Chinese Journal of Traumatology 18 (2015) 296e301

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Chinese Journal of Traumatology

journalhomepage:http://www.elsevier.com/locate/CJTEE

Review article

The management of naso-orbital-ethmoid (NOE) fractures

Jun-Jun Wei, Zhao-Long Tang, Lei Liu, Xue-Juan Liao, Yun-Bo Yu, Wei Jing*
State Key Laboratory of Oral Diseases, Department of Oral and Maxillofacial Surgery, West China Hospital of Stomatology, Sichuan University, Chengdu 610041, China

article info abstract

Article history: The bony naso-orbital-ethmoid (NOE) complex is a 3-dimensional delicate anatomic structure. Damages to this region may
Received 29 November 2014 result in severe facial dysfunction and malformation. The management and optimal surgical treatment strategies of NOE
Received in revised form 2 April fractures remain controversial. For a patient with NOE trauma, doctors should perform comprehensive clinical examination
2015
and radiographic analysis to assess the type and extent of fracture. The results of assessment will assist doctors to make a
Accepted 6 April 2015
patient-specific program for the sake of reducing post-operation complications and restoring normal appearance and function
Available online 6 August 2015
as much as possible. This review focuses on the advancement of manage-ment of NOE fractures including symptoms,
classifications, diagnosis, approaches, treatment and new techniques in this field.
Keywords:
NOE fracture
Diagnosis
Treatment © 2015 The Authors. Production and hosting by Elsevier B.V. on behalf of Daping Hospital and the Research Institute of
Surgery Surgery of the Third Military Medical University. This is an open access article under the CC BY-NC-ND license
Digital (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Due to the naso-orbital-ethmoid (NOE) complex's intricate anatomy, the appearance. This review will discuss the advancement in the field of NOE
fracture in this region has been a great challenge in maxillofacial trauma. The fracture management.
NOE complex is a 3-dimensional delicate anatomic structure. Damage to any
structure in this region, even minimal, is quite likely to result in abnormal 1. NOE anatomy
facial function and appearance.
1.1. Bony structure
Furthermore, this complex structure has a compact rela-tionship with the
brain and eyes, because it separates the nasal and orbital cavities from cranial The NOE complex consists of the nasal bones, frontal process of the
cavity. Therefore, as long as the fracture of the region is suspected, a maxilla, nasal process of the frontal bone, lacrimal bone, lamina papyracea,
thorough physical ex-amination and radiographic assessment, such as 2- ethmoid bone, sphenoid bone and nasal septum, which separate the nasal and
dimensional (2D) CT and 3-dimensional (3D) CT, must be performed to 1,2
orbital cavities from cranial cavity. The medial orbital wall is made up of
assess the type and extent of fracture after achieving the stable vital signs. the lacrimal bone and the lamina
1
papyracea of the ethmoid where blowout fracture is easy to occur (Fig. 1).

At present, different types of approaches for exposure have been

discussed, such as midfacial and endoscopic approach, as well as
management of the NOE fracture, such as bone tissue engineering. However,
every procedure has its advantages and disadvantages. According to
individual injures, the surgeon should select the patient-specific treatment to
restore the normal facial function and
* Corresponding author. Tel.: þ86 28 85503406.
E-mail address: jingwei@scu.edu.cn (W. Jing).
Peer review under responsibility of Daping Hospital and the Research Institute of Surgery
of the Third Military Medical University.
1.2. Medial canthal tendon (MCT)
MCT is the pivotal soft tissue in NOE area, which supports the canthus,
enables proper apposition between the eyelid and the globe, and performs as
2
the lacrimal pump. However, there are many controversies on the anatomy
of MCT. The main controversy is on the number of the tendon's limbs. Some
2
scholars referred that it had three limbs: anterior, superior, posterior, some
3
others argued that the superior limb did not exist. Furthermore, some reports
indicated posterior limb could not be detected histologi-cally as a discrete
structure in the specimens of autopsy, which was referred to a part of Horner's
4,5
muscle.

