Journal of Cranio-Maxillofacial Surgery (2008) 36, 346e353

� 2008 European Association for Cranio-Maxillofacial Surgery

doi:10.1016/j.jcms.2008.02.004, available online at http://www.sciencedirect.com

Clinical anatomy of the superior orbital fissure and the orbital apex

Jerzy REYMOND1, Jan KWIATKOWSKI2, Jaros1aw WYSOCKI3,4

1Department of Maxillofacial Surgery, Specialist Hospital in Radom, Poland; 2Department of Ophthalmology,Specialist Hospital in Radom, Poland; 3Clinic of Otolaryngology and Rehabilitation, II Medical Faculty,Warsaw Medical University Poland; 4 Institute of Physiology and Pathology of Hearing, Warsaw, Poland

SUMMARY. Background: There are discrepancies between authors as far as topography of superior ophthalmicvein in the orbital apex is concerned. Objectives: The aim was to determine the location of the structureswithin the posterior part of the orbit and in the superior orbital fissure. Material: One hundred preparationsof orbits were derived from the corpses sectioned in Forensic Medicine Department, University Medical School inWarsaw, Poland. Study design: Anatomical preparation was performed with use of standard set of microsur-gical equipment and operating microscope. Results: Nine various morphological types of the superior orbitalfissure were distinguished. Among those were two main categories: type ‘‘a’’ characterised by a clear narrowingwithin the fissure and type ‘‘b’’ which lacked such narrowing. The type ‘‘a’’ and ‘‘b’’ fissures were also differentin length whereby type ‘‘b’’ fissure was significantly shorter. A diversity of positioning of the soft structureswithin those types was successfully noted. In type ‘‘a’’ the superior ophthalmic vein was located typically, how-ever in type ‘‘b’’ fissures it was significantly more often the lowest structure in the posterior part of the orbitalapex (except for muscles and orbital fat). A short case report of patient with superior orbital syndrome wasadded. Conclusion: Position of soft tissue structures in superior orbital fissure depended on its morphologicaltype. � 2008 European Association for Cranio-Maxillofacial Surgery

Keywords: superior orbital fissure, orbital apex syndrome, anatomy, dimensions, case report

INTRODUCTION

Orbital anatomy, however described in anatomy text-books, is in need of updating from the current literatureand clinical experiences. Aside from a few books and ar-ticles on orbital anatomy (Natori and Rhoton, 1994,1995; Ettl et al., 1997, 2000; Ucerler and Govsa, 2006;Nagasao et al., 2007), there are clinical reports which re-fer to the subject only in a narrow content. There is a lackof thorough and exhaustive investigation into the topo-graphical anatomy of the superior orbital fissure, espe-cially regarding potentially serious complicationsoccurring postoperatively (Cruz and dos Santos, 2006).

The superior orbital fissure is a small but topographi-cally important area, which connects the middle cranialfossa and the orbit (Lang, 1979; Bergin, 1987; Natoriand Rhoton, 1994, 1995; Williams and Bannister, 1995;Govsa et al., 1999). The fissure is divided into clear topo-graphical divisions. Some researchers distinguish onlytwo compartments (Bergin, 1987; Morard et al., 1994;Govsa et al., 1999; Shapiro and Robinson, 1967). Thesuperior orbital fissure consists of the following components:

- Superior or superolateral part which includes the troch-lear, lacrimal, frontal nerves and the superior ophthal-mic vein.

- Inferior or inferomedial part which includes the superiorand inferior branches of the oculomotor nerve, thenasociliary nerve, the abducens nerve. Here also liesthe sensory root and the sympathetic root of the ciliary

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ganglion. The inferior ophthalmic vein, if it is presenthere, can at times pass through the tendinous annulusof Zinn.

This division originates in the very shape of the fissurein which in most cases a long and narrow lateral part andbroad and shorter medial part can be observed. Thisdivision is stressed even further by the tendinous annulusof Zinn. The location of the contents within the fissure isfairly constant. The superior branch of the oculomotornerve is the structure closest to the medial rim of the fis-sure; the trochlear nerve is the closest to the superior rimand the abducens nerve is the closest to the inferior rim(Govsa et al., 1999).

