Orbital Bony Anatomy and Orbital Fractures
R A Zaldvar, M S Lee, and A R Harrison, University of Minnesota, Minneapolis, MN, USA
2010 Elsevier Ltd. All rights reserved.
Glossary
Cantholysis A surgical section of a canthus or a
canthal ligament.
Canthotomy An incision of the canthus.
Dehiscence The opening of a previously closed
wound. It is often associated with contents emerging
from the open wound.
Enophthalmos A posterior displacement of the
eyeball into the orbit.
Hypertelorism An increase in the interorbital
distance.
Hypoesthesia Decreased tactile sensitivity.
Lagophthalmos An incomplete or defective
closure of the eyelids.
Meningitis An inflammation of the protective
membranes covering the central nervous system.
Mucocele A soft mucus-filled enlargement.
Oculocardiac reflex A decrease in the pulse rate
associated with traction applied to the extraocular
muscles and/or compression of the eyeball.
Proptosis A forward displacement of the eye in the
orbit.
Trochlea The fibrous loop in the superiomedial
orbit through which the tendon of the superior oblique
muscle passes.
The Bony Orbit
Early in embryogenesis, the bony orbit develops from the
mesenchyme that encircles the optic vesicle. Initially, the
optic axes are positioned approximately 160180 apart.
The optic cups begin to rotate anteriorly at the same time
as the orbital bones are formed. At birth, this angle is
reduced to approximately 45 . Hypertelorism, or
increased interorbital distance, may develop if there is
incomplete rotation. Premature ossification of orbital
bones may result in reduced orbital volume and proptosis,
as seen in Crouzons disease.
The adult bony orbit is four walled and pyramidal in
shape. The average volume of the orbit is 30 cc. The
orbital diameter measures approximately 4 cm in width
and 3.5 cm in height at the base or anterior entrance, and
has a depth of about 4.5 cm (Figure 1). The widest portion
of the orbit is 1 cm just inside the bony rim. The lateral
210
orbital walls subtend a 90 angle, and the medial walls are
roughly parallel to each other.
The Orbital Rim
The orbital rim is formed superiorly from the frontal
bone, laterally from the zygomatic bone, and inferiorly
from the zygomatic and maxillary bones (Figure 2). The
inferior-medial portion of the rim continues to form the
anterior lacrimal crest on the frontal process of the max-
illa, whereas the superior-medial rim continues to form
the posterior lacrimal crest. Throughout, the rim is
mainly rounded and thickened (greatest laterally). This
serves to protect the eye from trauma.
A neurovascular bundle traverses through the medial
third of the superior rim. Often (75%), it consists of a
notch and the remainder of the time it travels through a
true foramen, the supraorbital foramen. This is an impor-
tant landmark both for brow surgery and to facilitate the
identification of the inferior oblique. A vertical line from
the notch to the inferior rim is the point anterior to where
the inferior oblique originates. The infraorbital foramen,
conducting the infraorbital artery, vein and nerve, is also
located in this vertical plane, usually 410 mm below the
central portion of the rim. When performing orbital floor
surgery, care must be taken in elevating the periosteum
below this level so as not to injure this bundle.
The Medial Orbital Wall
The medial walls are nearly parallel to each other and
with the mid-sagittal plane. The wall measures approxi-
mately 4.55.0 cm from the orbital rim to the orbital apex.
It is formed by the maxillary, lacrimal, ethmoid, and
sphenoid bones (Figure 3). The maxillary and lacrimal
bones join to form the anterior and posterior portions
of the lacrimal sac fossa, respectively. Posterior to the
lacrimal fossa is the lamina papyracea of the ethmoidal
labyrinth. This is the thinnest bone of the bony orbit
measuring approximately 0.20.4 mm in thickness. This
is clinically important in that it is easily fractured in
trauma and during surgery, and is a minimal barrier to
the spread of infection from the adjacent ethmoid sinuses.
Dehiscences or erosions of the bony wall secondary to
chronic sinusitis may produce mucoceles either from the
ethmoidal or frontal sinuses.
Superiorly, at the junction of the lamina papyracea and
the orbital plate of the frontal bone is the frontoethmoid

