial computed tomography findings revealed that implanted cross-linked ADM successfully covered the defect while providing a significant volumizing effect., Conclusions: This is the first study to show the efficacy of cross-linked ADM for orbital medial wall fracture reconstruction. Our strategy of orbitalization of ethmoidal sinus with stacked cross-linked ADM would be an excellent surgical option., Competing Interests: The author reports no conflicts of interest., (Copyright © 2023 by Mutaz B. Habal, MD.)

The aim of this study is to investigate the feasibility of perpendicular plate of ethmoid as material for the reconstruction of medial orbital wall. The main outcome measurement was preoperative and postoperative orbital volume. The authors performed a study including 17 patients who have isolated medial orbital wall fracture (blow-out fracture). All the patients were fixed the defect using autologous perpendicular plate of ethmoid under endonasal approach. The authors compared the preoperative and postoperative orbital volume difference (unaffected orbit, affected orbit) of all the patients, and observed the improvement of diplopia or ocular motility disorders after operation. All 17 medial orbital wall reconstruction surgeries were successful with no severe postoperative ophthalmic complications. Statistically significant differences were found between the preoperative and postoperative orbital tissue volumes for the affected orbit. There was no statistically significant difference found between the tissue volume of the contralateral unaffected orbit and the affected orbit after reconstruction. And postoperative computed tomography showed the implant is in place and there is no medial rectus incarceration. Autologous perpendicular plate of ethmoid proved to be safe and effective in the reconstruction of medial orbital wall under endonasal approach with cost-effectivence, low complication rate, high biocompatibility, and minimally invasion., Competing Interests: The authors report no conflicts of interest., (Copyright © 2023 by Mutaz B. Habal, MD.)

Orbital fractures are among the most frequent facial injuries. Of the 3 most widely described approaches in the literature, the lower eyelid approach is the authors' preference. This study retrospectively analyzed the patients treated at the Trauma Center of the Umberto I Hospital, Sapienza University of Rome from January 2010 to December 2020. Inclusion criteria were as follows: diagnosis of pure/impure orbital bone fracture, complete clinical and radiological documentation, and a minimum of 12 months follow-up. Sex, age, etiology, treatment, and associated complications were analyzed using IBM SPSS Statistics. Two internationally validated scales were used for the functional and esthetic long-term evaluation: the Patient and Observer Scar Assessment Scale (POSAS) and the Vancouver one. The scales were compiled by the patient himself and by 3 independent expert observers. Of the 543 patients who underwent surgery in the specified period, 208 fully met the inclusion criteria. One hundred forty-two (68.2%) were males and 66 (31.8%) were females, with a mean age of 40.68 years. The main cause was represented by assaults (33.1%). One hundred seventy-nine patients had a pure orbital fracture (83.8%) and 29 an impure one (16.2%). The most frequent symptoms at the time of diagnosis were diplopia (31.2%), followed by anesthesia of the second trigeminal branch (24.3%). Open reduction with internal fixation was the preferred treatment and proved to be effective in reducing the main signs and symptoms of the fracture in a statistically significant way ( P < 0.05). Long-term esthetic results of the lower eyelid, using the Vancouver and POSASs, were respectively as follows: Vancouver Scar Scale mean total score was 2.41 (range: 0-8), observer POSAS mean total score was 1.83 (range: 1.2-3.9), observer general opinion mean score was 1.66, patient POSAS mean total score was 2.23 (range: 1.33-3.7), and patient general opinion mean score was 2.87. The lower eyelid approach has proven to be reproducible, with a fast-learning curve and a low complication rate. The analysis conducted highlighted an excellent long-term esthetic-functional result. Further studies will be needed to statistically compare the results obtained with other orbital floor surgical approaches., Competing Interests: The authors report no conflicts of interest., (Copyright © 2023 by Mutaz B. Habal, MD.)

