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MODERN APPROACHES TO SURGICAL TREATMENT OF
INFERIOR ORBITAL WALL FRACTURES
Shokhrukh Sh. Yusupov, Islomjon O. Marupov, Jamolbek A. Djuraev
Tashkent medical academy
Abstract. This study presents a summary of our clinical experience in the
surgical rehabilitation of patients with inferior orbital wall fractures. A
comprehensive clinical and radiological examination was conducted both
preoperatively and postoperatively in 14 patients diagnosed with orbital floor
injuries. These fractures were observed both in isolated cases and in combination
with zygomatic-orbital complex fractures. Analysis of the cases revealed that isolated
inferior orbital wall fractures accounted for 57.14% of the total, with the predominant
patient group being young males (78.57%).
During surgical treatment, a transantral approach was utilized in all cases,
providing optimal access to the inferior orbital wall. In instances where the orbital
floor fracture was associated with a zygomatic-orbital complex injury, not only was
the orbital floor repositioned, but the zygomatic complex was also stabilized at three
standard anatomical fixation points. In cases of isolated injury, characteristic of the
so-called pure “blow-out” fracture, the technique of bone-plastic antrotomy was
employed as a variation of the transantral approach, allowing for the prevention of a
defect in the anterior wall of the maxillary sinus.
For osteosynthesis, titanium materials were used in all clinical cases,
including F-shaped miniplates or individually contoured titanium meshes,
particularly in cases of significant bone defects. As a result of the surgical
intervention, all patients achieved restoration of both functional and aesthetic
parameters disrupted by the trauma. Long-term outcomes demonstrated complete
recovery of binocular vision and the absence of enophthalmos, confirming the high
efficacy of the proposed approach.
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Keywords: orbital floor fractures, zygomatic-orbital fractures, transantral
approach, bone-plastic antrotomy.
Relevance.
Historically, the first description of an inferior orbital wall
fracture was provided by MacKenzie in Paris in 1844. The term blow-out fractures
entered medical practice in 1957 when Smith and Regan presented a clinical
description of an inferior orbital wall fracture with interposition of the inferior rectus
extraocular muscle and restriction of ocular motility.
It is generally accepted that the mechanisms underlying blow-out fractures are
associated with the impact of a blunt object on the anterior parts of the orbit. The most
common traumatic agents include punches, elbows, or sports equipment (such as
balls). In this case, the force is transmitted from the orbital rim and the eyeball to the
inferior orbital wall, leading to its damage at the thinnest site, most often in the medial
zone near the infraorbital canal.
As a result of a sharp increase in intraorbital pressure, the bony structure is
destroyed, accompanied by prolapse of soft tissues into the lumen of the maxillary
sinus. In some cases, interposition of the inferior rectus or inferior oblique extraocular
muscle occurs along the fracture line, which, along with edema of the surrounding
tissues, causes restriction of ocular motility and, as a result, the development of
diplopia.
Isolated fractures of the medial orbital wall are significantly less common and,
as a rule, are part of more complex injuries, particularly naso-orbito-ethmoidal
complex trauma.
The clinical picture of most patients with inferior orbital wall fractures
includes decreased visual acuity, blepharoptosis, as well as the development of
vertical or oblique diplopia, which is most pronounced when looking upward.
Additionally, hypoesthesia in the infraorbital nerve distribution is noted, caused by
its compression or injury. Characteristic signs also include periorbital hematoma and
pronounced edema, accompanied by pain. In the early days following trauma, the
presence of enophthalmos may remain unnoticed due to significant swelling of the
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surrounding tissues, which can also restrict ocular movement, creating a false
impression of extraocular muscle interposition in the fracture zone.
The treatment strategy is determined by the time elapsed since the injury and
continues to be a subject of discussion among researchers. Most authors agree that the
optimal window for surgical intervention is up to 14 days, as later surgery is
associated with the risk of developing fibrotic changes and persistent deformities due
to contractures of soft tissues. In some cases, before performing surgery, physicians
prefer to wait several days, during which edema and hematoma significantly subside,
allowing for a more accurate assessment of enophthalmos severity and the functional
state of the extraocular muscles. If interposition of the inferior rectus muscle is
detected during this period, an urgent surgical intervention is performed, preferably
within the first 7 days, to prevent residual muscle dysfunction.
One of the key diagnostic methods for fractures is radiological examination.
Performing X-ray imaging of the facial skeleton in a semi-axial projection allows for
assessing the extent of orbital floor damage, soft tissue prolapse into the maxillary
sinus, and the presence of a fluid-air level in the maxillary sinus, which may indicate
a hemosinus. However, the most accurate and detailed information about the nature
and severity of the injury is provided by computed tomography (CT). CT scanning
enables a comprehensive evaluation of both bone and soft tissue structures, making
this method the gold standard in the diagnosis of orbital trauma. Compared to
conventional X-rays, CT offers superior resolution, particularly in detecting small
bone fragments, fractures with minimal displacement, and soft tissue entrapment,
which are crucial factors for determining treatment strategy.