Figure 1 Anterior view of the bony orbit with horizontal and vertical dimensions indicated.
Figure 2 Anterior view of the bony orbit with the bones that form the orbital margin identified.
Figure 3 Lateral view of the medial wall of the bony orbit with
the main bones identified.
Orbital Bony Anatomy and Orbital Fractures 211
suture line. This is the approximate roof of the ethmoid
and floor of the anterior cranial fossa. There are openings
at this level for the anterior and posterior ethmoidal
vessels and nerves. The anterior foramen is an average
of 24 mm behind the anterior lacrimal crest, whereas
the posterior foramen is approximately 12 mm posterior
to the anterior foramen and 6 mm from the optic canal.
These foramina are clinically important as they serve as
landmarks for the cribriform plate.
The Orbital Roof
The orbital roof is triangular in shape and formed by the
frontal bone and the lesser wing of the sphenoid bone
posteriorly (Figure 4). Superolaterally is a concave
depression known as the lacrimal gland fossa. Approxi-
mately 4 mm posterior to the rim, along the superomedial
portion of the roof, is a fibrocartilaginous trochlea for the
superior oblique tendon. Careful repositioning of the
212 Orbital Bony Anatomy and Orbital Fractures

Figure 4 Inferior view of the roof of the bony orbit with the main bones identified.

trochlea on the superomedial surface of the orbit

after surgery will help prevent postoperative motility Superior
disturbances.
The medial and superior aspects of the orbital roof are
adjacent to the ethmoidal and frontal sinuses, respectively.
Like the medial wall, the roof is thin and can become
secondarily involved with chronic sinus disease. In addi-
tion, care must be taken during surgery as damage to the Medial
roof can result in a cerebrospinal fluid leak and meningi-
tis. Along the apical, posteromedial portion of the roof lies Greater wing of the Zygomatic
sphenoid
the optic canal. It is bound by the sphenoid bone medially,
the lesser wing of the sphenoid bone superiorly, and the
optic strut laterally and inferiorly.

The Lateral Orbital Wall

The lateral orbital wall is the thickest and strongest of the
orbital walls. It is composed of the zygomatic bone ante-
riorly and the greater wing of the sphenoid posteriorly
(Figure 5). The medial and lateral walls are approxi-
mately the same length (4550 mm); however, because Figure 5 Medial view of the lateral wall of the bony orbit with
the main bones identified.
the lateral wall is at 45 to the medial wall, the lateral
orbital rim is approximately 1 cm posterior to the medial
rim. The thinnest part of the lateral wall is at the zygo- The superior and inferior orbital fissures separate the
maticosphenoidal suture approximately 1 cm posterior to lateral wall from the roof and floor, respectively. The
the orbital rim. This is important when taking off the superior orbital fissure lies between the greater and lesser
lateral wall for deep orbital surgery as it allows for out- wings of the sphenoid and transmits the third, fourth,
fracture and removal for additional exposure. ophthalmic division of the fifth and the sixth cranial