http://dx.doi.org/10.1016/j.cjtee.2015.07.006
1008-1275/© 2015 The Authors. Production and hosting by Elsevier B.V. on behalf of Daping Hospital and the Research Institute of Surgery of the Third Military Medical University. This is an open
access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
 J.J. Wei et al. / Chinese Journal of Traumatology 18 (2015) 296e301
Fig. 1. The bony architecture of NOE region.
1.3. Nasolacrimal duct (NLD)
NLD lies in the bone of the lateral nasal wall and extends to the nasal
cavity through the inferior meatus under the inferior turbi-nate, through which
1 focusing on the frontal process of the maxilla where the medial canthal
the tear was drained.
1.4. Buttress
The horizontal buttress is divided into the superior horizontal buttress and
the inferior horizontal buttress, which consists of the frontal bone, superior
orbital rims and inferior orbital rims. The medial vertical buttress consists of
the internal angular process of the frontal bone and the bilateral frontal
2 assist to assess the shape of the orbital rim and medial orbital walls. Attention
processes of the maxilla.
1.5. Blood supplying
The blood supplying for the midface and nasal region comes from the
branches of internal and the external carotid arteries. The anterior and
posterior ethmoid arteries descend from the internal carotid artery. The
maxillary artery from the external carotid artery and subsequent branches play
2
a mainstay role for supporting the midface.
1.6. Nerve
The NOE region is innervated by ophthalmic and maxillary nerves, which
2
are derived from the trigeminal nerve.
2. Symptom of NOE fracture
The clinic symptoms associate with the location and severity of the NOE
fracture. Gross facial edema may show firstly in the early stage of fracture,
2
which will result in distortion of soft tissue landmarks. It might be followed
by the symptoms in the eyes and nose. ophthalmic symptoms include
diplopia, telecanthus, enoph-thalmos, epiphora and shortened palpebral
fissure, which result from orbit wall or medal canthal tendon malformation.
Moreover, the nasal symptoms include retrusion of the nasal bridge, anosmia
caused by damage to the cribiform plate, and nasal congestion secondary to
septal hematoma or bony/cartilaginous deformity. Cerebrospinal fluid leak
2,6
(CSF) may also present, which needs to be highly valued.
3. Diagnosis
A comprehensive diagnosis should refer to the details about location,
extent and displacement of fractures as far as possible, which can be obtained
by combination of careful physical
297
examination and radiographic imaging. In addition, a pretraumatic
7
photograph can provide additional details.
Physical examination: Palpation is an effective way to assess the location
of fracture in physical examination. The palpation of nasal dorsum can
2
indicate whether central nasal support structures have been fractured. If
intercanthal distance is more than 35 mm, a displaced fracture may occur in
medial wall and if the distance more than 40 mm, the displaced fracture can
2
be diagnosed. However, in acute phase, the examiner may fail to perform
phys-ical examination because of drastic pain, and initial symptoms may
cover up real existing characteristics resulting in misdiagnosis. Physical
examination findings often fail to elucidate the all details of injuries, so the
radiographic imaging can provide more details for the diagnosis and
7,8
management of NOE fractures.
Radiographic imaging: In radiographic imaging, the combina-tion of 2D
CT and 3D CT has been increasingly popularized. Remmler's statistical
analysis indicated that combining 3D CT and 2D CT could provide more
9
details in the evaluation of NOE frac-tures. In 2D CT, axial scans (Fig. 2)
can provide the basic infor-mation about the severity of the injury, mainly
tendon attaches, and doctors need to pay additional attention to the frontal
7
sinus. Axial dimension is helpful to follow the ascension of the lacrimal
7,8
canal whether the medial orbital wall is ‘blown out’. Coronal dimension is
significant insight to provide details of frac-tures of the middle third of the
orbit and the status of the anterior cranial fossa. These sections can assess
‘blow-out’ fractures of the area where the orbital floor joins the medial wall,
which greatly increases orbital volume. Simultaneously, these images also
should be paid to the cribriform plate, because the frac-ture of anterior cranial
fossa occurs sometime. Symmetry is important in all scans. If only one side is
injured, then comparison with the opposite side helps to quantify the amount
7
of displace-ment. The surgeons all need to carefully observe the radiographic
images, because the bulk of information from CT scan is so essential to guide
clinic treatment.
4. Classification
Among classifications of NOE fractures, the most widely accepted
classification system was established by Markowitz et al.
Fig. 2. Axial CT of patient with NOE fracture. Arrow indicates the frontal process of maxilla.
298 J.J. Wei et al. / Chinese Journal of Traumatology 18 (2015) 296e301