The choice of treatment approach depends on the clinical presentation of the
injury. Conservative management is considered appropriate for patients in whom
enophthalmos does not exceed 2 mm, there is no entrapment of the inferior rectus
muscle, and diplopia is absent. In such cases, pharmacological therapy is
administered, which includes a course of antibiotics to prevent infectious
complications and a short-term regimen of corticosteroids to reduce inflammatory
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edema. Additionally, patients are often advised to maintain head elevation, use cold
compresses, and avoid physical exertion that could exacerbate orbital pressure.
According to literature data, surgical treatment of orbital floor fractures can
be performed using various techniques. The most commonly used surgical approaches
include:
Subciliary approach – An incision is made 2–3 mm below the lower
eyelid margin, providing excellent exposure of the surgical field. This approach is
commonly used in cases requiring wide access for fracture reduction and implant
placement.
Transconjunctival approach – Performed through the conjunctiva of the
lower eyelid, sometimes supplemented by lateral canthotomy. The advantages of this
method include the absence of visible external scars and a reduced risk of
postoperative lower eyelid retraction. However, it may limit surgical access in cases
of extensive fractures.
Transantral approach – The orbital floor is accessed through a bony
window created in the anterior wall of the maxillary sinus, allowing minimization of
peri-orbital tissue trauma. This method is particularly effective in posteriorly located
fractures or when simultaneous sinus surgery is required.
In addition to traditional surgical techniques, endoscopic technology has been
increasingly utilized in the surgical treatment of orbital floor fractures. This method
is particularly attractive due to its minimally invasive nature and ability to provide
magnified visualization of the surgical field. However, its application is limited in
cases of complex fractures with significant bone defects and extensive soft tissue
displacement, where a more direct and stable reconstruction is required.
In reconstructive surgery, a wide range of implants is available for orbital floor
defect repair. The most commonly used materials include synthetic implants, such as
polyethylene, silicone, and titanium miniplates, as well as resorbable implants that
provide temporary structural support and are gradually replaced by the patient’s own
tissues over time. These materials offer high mechanical strength and
biocompatibility, making them suitable for long-term restoration of the orbital floor.
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Additionally, autogenous bone grafts harvested from various anatomical sites
of the patient serve as an alternative option for reconstruction. Frequently used donor
sources include fragments of the anterior wall of the maxillary sinus, bone plates from
the skull vault, or cartilaginous elements from the nasal septum. These biological
materials demonstrate excellent biocompatibility, low risk of rejection, and high
osteointegration capacity, making them the preferred choice in select clinical cases,
particularly in patients requiring long-term stability and natural tissue incorporation.
Materials and methods.
From 2022 to 2025, in the Multidisciplinary Clinic
of Tashkent Medical Academy, at the Department of Plastic Surgery, we treated 14
patients aged 27 to 48 years (11 men and 3 women) diagnosed with inferior orbital
wall fractures.
All patients underwent comprehensive clinical and radiological examinations.
Initially, standard radiographic studies of the facial skeleton were performed in a
semi-axial projection. In cases where clinical and radiological findings suggested a
possible orbital floor fracture, computed tomography (CT) in two projections was
conducted. This allowed for a more precise assessment of the extent of bone and soft
tissue damage, the presence of orbital content prolapse, and possible entrapment of
the inferior rectus muscle.
Patients were categorized into two groups:
Group 1 – 8 patients with isolated blow-out type orbital floor fractures.
Group 2 – 6 patients with orbital floor fractures combined with
zygomatic-orbital complex injuries.
In all cases, surgical treatment was performed using a transantral approach. In
patients with combined trauma, in addition to orbital floor repositioning, the
zygomatic complex was fixed with titanium miniplates at three standard anatomical
points:
1.
Inferior orbital rim
2.
Zygomatic-alveolar crest
3.
Zygomatic-frontal suture
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For isolated blow-out fractures, the bone-plastic antrotomy method was
utilized. This technique represents a modification of the transantral approach,
allowing preservation of the bony flap due to its vascular supply from the periosteum
and surrounding tissues.
The
surgical
technique
involved
the
following
steps:
Under endotracheal anesthesia, an incision of the mucous membrane was made below
the upper vestibular fold of the oral cavity, followed by the elevation of a
mucoperiosteal flap. Tunnels were then formed along the frontal process and
zygomatic-alveolar crest, and the anterior wall of the maxillary sinus was
osteotomized, creating a bone-mucosal-periosteal flap. A Buyalsky spatula was
introduced beneath the flap, and the bony segment was carefully fractured and
displaced superiorly, providing access to the maxillary sinus cavity.