Preoperative computer-assisted planning and intraoperative navigation are becoming popular for orbital fracture treatment. However, not all institutions currently have access to these computer-aided applications. The authors present a simple and intuitive operative algorithm to guide orbital fracture reconstructions. The operative algorithm was based on linear measurements of orbital defects on high-resolution Computer tomography (CT) scans using specific axial, coronal, and sagittal plane images. The fractures were then divided into 3 types based on site and defect-size area. For each type, the authors suggested a surgical approach and material reconstruction. Between February 2022 and January 2023, 57 patients were treated according to the described CT-based protocol. The quality of reconstruction was classified as ideal, satisfactory, acceptable, and poor based on postoperative CT. Diplopia, enophthalmos, and postoperative complications were assessed. Fifty-seven patients were included. Forty-four (77.2%) patients were included in the type 1 group, 4 (7.01%) in the type 2 group, and 9 (15.79%) in the type 3 group. The reconstruction was considered ideal in 54 (94.7%) cases, satisfactory in 2 (3.5%), and acceptable in 1 (1.8%). No revision surgery was required. In all cases, preoperative diplopia was settled out, and only 1 patient reported postoperative enophthalmos. No complications occurred, with good clinical results and orbital symmetry. The linear CT measurement-based protocol is a simple and reliable workflow to guide the surgeon's choice of reconstruction material and surgical approach for primary orbital reconstruction. It allows good management of orbital trauma and could help standardize treatment decisions with an imaging technique available in all institutions., Competing Interests: The authors report no conflicts of interest., (Copyright © 2023 by Mutaz B. Habal, MD.)

Background: Intraoperative computed tomography (CT) allows surgeons to make adjustments during orbital fracture repair that may impact postoperative outcomes. Learning/Study Objectives: To determine the impact of intraoperative CT use on intraoperative revision and surgical outcomes for orbital fracture repair. Methods: A systematic review was performed in concordance with the Preferred Reporting Items of Systematic Reviews and Meta-Analyses (PRISMA) guidelines: the population was patients undergoing orbital fracture repair; intervention was use of intraoperative CT; comparison was patients not undergoing intraoperative CT; and outcomes were intraoperative revision rate, postoperative complications, and secondary revision surgeries. Meta-analysis was performed on the rate of intraoperative revision. Results: The search criteria yielded 790 articles, 377 were eligible for review, and 20 articles met criteria for analysis. In 19, intraoperative imaging led to immediate surgical corrections, with a random pooled effect size of 0.27 (0.20-0.35). Six studies reported secondary revision surgery rates (range 0-10.5%), and six studies reported postoperative complication rates (range 10-30%). Conclusions: Intraoperative imaging helps surgeons make precise, real-time adjustments in 27% of orbital fracture repair cases, which may improve surgical outcomes; however, more research is needed to investigate its impact on health care costs, operating time, and radiation exposure.

Background: Although orbital fractures are common, prediction of outcomes in orbital surgery can be quite challenging., Purpose: We aim to identify predictors of intraoperative difficulty, operating time, and postoperative examination abnormalities in subjects undergoing post-traumatic orbital reconstructions., Study Design, Setting, and Sample: This is a retrospective cohort study of all consecutive orbital operations performed at a private, Level 1 trauma center in Portland, Oregon, USA over an 82-month period. All subjects that underwent exploration of the internal orbit for traumatic indications during the study period were included in the cohort., Predictor Variables: Four plating styles, surgical approach (transorbital vs transantral), days from injury to first surgery, fracture size (approximated as a rectangle using linear measurements from computed tomography scans), anteroposterior fracture position, and medial wall involvement were examined., Outcome Variables: The primary outcome variable was intraoperative difficulty (defined as requiring revision after intraoperative imaging or return to the operating room). Secondary outcome variables included operating time and postoperative examination abnormalities., Covariates: Age and sex were included., Analyses: χ 2 and Regression analyses were performed using a significance level of P < .05., Results: One hundred and sixty four orbital operations were performed (90 isolated injuries and 74 combined orbital/midface injuries) on 155 subjects (73% male, mean age 39.8 years, standard deviation 16.7). In subjects with isolated orbital fractures, medial wall involvement was associated with intraoperative difficulty (P = .01). When using a transantral approach, intraoperative difficulty was more likely in more anterior fractures (P = .02). Plating style was associated with operating time (P = .03), with median times from 81 to 105 minutes (range 21 to 248 minutes). Postoperative examination abnormalities were more likely in the transorbital approach group (P = .01). Neither days to first surgery nor intraoperative difficulty were associated with postoperative examination abnormalities. Postoperative eyelid changes were seen in 13.6% of transorbital approaches and 0% of transantral approaches. Correction of gaze restriction and enophthalmos were more likely than correction of diplopia (P < .01)., Conclusions and Relevance: Medial wall involvement is associated with intraoperative difficulty in orbital surgery. Anteriorly positioned fractures are better treated transorbitally, while posterior fractures may be amenable to transantral repair, thus avoiding risk of lower eyelid changes., (Copyright © 2023 American Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.)