They divided NOE fractures into 3 types, based on whether the medial canthal
tendons attached the central fragment. For type I injury, the medial canthal
tendon attaches a single-segment central fragment (Fig. 3A). For type II
injury, the central fragment is comminuted, with the medial canthal tendon
attached (Fig. 3B). For type III injury, the MCT is separated with the
10
comminuted central fragment (Fig. 3C).
5. Approaches
It is essential to select proper approaches to get the biggest exposure for
subsequent treatment via the smallest incision. The coronal incision is
commonly used to provide sufficient exposure for performing the restoration
of the NOE fractures and dose not increase facial scar. However, when the
fracture involves lower midface, the incision may be not sufficient to achieve
11
desired exposure. Moreover, some fractures need to increase additional skin
incisions, such as infraorbital, sublabial, subciliary, trans-conjunctival, and/or
11
lateral rim incisions, which may lead to facial scar. To avoid these
disadvantages, some authors paid more attention to midfacial degloving
(MFD) approach which provides exposure of the entire midfacial skeleton via
maxillary sublabial incision and can be extended superiorly and laterally
according to the range of fracture. However, the MFD approach will also pro-
duce complications, such as temporary infraorbital anesthesia, nasal
11,12
obstruction and nasal cosmetic deformity. In recent years endoscopic
application has been emphasized in manage-ment of fractures, which can
produce similar outcomes via a smaller incision providing reduced patient
morbidity and oper-ating time, as well as quicker patient recovery. However,
this technique requires dedicated instrumentation and experienced surgeon to
13
make it fully work. In addition, some local incisions have been modified to
achieve better outcomes, for example, from the transcutaneous lynch
perinasal and sub-brow incision to the transcutaneous medial canthal tendon
incision. Trans-cutaneous medial canthal tendon approach was also described
to expose safely the entire medial orbital wall, nose and the orbital apex by a
1.5- to 2.0-cm transcutaneous medial canthal tendon incision, which was
14
more cosmetically acceptable compared with the lynch incision.
6. Treatment
10
For type I injury : according to the location and displacement of fracture,
proper approach and adequate management should be performed to stable the
superior horizontal buttress, the inferior horizontal buttress and the vetical
15
buttress by junctional plate and screw fixation. In addition, Balaga et al
recommended a minimal invasive approach: transnasal fixation, which could
produce the midfacial symmetry with small visible scar.
For type II injuries, as long as the medial orbital wall bony fragments is
restored in proper position with the use of microplates
Fig. 3. A: Type I injury of NOE fracture. B: Type II injury of NOE fracture. C: Type III injury
of NOE fracture.
6
or titanium mesh, the medial canthal tendon can achieve proper reduction. In
16
Baek et al report, there were two types of mesh: absorbable mesh plates and
titanium dynamic mesh plates, each seemed to have the similar effect and
safety for orbital wall reconstruction in long-term follow-up.
For type III injuries, the fracture is more complex and chal-lenging to
repair. In process of management two mainstay issues must be solved, which
are reconstructing the orbital wall and rebuilding the original attachment of
MCT to their pre-trauma state.
6.1. Reconstruction of the original attachment of MCT
The reattachment of MCT significantly impacts the facial func-tion and
appearance. Different techniques had been described, such as transnasal
6 17
wiring and the Mitek Mini GII Anchor System. Transnasal wiring is one
of the most common techniques which have been improved significantly in
6
recent years. In Terry's report, the transnasal wiring was achieved after
adequate exposure via coronal incision, and surgeons needed to drill or select
two (for unilateral injury) or four holes (for bilateral injury) in medial orbital
wall reconstruction, which must accord to the position where the MCT
normally attaches. After two 28-gauge wires went through the selected holes,
the wires formed a tight bond and were placed in nasal cavity for unilateral
injury cases. For bilateral injury, the wires went to the opposite side through
the holes and then an 18-gauge needle began to penetrate from the skin
surface above and below the medial canthal tendon, to the bony surface of the
medial orbital wall. The wires were penetrated through the corresponding
needle. To hide the wires, an incision between the two wires needed to be
6 18
made and dissected down to the plane of the MCT. Kim et al reported an
oblique transnasal wiring that was performed by a YeV epicanthoplasty
incision rather than the well-known classical bicoronal approach, which could
assist in minimizing unsightly scar formation (Fig. 4).
6.2. Reconstructing the orbital wall
It is paramount to reconstruct the orbital wall to correct tele-canthus,