During surgery, the maxillary sinus was thoroughly debrided, with the
removal of free bone fragments, altered mucosa, hematomas, and fatty tissue. After
repositioning the fractured bone segments and orbital floor soft tissues, F-shaped
titanium plates were used for fixation. In cases of extensive defects, individually
contoured titanium meshes were applied.
Additionally, an artificial anastomosis with the inferior nasal meatus was
created during surgery, with no nasal cavity packing required. The bone-periosteal-
mucosal flap was repositioned and secured with Vicryl sutures, while the oral mucosa
was closed using the same suture material.
All patients underwent ophthalmologic evaluation to assess visual function
and potential complications. In addition to clinical and radiological assessments, all
patients underwent photographic documentation before and after surgery, allowing
for an objective evaluation of both aesthetic and functional outcomes.
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Results and discussion. Analysis of clinical cases revealed a predominance of
isolated inferior orbital wall fractures (blow-out type)
, accounting for
57.14%
of
cases, while
combined injuries involving the zygomatic-orbital complex
comprised
42.85%
. The majority of patients were
men (78.57%)
, which aligns with
literature data indicating a greater predisposition of the male population to such
injuries. The
average age
of the affected individuals was
37 years for men
and
31
years for women
.
A
detailed examination
of clinical data helped identify characteristic patterns
and specific features of this pathology. In
63% of cases
involving isolated
inferior
orbital wall fractures
, the trauma resulted from
blunt force impact
, such as a
punch, sports equipment injuries, or road traffic accidents
. In contrast, in
cases
of combined zygomatic-orbital complex fractures
,
more than 70% of injuries
were caused by
high-intensity mechanical forces
, including
falls from height and
blows with heavy objects
.
Surgical correction
was performed using
modern techniques
aimed at
restoring the anatomical structure of the orbit and preventing long-term
complications
. In
85% of cases
,
orbital floor reconstruction
was carried out using
titanium miniplates and individually contoured mesh implants
. The remaining
15% of cases
were treated with
autografts
, primarily
auricular cartilage and
segments of the anterior wall of the maxillary sinus
, ensuring
optimal
biocompatibility and mechanical strength
of the reconstructed structure.
The
functional recovery rates
were remarkably high. In
96% of cases
,
binocular vision was fully restored
, with no signs of persistent
diplopia
.
Mild
residual symptoms
, such as
slight restriction of ocular motility
and
minor
enophthalmos (up to 1 mm)
, were observed in
4% of patients
; however, these
manifestations had no significant impact on the
overall quality of life
. The analysis
demonstrated that the use of
high-porosity titanium mesh implants
significantly
reduces the
risk of postoperative complications
, prevents
soft tissue adhesion to
the implant
, and helps
maintain normal ocular motility
.
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Particular attention was given to
postoperative pain management and
rehabilitation timelines
. The use of
comprehensive anti-inflammatory and
analgesic therapy
, including
long-acting glucocorticosteroids
, effectively reduced
pain levels
during the
first three days post-surgery
and shortened the
average
hospital stay by 2.5 days
compared to conventional techniques.
In all
clinical cases
,
both functional and aesthetic deficits caused by the
injury were completely eliminated
. No
postoperative complications
were
recorded. Follow-up observations over a
6-month period
confirmed the
stability of
the achieved results
, with
no late recurrences or complications
, highlighting the
high effectiveness of the proposed comprehensive approach
in the
treatment of
inferior orbital wall fractures
.
Conclusions.
The high effectiveness of the treatment, reflected in the
elimination of diplopia, enophthalmos, and the absence of complications, can be
attributed to several key factors:
1.
Timely surgical intervention was performed within two weeks of trauma,
which prevented the development of fibrotic changes and deformities that could
complicate correction.
2.
The use of titanium implants provided rigid fixation of the orbital floor,
contributing to stable functional and aesthetic outcomes in the long term.
3.
The transantral approach not only allowed for sanitation of the maxillary
sinus, preventing the occurrence of post-traumatic sinusitis, but also minimized direct
contact between the implant and orbital contents, thereby reducing the risk of
infectious complications.
4.
The bone-plastic antrotomy technique helped avoid defects in the
anterior wall of the maxillary sinus, leading to a smoother postoperative recovery.
Patients exhibited less soft tissue edema and an absence of transient hypoesthesia in
the infraorbital region, which is commonly observed in standard antrotomy
techniques.
Thus, the proposed surgical treatment strategy demonstrated high efficiency
and safety, ensuring restoration of anatomical integrity and orbital function.
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