nerves from the middle crania fossa. The ophthalmic veins,
a branch of the ophthalmic artery, and the sympathetic root
of the ciliary ganglion are also transmitted through this
fissure. The inferior orbital fissure transmits the zygomatic
branch of the maxillary division of the fifth nerve, the
infraorbital nerve and vessel, and the venous communica-
tions between the inferior ophthalmic veins and the ptery-
goid plexus. Along the lateral wall are also several small
foramina that perforate the wall just behind the rim later-
ally and inferiorly. They transmit branches of the lacrimal
artery and zygomatic nerve out of the orbit as the zygoma-
ticotemporal and zygomaticofacial neurovascular bundles.
The Orbital Floor
The floor of the orbit is formed by the zygomatic bone,
the orbital surface of the maxilla, and the orbital process
of the palatine bone (Figure 6). It is the shortest of
the orbital walls (40 mm). Similar to the roof, it is
triangular in shape. Posteriorly, the floor is separated
from the lateral wall by the inferior orbital fissure. It
continues anteriorly as the infraorbital groove and canal.
The canal runs approximately in the center of the floor
from posterior to anterior and carries the maxillary divi-
sion of the trigeminal nerve and associated infraorbital
artery. This bundle exits approximately 410 mm inferior
to the orbital rim through the infraorbital foramen. The
visualization of this groove during orbital floor surgery
is important in preventing inadvertent trigeminal hypo-
esthesia. Medial to the infraorbital canal is the thinnest
portion of the orbit where most blowout fractures occur.
It is also where the floor is decompressed for surgical
treatment of patients with thyroid eye disease.
Figure 6 Superior view of the floor of the bony orbit with the
main bones and fissures identified.
Orbital Bony Anatomy and Orbital Fractures 213
Orbital Fractures
Blunt trauma to the eye and orbit can cause injury to the
thin orbital walls. It is believed that both direct and
indirect forces are involved in injury to the orbital
bones. The indirect injury occurs as a result of increased
hydraulic forces in the confined area of the orbit causing
the bone to buckle or blowout into the sinuses. The
inferior and medial walls are the most susceptible to this
injury. When the fracture is confined to the floor or
medial wall, the term pure blowout fracture is used.
With more severe injuries, the fractures can extend
beyond the orbit, producing rim displacement and maxil-
lary buttress fractures and even separation of the midface
from the skull base (Le Fort III; Figure 7).
Indications for blowout fracture repair of the orbital
floor include rectus muscle entrapment, enophthalmos
greater than 2 mm, and large fractures (>50% of the
floor or wall). These large floor fractures will often lead
to enophthalmos, globe malposition, or both. Similar indi-
cations for medial wall repair are used. Repair is often
performed within 23 weeks after injury. This allows time
for the edema to subside, yet is within a window of time
that postinflammatory adhesions are not well formed.
However, in pediatric cases with clear entrapment, there
is evidence that surgery should proceed as soon as possi-
ble to limit ischemic damage to the muscle. This group
can present with various symptoms when there is a history
of trauma. These may include bradycardia, nausea, or
syncope secondary to the oculocardiac reflex and
warrant early repair.
Figure 7 Maroon lines indicate location of a Le Fort III fracture,
which is composed of a horizontal fracture that includes the
frontozygomatic sutures, the greater wings of the sphenoid, the
ethmoid and nasal bones, and a second fracture through the
zygomatic arches. This results in a separation from the rest of the
cranial bones of the maxillary and zygomatic bones.
214 Orbital Bony Anatomy and Orbital Fractures

Orbital Floor (Blowout) Fracture Using a curved iris scissors or monopolar cautery, the
incision is carried down to the lateral orbital rim perios-
Various approaches to the orbital floor have been
teum over the zygoma. The inferior crus of the lateral
described, including a subciliary incision or through a
canthal tendon is released (Figure 8(b)). The conjunctiva
laceration of the lower lid sustained during the injury;
and inferior lid retractors are incised just below the tarsus
however, the degree of postoperative sequelae, including
from the lateral canthus incision to just lateral to the
lower-eyelid retraction and lagophthalmos, has led to a
caruncle (Figure 8(c)). A Desmarres retractor can be
shift to a tranconjunctival approach. This approach is
used to retract the tarsal conjunctiva anteriorly. The inci-
associated with fewer complications and has gained wide-
sion is carried down to the orbital rim periosteum.
spread acceptance.
A malleable retractor is then used to retract the orbital
First, local anesthesia is infiltrated into the lateral canthal
septum and fat. The inferior orbital rim periosteum is
and lower eyelid with 1% lidocaine with epinephrine
incised and gently dissected from the orbital floor with a
(1:100 000) mixed 50:50 with 0.5% Marcaine (bupivacaine).
periosteal elevator (Freer or Coddle elevator; Figure 8(d)).
Forced ductions are performed bilaterally to determine
The malleable retractor is then repositioned in the subper-
the amount of restriction prior to repair. A 1015-mm
iorbital plane, and using a hand-over-hand technique, the
lateral canthotomy is performed in a relaxed skin tension
fracture is exposed (Figure 8(e)). Herniated orbital tissue is
line using a No. 15 Bard-Parker blade (Figure 8(a)).