A few mucoceles developing secondary to facial bone fractures have been reported. Mucocele formation is thought to be attributable to displacement of the respiratory mucosa with obstruction of the sinus opening, especially if untreated. Accurate diagnosis and management are required; a growing mucocele will gradually destroy adjacent bony structures and cause irreversible complications. The authors describe a patient who presented with diplopia and mild discomfort when gazing upward. She had undergone reconstruction of medial and inferior orbital fractures 20 years previously. The patient was diagnosed with a mucocele developing after orbital fracture repair. The patient underwent mucocele removal and orbital reconstruction using a polyetheretherketone patient-specific implant. In a patient with orbital symptoms but without acute trauma, a mucocele should be among the differential diagnoses if history-taking reveals past orbital trauma and surgery. A polyetheretherketone patient-specific implant was effective for orbital reconstruction after mucocele removal., Competing Interests: The authors report no conflicts of interest., (Copyright © 2023 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of Mutaz B. Habal, MD.)

The purpose of this study was to verify whether the accuracy of automatic segmentation (AS) of computed tomography (CT) images of fractured orbits using deep learning (DL) is sufficient for clinical application. In the surgery of orbital fractures, many methods have been reported to create a 3D anatomical model for use as a reference. However, because the orbit bone is thin and complex, creating a segmentation model for 3D printing is complicated and time-consuming. Here, the training of DL was performed using U-Net as the DL model, and the AS output was validated with Dice coefficients and average symmetry surface distance (ASSD). In addition, the AS output was 3D printed and evaluated for accuracy by four surgeons, each with over 15 years of clinical experience. One hundred twenty-five CT images were prepared, and manual orbital segmentation was performed in all cases. Ten orbital fracture cases were randomly selected as validation data, and the remaining 115 were set as training data. AS was successful in all cases, with good accuracy: Dice, 0.860 ± 0.033 (mean ± SD); ASSD, 0.713 ± 0.212 mm. In evaluating AS accuracy, the expert surgeons generally considered that it could be used for surgical support without further modification. The orbital AS algorithm developed using DL in this study is extremely accurate and can create 3D models rapidly at low cost, potentially enabling safer and more accurate surgeries., Competing Interests: Conflict of interest None., (Copyright © 2023 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

Purpose: Ocular pathology (OP) following orbital fracture can vary vastly in complexity and severity. Extra-ocular motility (EOM) limitations are frequently present in orbital trauma cases, with patterns of duction limitations being symmetrical or asymmetrical. The aim of this study was to identify if there was any association between increased OP following orbital fracture cases based on the pattern of EOM deficits., Methods: This is a retrospective cohort study of patients with fractured orbits presenting with or without EOM limitations to a level 1 trauma center between August 2015 to January 2018. All pertinent elements of the ophthalmic examination were recorded. Outcome measures: Chi-square analyses assessed for association between symmetrical or asymmetrical EOM limitation and OP. Odds ratios were calculated with 95% confidence interval., Results: 278 orbits with wall fractures were included in this study. A significant correlation between EOM limitation and increased OP following orbital trauma was found (p = 0.000081). Cases with symmetrical and asymmetrical EOM limitation were 7.9 (95%CI: 2.3-27.2) and 5.22 (95%CI: 1.9-13.9) times more likely to have OP than cases with no EOM limitation, respectively. With extraocular muscle entrapment excluded, cases with symmetrical limitations had a significantly higher incidence of OP than cases with asymmetrical limitations (p = 0.0161)., Conclusions: OP is frequently observed in cases of orbital fracture. While any EOM limitations should prompt the clinicians to anticipate OP, intra-ocular injury may be more likely in cases of symmetrical EOM limitation. Future prospective studies are needed to further elucidate the relationship between EOM symmetricity and OP following orbital trauma.