enophthalmos and epiphora resulting from the volume change of the orbital
cavity. So far, bone graft and biomaterials have always been studied and
modified in treatment of craniofacial
19
defect. Bone grafts include autografts such as scapular bone graft,
20 21 22,23
olecranon bone graft , maxillary bone graft, and allografts.
Biomaterials have been reported by many authors, including tita-nium
24 25 26,27
mesh, absorbable mesh, ultra-high molecular weight polyethylene,
28
hydroxyapatite (HA), and so on.
6.3. Bone tissue engineering
The reported techniques to restore oral-maxillofacial function and
appearance after trauma have significant limitations to affect the outcome of
surgical interventions. Bone tissue engineering (BTE) is taken into
consideration by surgeons and scientists to restore the craniofacial bone
defect. BTE can achieve bone regen-eration by the reaction of three essential
constituents: scaffolds, signals and cells. As for cells, Bone marrow-derived
mesenchymal
Fig. 4. Medial canthal horizontal and periciliary incision, YeV epicanthoplasty.
 J.J. Wei et al. / Chinese Journal of Traumatology 18 (2015) 296e301
stem cells (BMSCs) and adipose-derived mesenchymal stem cells (ADSCs)
are present emphasis in studies of bone regeneration, which are used to
29
differentiate into osteoblasts. In addition, suf-ficient blood supply plays an
indispensable role in the process of bone regeneration. Some researchers
recommended to combine endothelial progenitor cells (EPCs) and MSCs to
30,31
inspire and enhance neovascularization. Moreover the scaffolds provide
an environment just like the extracelluar matrix, which contains the cells and
growth factors needed in the process of bone formation. The scaffolds can be
fabricated by Computer-Aided Design/Com-puter-Aided Manufacture
(CAD/CAM), 3D rapid prototyping and electrospinning to achieve
predesigned shape and emulate the native extracellular matrix as far as
possible. Recently biomimetic scaffolds have attracted researchers' attention.
Biomaterials which are applied in scaffolds can be classified into natural and
synthetic polymers, bioactive ceramics and glass, hydrogels and metals.
Sometimes composite scaffolds show both of the advantages from two
32
different kinds of biomaterials. As to signals, the studies of bone
morphogenic proteins (BMPs) have achieved significant re-sults. For
example, certain reports described that some products containing rhBMP-2
32
and rh-BMP-7 had been implied in clinic regenerative treatment. Recently,
the development of gene therapy has also provided a new approach for
regenerating tissues, which can modify the implanted cells genetically using
viral and
33,34
non-viral vectors in order to strengthen bone tissue regenera-tion.
Although BTE have achieved significant improvement in
animal models and clinic treatment, it is still difficult to get full success in this
35
field.
7. Computer applications
More and more advanced computer applications are applied in clinic
treatment, in order to achieve better outcomes than tradi-tional techniques.
Firstly, 3D CT can provide more details to achieve comprehensive diagnosis
and design individual treatment. Remmler et al's statistical analyses indicated
that combining 3D and 2D CT had full advantage to explore details in the
evaluation of NOE fractures. Moreover the CAD/CAM system has been
applied to clinic procedure to assist surgeons making a plan regarding how to
exactly restore function and appearance in operation. Fan et al carried out a
prospective study on 17 patients with unilateral complex orbital fractures,
which achieved better outcomes in correction of facial deformities, volume of
orbit enophthalmos and diplopia, as well as extraocular movement with the
36
help of CAD/ CAM. In addition, computer applications can make a patient-
specific implant by imitating the normal anatomy of an uninjured orbit.
Furthermore this technique has been continuously improved and verified in
37 43
order to obtain better and better accuracy and feasibility. e The computer-
aided surgery (CAS) navigation sys-tem can further improve the outcome of
surgical intervention. In traditional maxillofacial surgery, due to the limited
exposure of surgical site, the surgeons cannot see directly the operative site
and assess immediately whether proper bony reduction is achieved during
operation. However, in the CAS navigation system, the sur-geons can achieve
intraoperative control of surgical intervention about fracture reduction and
material implant by comparing the real with the virtually pre-operative bone
44,45 45
position designation. Yu et al reported a series of study of 104 patients
using CAS and the results showed that all patients achieved an obvious
improve-ment of function and appearance and no serious complications
occurred. Recently, 3D printing has been studied as a promising technique for
assisting in making the maxillofacial bone defect reconstruction safer and
more accurate, and it also has potential to be applied in fabricating scaffolds
46,47
of bone tissue engineering.