Figure 8 (a) A lateral canthotomy incision is made down to the periosteal level in order to expose the lateral canthal periosteum. This is
important in order to be able to reattach the tarsoteninous strap. (b) Next, a lateral cantholysis is performed, which detaches the inferior
crus of the lateral canthal tendon from the lateral orbital rim. (c) This incision is made transconjunctivally to extend the horizontal length
of the eyelid to the caruncle medially, at a distance of 4 mm below the inferior border of the tarsus. (d) Using a periosteal elevator, the
subperiosteal dissection is begun. The periosteum is thicker at the arcus marginalis, and can be grasped to aid dissection. (e) The
retraction of the orbital contents superiorly is performed with a malleable retractor, and a subperiosteal pocket is formed. (f) Herniated
orbital tissues are elevated in order to visualize the fracture site completely and ensure there is no remaining trapped tissue remaining at
the fracture site.
 Orbital Bony Anatomy and Orbital Fractures 215

Figure 9 (a) The retractors and periosteum are closed, followed by reattachment of the lateral canthal tendon to the periosteum at
the lateral orbital rim. (b) Careful approximation of the eyelid margins during closure is important, which are here closed using a
horizontal mattress suture.

gently elevated through the fracture site with blunt dissec-

tion until the entire rim of the fracture can be identified
(Figure 8(f )). It is important to ensure complete exposure
of the fracture to avoid the possibility of leaving entrapped
orbital tissue. If the orbital contents are entrapped, the
fracture may be enlarged to free the tissue. Bony fragments
may be removed with Takahashi forceps. Hemostasis is
maintained with bipolar cautery. A paper or foil template
is then cut and placed over the fracture site to adequately
span the entire bony defect. An alloplastic sheet such as
porous polyethylene Medpor (Porex, College Park, GA,
USA) or nylon foil sheet SupraFoil (Supramid Alexandria,
VA, USA) is then fashioned using the template as a guide.
The volume can also be addressed by adding additional Figure 10 Access to the medial orbit by a transcaruncular
sheets. The implant should be positioned posterior to the incision line.
anterior orbital rim to minimize extrusion. Usually, no
fixation is required; however, if the implant tends to ride titanium orbital floor implant (Synthes (USA), Paoli, PA,
forward, one can create a small flap into the anterior part of USA) or a Medpor Titan implant can be positioned over
the alloplastic sheet and tuck into the fracture site. Forced the defect and fixed rigidly to the orbital rim. If, however, the
ductions are performed to demonstrate the free movement rim fractures are unstable, they should be stabilized first
of the globe. The anterior periosteum is closed with a utilizing a screw and plating system, followed by repair of
single 5-0 polyglactin suture centrally to prevent anterior the orbit floor.
migration of the implant. The inferior crus of the lateral
canthal tendon is then sutured to the superolateral portion
Medial Wall Fractures
of the orbital rim in a mattress fashion with a double armed
5-0 polyglactin suture (Figure 9(a)). The lateral canthal Medial wall fractures often occur in combination with
angle is reformed with a 6-0 polyglactin suture placed floor or other orbital trauma; however, isolated fractures
through the gray line of the upper, and then lower, eyelid. of the medial wall can occur. If this is the case, they can be
The lateral canthotomy skin incision is reapproximated observed only if there is no evidence of medial rectus
with 6-0 Fast Absorbing Plain Gut suture (Ethicon, Inc., entrapment, the bony defect is nondisplaced or small, and