Displacement of the globe of the eye into the maxillary sinus is very rare in cases of facial trauma. Herein, we report a case of complete dislocation of the left globe into the maxillary sinus following a road traffic collision. The patient had prompt surgery to replace the globe after CT imaging confirmed the diagnosis. Subsequently, ongoing follow-up has focused on cosmesis in the affected, non-seeing eye. A multidisciplinary approach has been key throughout the patient's journey., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2023. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Magnetic resonance imaging (MRI) is being increasingly considered as an alternative for the evaluation and reconstruction of orbital fractures. No previous research has compared the orbital volume of an MRI-imaged, three-dimensional (3D), reconstructed, and virtually restored bony orbit to the gold standard of computed tomography (CT)., Purpose: To measure the orbital volumes generated from MRI-based 3D models of fractured bony orbits with virtually positioned prebent fan plates in situ and compare them to the volumes of CT-based virtually reconstructed orbital models., Study Design: This retrospective in-vitro study used CT and MRI data from adult patients with orbital trauma assessed at the Royal Brisbane and Women's Hospital Outpatient Maxillofacial Clinic from 2011 to 2012. Only those with orbital blowout fractures were included in the study., Predictor Variable: The primary predictor variable was imaging modality, with CT- and MRI-based 3D models used for plate bending and placement., Main Outcome Variable: The primary outcome variable was the orbital volume of the enclosed 3D models., Covariates: Additional data collected was age, sex, and side of fractured orbit. The effect of operator variability on plate contouring and orbital volume was quantified., Analyses: The Wilcoxon signed rank test was used to assess differences between orbital volumes with a significance level P < .05., Results: Of 11 eligible participants, six patients (four male and two female; mean age 31 ± 8.6 years) were enrolled. Two sets of six CT-based virtually restored orbits were smaller than the intact contralateral CT models by an average of 1.02 cm 3 (95% CI -0.07 to 2.11 cm 3 ; P = .028) and 0.99 cm 3 (95% CI 0.07 to 1.91 cm 3 ; P = .028), respectively. The average volume difference between the MRI-based virtually restored orbit and the intact contralateral MRI model was 0.97 cm 3 (95% CI -1.08 to 1.94 cm 3 ; P = .75). Imaging modality did affect orbital volume difference for 1 set of CT and MRI models (0.63 cm 3 ; 95% CI -0.11 to 1.29 cm 3 ; P = .046) but not the other (0.69 cm 3 ; 95% CI -0.11 to 1.23 cm 3 ; P = .075). Single operator variability in plate bending did not result in significant (P = .75) volume differences., Conclusions: MRI can be used to reconstruct orbital volume with a clinically acceptable level of accuracy., (Crown Copyright © 2023. Published by Elsevier Inc. All rights reserved.)

The purposes of this study were to compare the pressure onto the orbital floor and medial orbital wall between 3-dimensional printer skull models with unilateral orbital floor and medial orbital wall fractures and to compare the morphology of the orbital floor and medial orbital wall between patients with unilateral orbital floor and medial orbital wall fractures. The skull models were created based on computed tomographic (CT) data obtained from every 10 patients with unilateral orbital floor and medial orbital wall fractures. The orbital spaces of these models were filled with silicone, the silicone surface was pushed down, and pressures onto the orbital floor and the medial orbital wall were measured. On preoperative computed tomographic images taken in the same 20 patients, the superior and lateral bulges of the orbital floor and medial orbital wall were measured, respectively. The measurements were done on the unaffected sides. Consequently, the pressure onto the orbital floor was significantly higher in the orbital floor fracture models than in the medial orbital wall fracture models, although the pressure onto the medial orbital wall was not significantly different between the models. As for the morphologic study, the superior bulge of the orbital floor was higher in the orbital floor fracture group than in the medial orbital wall fracture group. The results of this study indicate that since the orbital floor with a high superior bulge receives high hydraulic pressure, patients with a high superior bulge have a greater risk of orbital floor fracture., Competing Interests: The authors report no conflicts of interest., (Copyright © 2023 by Mutaz B. Habal, MD.)