299
8. Discussion
Althrough a number of procedures of NOE fractures have been described,
management of NOE fractures remains one of the most difficult issues to fully
restore the original facial appearance and function due to the anatomic
complexity in this region. Each injury of soft and hard tissue may result in the
abnormal facial function and appearance. Thus in the program of
management, there are some essential and controversial clinic issues to solve.
For example, the NLD has relatively high incidence to be injured in trauma
and surgical intervention. The issue about whether surgeons should employ
intraoperative lacrimal intubation to prevent epiphora still needs to be
identified. Some authors did not recommend exploring and assessment of the
lacrimal pathway with intubation during initial management of fracture,
which could injure the lacrimal pathway because of the soft tissue swelling or
bone displacement, unless the lacrimal pathway presented remarkable
7,48
laceration. So management of epiphora should be delayed to perform.
49
However Iwai et al's results showed that intraoperative lacrimal intubation
could reduce the incidence of permanent epiphora for the patients with
fracture of the NOE complex.
Regarding to the number of MCT's limb, 3-limb, 2-limb, even 1-limb
were all reported, and several authors held the opinion that the number could
2 5
vary from the race and age. e The location of MCT significantly influences
patient's appearance and it's displacement could cause telecanthus and
shortened palpebral fissure. Therefore, it plays key role to ensure the proper
insertion and reattachment of MCT for achieving acceptable appearance.
Moreover, the NOE fracture may also occur in pediatric popu-lation, not
very frequently though. The difference between the pediatric and adult facial
skeleton makes the management more challenging and complex. Firstly, the
development of frontal sinus from the age of four to five years has an effect
on the clinical symptoms and signs of the NOE fracture. Secondly, the growth
dynamics of the pediatric craniofacial skeleton should be taken into
consideration in the pre-operative plan, because the rigid fixation and the
implant may impact on the craniofacial growth resulting in long-term
50
cosmetic problem. Given these factors, the application of resorbable
fixation has been taken into consideration in the treatment of pediatric fracture
51 53
patients, and its effectiveness also has been proved gradually. e Also, the
resorbable fixation in the pediatric type I NOE fracture has been applied to
54
achieve good outcomes. Actually in some cases resorbable fixation has
been recommended to be the standard for the fixation of pediatric facial
fractures.
As to bone defect, it is essential to select proper plan to fill the defect for
restoring the normal appearance and function. Autograft has been the gold
standard for bone defect. However, there are many factors to limit its
application. The survival of autograft can be affected by many factors, such as
graft orientation, embryonic origin, periosteum, rigid fixtion,
revascularization, recipient site and mechanical stress. The autograft has been
only used in recon-struction of critical size bone defect and increase the time
and risk
22,55
of surgery, such as the morbidity and complications of donor-site bone.
Allograft also has the limitations of immunologic rejec-
55
tion and disease transmission from donor to recipient. Since there are no
ideal approaches to fulfill the requirement of bone defect treatment, bone
tissue engineering is supposed to be helpful to the surgeons. Although there
are still limitations and challenges to apply the bone tissue engineering into
clinical cases as gold stan-dard, some successful clinical trials increased
confidence of the researchers and surgeons. Warnke et al applied the theory of
BTE to achieve a free bone-muscle flap to repair the mandibular defect and
56
observed new bone formation, satisfying the aesthetic outcome. This
clinical trial made prefabricated titanium mesh cage filled
300 J.J. Wei et al. / Chinese Journal of Traumatology 18 (2015) 296e301
with bone mineral blocks and soaked in recombinant human bone
8 defects with titanium mesh. J Maxillofac Oral Surg. 2013;12: 418e423.
morphogenetic protein (rhBMP) and the patient's bone marrow. The
transplant was implanted into the mandibular defect after kept in latissimus
dorsi muscle for 7 weeks. Mesimaki et al successfully achieve maxillary
57
reconstruction with GMP adipose stem cells.
58
Later study also provided evidence for the clinical application of BTE.
In addition, computer applications improve the surgical accu-racy and
feasibility to a great extent, but it is still difficult to be popularized due to the
expensive cost. However, as the advance-ment of basic study and clinical
practice, these applications would play a key role in the management of NOE
fractures.
Fund
This study was supported by the National Natural Science Foundation of
China (No. 81270421).
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