Patients · Orbit
Orbital floor fracture: when is an implant needed, and when should it be custom-made?
A blow to the eye, from a punch, a fall or an accident, can break the thin bony floor between the orbit and the maxillary sinus. Often the fracture heals without surgery. Sometimes it must be rebuilt. Here is how surgeons decide.
3 min read3 sources
What is an orbital floor fracture?
The orbit is the bony cavity that holds the eye, its muscles and fat. Its very thin floor separates it from the maxillary sinus. A direct blow can transmit enough pressure to break it: this is the so-called “blow-out” fracture.
It can cause double vision when the inferior rectus muscle or the surrounding tissue is caught in the fracture, sinking of the eye into the orbit (enophthalmos) and loss of feeling in the cheek, through injury to the infraorbital nerve [1].
Warning signs
- double vision, especially when looking up or down;
- an eye that looks sunken or lower than the other;
- numbness of the cheek, the side of the nose or the upper lip;
- in children: pain on moving the eye, nausea, vomiting or even fainting, sometimes with no visible bruising.
In children, the still flexible bone can snap shut like a trapdoor on the muscle. The eye looks almost normal from the outside, hence the name “white-eyed” fracture: it is a surgical emergency [1].
Diagnosis relies on an eye examination and a CT scan, which shows the fracture, its size and any trapped tissue.
When is surgery needed?
No randomised trial has set the indications; recommendations rest on analysis of the literature [1]:
| Situation | Suggested management |
|---|---|
| Persistent oculocardiac reflex, “white-eyed” fracture, early sinking or lowering of the eye | Immediate repair |
| Double vision, positive forced duction test and entrapment visible on CT, little improvement | Repair within 2 weeks |
| Large floor fracture likely to cause delayed sinking of the eye | Repair within 2 weeks |
| Minimal double vision, absent in straight-ahead and downward gaze, good motility, no sinking | Observation |
From the evidence-based analysis published in Ophthalmology in 2002 [1].
The decision rests with the maxillofacial surgeon or the specialist ophthalmologist, after examination and CT.
Which implant for the reconstruction?
Repairing the floor means freeing the tissue caught in the fracture, then covering the defect to restore the volume of the orbit. Several options exist:
- preformed titanium plates with an average anatomical shape;
- titanium mesh cut and shaped during surgery;
- resorbable sheets for small defects;
- implants designed from the patient’s CT scan, usually by mirroring the healthy orbit.
In a German study of 75 reconstructions, 66.6% of preformed implants were imperfectly positioned against 10% of custom implants, with 13% revision surgery against none [2]. A meta-analysis of 628 patients finds orbital volume better restored with custom implants, but no statistically significant difference in clinical outcomes [3].
Custom implants are used mainly for extensive or multi-wall fractures, when the bony support at the back of the orbit is missing, and for secondary correction of an eye that remains sunken. The design lead time must then fit within the repair window.
After surgery
Double vision can take several weeks to settle; follow-up checks eye movement, eye position and vision. For the first days, avoid blowing your nose hard: the fracture opens into the sinus.
This article informs but does not replace an examination. Any loss of vision after a blow to the eye is an emergency.
Sources
Documents accessed in October 2026. Amounts are given in the currency and for the year of each source.
- 1Burnstine MA. Clinical recommendations for repair of isolated orbital floor fractures: an evidence-based analysis. Ophthalmology. 2002;109(7):1207-1210. doi.org
- 2Pietzka S, Wenzel M, Winter K, et al. Comparison of anatomical preformed titanium implants and patient-specific CAD/CAM implants in the primary reconstruction of isolated orbital fractures: a retrospective study. J Pers Med. 2023;13(5):846. doi.org
- 3Kotecha S, Ferro A, Harrison P, Fan K. Orbital reconstruction: a systematic review and meta-analysis evaluating the role of patient-specific implants. Oral Maxillofac Surg. 2023;27(2):213-226. doi.org
General information: this article does not replace your surgeon’s advice. Prices vary with the patient, the hospital and the implant; only a formal quote is binding.
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