Introduction: Orbital blowout fractures are commonly reconstructed with implants shaped to repair orbital cavity defects, restore ocular position and projection, and correct diplopia. Orbital implant shaping has traditionally been performed manually by surgeons, with more recent use of computer-assisted design (CAD). Accuracy of implant placement is also key to reconstruction. This study compares the placement accuracy of orbital implants, testing the hypothesis that CAD-shaped implants indexed to patient anatomy will better restore orbit geometry compared with manually shaped implants and manually placed implants., Methods: The placement accuracy of orbital implants was assessed within a cadaveric blowout fracture model (3 skulls, 6 orbits) via 3-dimensional CT analysis. Defects were repaired with 4 different techniques: manually placed-manually shaped composite (titanium-reinforced porous polyethylene), manually placed CAD composite, indexed placed CAD composite, and indexed placed CAD titanium mesh., Results: Implant placement accuracy differed significantly with the implant preparation method ( P =0.01). Indexing significantly improved the placement accuracy ( P =0.002). Indexed placed titanium mesh CAD implants (1.42±0.33 mm) were positioned significantly closer to the intact surface versus manually placed-manually shaped composite implants (2.12±0.39 mm)., Discussion: Computer-assisted design implants indexed to patient geometry yielded average errors below the acceptable threshold (2 mm) for enophthalmos and diplopia. This study highlights the importance of adequately indexing CAD-designed implants to patient geometry to ensure accurate orbital reconstructions., Competing Interests: O.A., G.E., and J.G.M. are all partners in Calavaera Surgical design. The remaning authors report no conflicts of interest., (Copyright © 2023 by Mutaz B. Habal, MD.)

Functional endoscopic sinus surgery has become popular worldwide. However, serious complications have been reported with it. A preoperative imaging evaluation is thus essential to avoid complications. The authors compared 0.5 mm slice computed tomography (CT) images reconstructed from sinus CT data with conventional 2 mm slice CT images. The authors evaluated patients who underwent endoscopic surgery. Data regarding age, sex, history of craniofacial trauma, diagnosis, operative procedure, and CT findings of eligible patients were extracted from medical records and retrospectively reviewed. One hundred twelve patients underwent endoscopic surgery during the study period. Six patients (5.4%) had orbital blowout fractures, and half of them could only be identified by 0.5 mm slice CT images. The authors presented the usefulness of 0.5 mm slice CT images in the preoperative imaging evaluation of functional endoscopic sinus surgery. Surgeons should also recognize that a small number of patients have "stealth" (asymptomatic and unrecognized) blowout fractures., Competing Interests: The authors report no conflicts of interest., (Copyright © 2023 by Mutaz B. Habal, MD.)

Background: Orbital floor fracture defect size and inferior rectus (IR) rounding index are currently accepted indications for surgery to prevent late enophthalmos. The authors analyzed the positive predictive value (PPV) of these indications., Methods: Twenty-eight patients with orbital floor fractures presenting without enophthalmos underwent Hertel exophthalmometry at presentation and at weeks 1, 2, 3, 6, 13, 26, and 52 or more after injury. Orbital defect size and IR rounding index were measured from computed tomographic scans, and PPVs of defects of 1.5 to 2 cm 2 or larger and IR rounding index of 1 or higher for enophthalmos (≥2 mm) were calculated., Results: Nineteen patients had isolated orbital floor fractures (group A), three had noncontinuous orbital floor and medial wall fractures (group B), and six had continuous orbital floor with medial wall fractures (group C). Mean follow-up time was 440 days. Of all patients, 20 had a defect size of 1.5 cm 2 or larger, 12 had a defect of 2.0 cm 2 or larger, and 13 had an IR rounding index of 1 or higher. Of the 28 patients, only one from group A and two from group C developed enophthalmos of 2 mm only. The PPVs of orbital floor defect size of 1.5 cm 2 or larger and 2 cm 2 or larger (groups A and B only) for late enophthalmos were 6.7% and 0%, respectively. The PPV of IR rounding index of 1 or higher for late enophthalmos (all groups) was 0%., Conclusions: For patients with orbital floor fractures presenting without enophthalmos, defects of 1.5 cm 2 or larger and 2 cm 2 or larger, and IR rounding index of 1 or higher, are weakly predictive of late enophthalmos. Furthermore, patients who do not develop enophthalmos within 3 weeks of injury are unlikely to develop significant (>2 mm) late enophthalmos., Clinical Question/level of Evidence: Risk, III., (Copyright © 2023 by the American Society of Plastic Surgeons.)