Somerville, NJ, USA) in a running or interrupted fashion enophthalmos greater than 2 mm is not present. Should it
(Figure 9(b)). The conjunctival incision is not closed. Anti- need repair, various approaches can be employed depend-
biotic ophthalmic ointment is placed along the lateral ing on the size.
canthotomy incision, and antibiotic/steroid combination A small fracture of the medial wall can be approached
drops are used for 1 week postoperatively. by a transcaruncular technique (Figure 10). The trans-
In cases where the entire floor is absent and no medial and caruncular approach allows moderate access to the orbit
or lateral edge exists to support the Medpor sheet, a Synthes without a visible skin incision. An incision is made
216 Orbital Bony Anatomy and Orbital Fractures
through the conjunctiva and Tenons capsule just medial
to the bulk of the caruncle and extends superiorly and
inferiorly in the fornices. Dissection is then carried just
posterior to the lacrimal sac. A malleable retractor is used
to retract the globe and orbital tissues. The periosteum is
incised posterior to the lacrimal sac, and periosteal eleva-
tors are used to expose the fracture. Once all edges of the
fracture have been exposed, a Medpor sheet, or equivalent
barrier sheet, can be placed to cover the entire fracture
(Figure 11). No fixation screws or sutures are needed.
Forced ductions are then checked to assure there is no
entrapment of muscle.
Lynch incision or a direct approach can be used if the
fracture is large or if combined with a large floor defect.
The medial canthal area is infiltrated with local anes-
thetic. The Lynch incision is performed by marking a
gull wing approximately 5 mm anterior to the medial
canthus (Figure 12). Hemostasis is obtained with mono-
polar cautery and the periosteum is exposed. The perios-
teum is incised and elevated using a Freer elevator. The
lacrimal sac and medial canthal tendon are elevated with
the periosteum. A malleable retractor is positioned in the
subperiosteal space, and the full extent of the fracture is
exposed (Figure 13). Then, as with the smaller fractures,
the herniated orbital tissue is gently elevated through the
Figure 11 (a) Axial view of the transcaruncular approach to the medial extraperiosteal orbital space, indicated by the black arrow.
(b) View of the medial orbital wall. Retractors are used to displace the lacrimal sac medially, while another retractor displaces the
orbital contents temporally.
Figure 12 (a) Lynch incision. (b and c) Variations of the standard Lynch incision.
fracture site with blunt dissection until the entire rim of
the fracture can be identified. The fracture can be
enlarged if the orbital contents are entrapped.
A template is cut and placed over the fracture site to
adequately span the entire bony defect. An alloplastic
sheet of Medpor is then cut using the template and placed
over the defect. If the defect is greater than 50% of the
medial wall or unstable, a combined titanium alloplastic
sheet (MED TITAN) can be used to fix the defect. Care
must be taken to protect the lacrimal sac by placing a
notch in the sheet. Combined floor and medial wall frac-
tures are repaired using the lateral canthotomy approach
to the floor combined with the medial Lynch or transcar-
uncular approach. The anterior periorbita is closed with
5-0 polyglactin suture in an interrupted fashion, the
deep tissues are closed with interrupted or running 5-0
polyglactin suture, and the skin is closed with a running
6-0 Fast Absorbing Plain Gut suture. Antibiotic ointment
is applied over the wound.
ZygomaticMaxillary Complex Fractures
(Tripod)
Zygomaticmaxillary complex fractures involve the infe-
rior and lateral orbital rim, zygomatic arch, and lateral