Objective: For patients without dysfunctions, the main purpose of secondary correction for craniofacial fractures is restoring facial symmetry. Computer-assisted surgery techniques including virtual surgical planning and intraoperative navigation provide the help to restore the bony symmetry as much as possible. The authors retrospectively quantitatively analyzed patients who received computer-assisted secondary correction for craniofacial fractures on facial symmetry pre and postoperation., Methods: This observational study reviewed the medical records of 17 patients requiring secondary correction for craniofacial fractures. Pre and postoperative computed tomography data were used to quantitatively analyze the changes in facial symmetry and enophthalmos., Result: All patients enrolled in this study showed mid-facial asymmetry but without dysfunctions except for enophthalmos, and 5 patients had bone defects in the frontal-temporal area. The corrective surgical techniques were different for each patient according to their specific condition. Virtual surgical planning with or without intraoperative navigation was performed for all patients. Compared with the preoperative condition, their facial symmetry was significantly improved. The maximum discrepancy value between the affected side and the mirrored unaffected side decreased from 8.10 ± 2.69 to 3.74 ± 2.02 mm postoperatively, and the mean discrepancy value decreased from 3.58 ± 1.29 to 1.57 ± 0.68 mm. In addition, the Enophthalmos Index decreased from 2.65 to 0.35 mm., Conclusion: This observational study objectively demonstrated that computer-assisted secondary correction for craniofacial fractures can significantly improve facial symmetry. And the authors recommend that virtual surgical planning and intraoperative navigation should be a must step in craniofacial fracture correction., Competing Interests: The authors report no conflicts of interest., (Copyright © 2023 by Mutaz B. Habal, MD.)

Background: Superior orbital rim fractures are challenging fractures as they often concomitantly occur with additional calvaria fractures. Virtual surgical planning (VSP) has been underutilized in this area of craniomaxillofacial trauma for reconstruction., Purpose: The purpose of this study is to qualitatively describe the use of VSP and anatomically perfected stereolithic models in treatment of superior orbital rim fractures in combined neurosurgery/oral and maxillofacial surgery cases., Study Design, Setting, Sample: This study is a retrospective case series of subjects who were treated at the Massachusetts General Hospital (July 2022 to November 2022). Inclusion criteria include subjects who had both calvaria and maxillofacial injuries requiring concurrent operative intervention on their superior orbital rim fractures and the use of VSP., Predictor/exposure/independent Variable: Not applicable., Main Outcome Variable: The outcome variable of interest is the difference in the planned position of the orbital rim repair compared to the actual position achieved., Covariates: None., Analyses: Heat map analysis was used to compare the difference in the planned position versus the actual position achieved., Results: There were six orbits (five subjects, mean age 33.8 ± 21.49 years) that met the criteria. The mean difference in planned versus actual orbital volume achieved was 2.52 ± 2.48 cm 3 . The superimposition of the postoperative scan to the planned simulation revealed 84% ± 3.27% of the voxel surface was within +2 and -2 millimeters of its planned position., Conclusion and Relevance: This study has demonstrated the use of VSP in combined neurosurgery and oral and maxillofacial surgery procedures in the fixation of superior orbital rim fractures. This case series highlights that the postoperative position achieved in the six orbits was within 84% of the planned position., (Copyright © 2023 American Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.)

We present clinical and imaging predictors of ocular injuries that required medical management versus surgical intervention in cases of orbital fractures. From 2014 to 2020, a retrospective review of patients with orbital fractures who received ophthalmologic consultation and computed scan (CT) analysis at a level I trauma center was performed. Inclusion criteria were patients with confirmed orbital fracture on CT and ophthalmology consultation. Patient demographics, associated injuries, comorbidities, management, and outcomes were collected. Two hundred and one patients and 224 eyes (11.4% bilateral orbital fractures) were included. Overall, 21.9% of orbital fractures presented with a significant concomitant ocular injury. Associated facial fractures were present in 68.8% of eyes. Management included surgical treatment in 33.5% of eyes and ophthalmology-directed medical treatment in 17.4%. On multivariate analysis, clinical predictors of surgical intervention were retinal hemorrhage (OR=4.7 (1.0-21.0), P =0.0437), motor vehicle accident injury (OR=2.7 (1.4-5.1), P =0.0030) and diplopia (OR=2.8 (1.5-5.3), P =0.0011). Imaging predictors of surgical intervention were herniation of orbital contents (OR=2.1 (1.1-4.0), P =0.0281) and multiple wall fractures (OR=1.9 (1.01-3.6), P =0.0450). Predictors of medical management were corneal abrasion (OR=7.7 (1.9-31.4), P =0.0041), periorbital laceration (OR=5.7 (2.1-15.6), P =0.0006), and traumatic iritis (OR=4.7 (1.1-20.3), P =0.0444). We demonstrated a 22% incidence of concomitant ocular trauma in orbital fracture patients at our level I trauma center. Predictors of the surgical intervention included multiple wall fractures, herniation of orbital contents, retinal hemorrhage, diplopia, and motor vehicle accident injury. These findings emphasize the importance of a multidisciplinary team in managing ocular and facial trauma., Competing Interests: The authors report no conflicts of interest., (Copyright © 2023 by Mutaz B. Habal, MD.)

Purpose: Orbital volume increase has been previously linked with post-traumatic enophthalmos. However, this varies and some studies show no correlation. This systematic review and meta-analysis aimed to synthesize the correlation between orbital volume and enophthalmos and to determine if surgical intervention, enophthalmos measurement method, fracture location, or timing affect this correlation., Methods: Automation tools were used to assist in this review of 6 databases. Searches were performed across all dates. Included studies quantitatively reported orbital volume and enophthalmos following traumatic orbital wall fractures in at least 5 adult subjects. Correlational data were extracted or calculated. Random-effects meta-analysis was used with subgroup analyses for each of the secondary aims., Results: Twenty-five articles describing 648 patients were included. The pooled correlation between orbital volume and enophthalmos was r =0.71 ( R2 =0.50, P <0.001). Operative status, enophthalmos measurement method, and fracture location did not affect pooled correlation. The delay between trauma or surgery and enophthalmos measurement was not shown to modulate correlation for unoperated patients ( R2 =0.05, P =0.22) but showed a negative relationship for postoperative patients ( z =-0.0281, SE=0.0128, R2 =0.63, P =0.03), but this was heavily influenced by a single article. All results had high residual heterogeneity. Studies were rated as moderate, low, or very low quality with few stating explicit hypotheses or limitations., Conclusions: Bony orbital volume expansion accounts for around 50% of post-traumatic enophthalmos. The other half is probably explained by soft tissue or geometric bony, rather than volumetric, changes., Competing Interests: The authors report no conflicts of interest., (Copyright © 2023 by Mutaz B. Habal, MD.)

Background: The use of an acellular dermal matrix is rarely reported in orbital wall fracture reconstruction. This study aimed to share the author's experience with the cross-linked acellular dermal matrix as an allograft material for enophthalmos correction., Methods: In this retrospective study, the author evaluated the medical records and 3-dimensional facial computed tomography scans of patients with enophthalmos caused by neglected orbital fractures between May 2021 and June 2022. Facial computed tomography scans confirmed the clinical diagnosis of enophthalmos. A single surgeon performed all surgical operations. In all patients, the author accessed the orbital floor via subciliary incision while approaching the medial wall with a retrocaruncular incision. After fully exposing the lesion, the author used a 1.0-mm-thick cross-linked acellular dermal matrix (ADM) (MegaDerm; L&C Bio, South Korea). After trimming the cross-linked ADM to a proper size, the author implanted the ADM into the lesion., Results: During May 2021 and June 2022, 3 cases of enophthalmos were successfully corrected with cross-linked ADM at the author's hospital. All patients were improved clinically and radiologically., Conclusion: This is the first study to show the effectiveness of cross-linked ADM for the correction of enophthalmos., Competing Interests: The authors report no conflicts of interest., (Copyright © 2023 by Mutaz B. Habal, MD.)