wall of the maxillary sinus. Left uncorrected, these frac-
tures may produce flattening and depression of the cheek
in addition to impingement on the coronoid process of the
mandible, leading to pain and difficulty in opening the
mouth. These fractures should be repaired within the first
2 weeks of injury with open, meticulous anatomic reduc-
tion of the fracture and fixation.
The lateral canthal and lower-eyelid areas are infil-
trated with local anesthetic. A lateral canthotomy is per-
formed as shown in Figure 8. Using the monopolar
cautery, the incision is carried down to the lateral orbital
rim periosteum over the zygoma. The upper and lower
crus of the lateral canthal tendon are released, and the
lateral wall periosteum is incised 2 mm lateral to the
orbital rim and gently dissected from the zygoma and
maxillary bone to define the fracture sites. The perios-
teum is then dissected from the lateral orbital wall. The
conjunctiva and inferior lid retractors are incised below
the tarsus from the lateral canthus to just lateral to the
caruncle. A Desmarres retractor is used to retract the
Figure 13 This dissection approach results in an extensive
view of the medial orbital wall. The suture lines emerging laterally
and medially represent the incision line.
Figure 14 (a) At 1015 mm superior to the mucogingival junction, a gingivobuccal (sublabial) incision is made at the level of the first
molar tooth. (b) As the incision proceeds anteriorly, it is made for inferiorly as it nears the piriform rim. This is 5 mm superior to the
mucogingival junction.
Orbital Bony Anatomy and Orbital Fractures 217
tarsal conjunctiva inferiorly, and the incision is deepened
to the orbital periosteum. The orbital septum and fat are
retracted with a malleable retractor and the inferior
orbital rim periosteum is incised. A periosteal elevator is
used to dissect the periosteum from the orbital floor and
malleable retractors are then used to expose the full
extent of the fracture using a hand-over-hand technique
(Figure 8). To ensure the exact realignment and stabili-
zation of the maxillary buttress, a superior buccal sulcus
incision is made from the base of the canine to the base of
the second bicuspid (Figure 14). The subperiosteal plane
is created to expose the fracture. The displaced bone is
reduced to the correct anatomic position using a towel
clip or Kolker clamp. The fragments can be stabilized with
miniplates. The periosteum over the lateral and inferior
orbital rims is closed with interrupted 5-0 polyglactin
sutures. The upper and lower crus of the lateral canthal
tendon are reunited with a 5-0 polyglactin suture, and this
suture is secured to the lateral orbital periosteum. The
lateral canthal angle is reformed with a 6-0 polyglactin
suture placed in the gray line of the upper, and then lower,
eyelid. The lateral canthotomy skin incision is reapproxi-
mated with 6-0 Fast Absorbing Plain Gut suture in a
running or interrupted fashion. The conjunctival incision
is not closed, whereas the buccal incision is closed with
3-0 chromic sutures. Antibiotic ophthalmic ointment is
placed in the inferior fornix and over the lateral canthus.
Postoperative Care
In the immediate postoperative period, a delayed retro-
bulbar hemorrhage is the main concern. The patient and
family should be made aware of these symptoms
(increased pain and sudden proptosis) and if present, the
vision should be checked one eye at a time to establish its
presence. The inability of the patient to see or open the
218 Orbital Bony Anatomy and Orbital Fractures
eyelid because of tense swelling should be evaluated
immediately and may necessitate the release of sutures
and a return to the operating room to manage any persis-
tent bleeding. Pupils are often unreliable after surgery
due to the effects of epinephrine in the local anesthetic
and systemic medications given by the anesthesia staff.
As with care following orbital fractures, patients are
warned not to blow their nose as air can enter into the
orbit, and, if allowed to develop sufficient pressure, it can
lead to vision loss via central retinal artery occlusion. Air
in the orbit can be drained with a large bore needle and
syringe of sterile water. The presence of bubbles in the
water confirms the release of air. Intravenous antibiotics
are recommended at the time of surgery if an implant is
placed, and generally the patients are given postoperative
antibiotics for 57 days. Antibiotic ointment is placed in
the fornices and on any surgical wounds at the end of the
surgery and then used twice a day for 1 week. Sports and
significant exertion can be resumed around 6 weeks post-
operatively.
Complications associated with orbital implants are
infrequent; however, they may include fistula formation,
migration, motility restriction, infection, globe elevation,
cyst formation, proptosis, and optic nerve trauma. As
mentioned earlier, care should be taken to avoid injury
to the lacrimal sac by appropriately sizing the implant and
cutting a notch as described. A thorough understanding of
orbital and facial anatomy combined with appropriate
surgical techniques will help limit these complications.
See also: Cranial Nerves and Autonomic Innervation in
the Orbit; Orbital Masses and Tumors; Orbital Vascular
Anatomy.
Further Reading
Doxanas, M. T. and Anderson, R. L. (1984). Clinical Orbital Anatomy.
Baltimore, MD: Williams and Wilkins.
Dutton, J. J. (1994). Atlas of Clinical and Surgical Orbital Anatomy.
Philadelphia, PA: W.B. Saunders Company.
Wobig, J. L. and Dailey, R. A. (2004). Oculofacial Plastic Surgery. New
York: Thieme.
Zide, B. M. and Jelks, G. W. (2006). Surgical Anatomy around the Orbit:
The System of Zones A Continuation of Surgical Anatomy of the
Orbit. Philadelphia, PA: Lippincott Williams and Wilkins.