Others state that three separate compartments withinthe fissure can be distinguished: lateral, medial and infe-rior (Natori and Rhoton, 1994, 1995; Ettl et al., 1997,2000). The lateral component is consistent with the nar-row part of the superolateral fissure and contains thetrochlear nerve, the frontal nerve, the lacrimal nerveand the superior ophthalmic vein. The medial part is con-sistent with the tendinous annulus of Zinn and containsthe superior and inferior branches of the oculomotornerve as well as the nasociliary nerve, the abducens nerveand the roots of the ganglion. The inferior part lies belowthe tendinous annulus and is mainly filled with the adi-pose tissue; the inferior ophthalmic vein is located hereas well (Natori and Rhoton, 1995). According to Ettlet al. (1997, 2000), the superior ophthalmic vein passesthrough the medial part. This observation was drawn

Superior orbital fissure 347

from analysis of magnetic resonance imaging (MRI) im-ages, however, it has only been confirmed by Bergin(1987).

The pathological processes may occur in the superiororbital fissure have variable symptomatology (Bowerman,1969; Ferguson, 1974; Pogrel, 1980; Sieverink and vander Wal, 1980; Miller, 1985; Zachariades et al., 1985;Ghobrial et al., 1986; Ettl et al., 2000; Fauci et al.,1983; Hedstrom et al., 1974). Among them there are syn-dromes of the orbital apex, the superior orbital fissure andcavernous sinus. The orbital apex syndrome affects thecranial nerves: II, III, IV, V1 and VI. The superior orbitalfissure syndrome involves: III, IV, V1 and VI. The cavern-ous sinus syndrome affects III, IV, V1, V2, VI and the sen-sory plexus of the ophthalmic artery. The superior orbitalfissure and the orbital apex syndromes usually occur to-gether.

The research aim was to determine the location of thestructures which pass through the superior orbital fissurewhich regard to preferred points of measurement and toprovide clinically useful information. Another importantgoal of the research was to establish if there is a signifi-cant connection between the distribution of vascular andneural elements within the fissure and its morphologicalshape and type.

Fig. 1 e Superior orbital fissure measurements scheme. (a) Maximumlength of the fissure and (b) maximum width of the fissure.

MATERIALS AND METHODS

One hundred human orbit preparations were collected: 50female and 50 male adult cadavers. In each group therewere 25 left orbits and 25 right orbits. All were obtainedduring regular medical autopsies. The samples for the re-search were selected from consecutively performed autop-sies. Possible head-injuries and cases of skull fractureswere excluded. After opening the skull, the bone unit en-compassing about 1/3 of the posterior part of the orbit, thelateral wall of sphenoid body and all bony margins of su-perior orbital fissure were removed. Specimens were thenfixed in a 10% formalin solution; the bony unit was dis-sected with standard microsurgical tools under the micro-scope. The shape of the orbital fissure was analysed: ninebasic morphological types AeI and two general types ‘‘a’’

Fig. 2 e Scheme of measurements determining location of optic nerve regarddistinguished. (a) Distance from the optic nerve centre to the upper margin of oof superior orbital fissure, (c) distance from the optic nerve centre to the latecentre to the point determined by the narrowing of the fissure (type ‘‘a’’) or thfissure. (1) Optic nerve, (2) content of superior orbital fissure, (3) content of

and ‘‘b’’ were determined. The maximum length andwidth of the fissure were measured, according to Fig. 1.Then, using a graticule, distances between margins ofthe fissure, and between the optic nerve and bony ridgesof fissure were measured, as in Figs. 1 and 2. All the mea-surements were made to methric 0.1 mm. After dissectionof all the structures within the orbit had been completed,the topographical arrangement of structures in the orbitalapex was determined.

The measurements and observation results were analysedstatistically; first, the descriptive statistical values were cal-culated (range, mean, and standard deviation [SD]). The dif-ferences among the calculated mean values were analysedusing Student’s t-test. The differences between non-parametric features were analysed using chi-squared test.The results were presented as diagrams and tables and com-pared with the data provided from the literature.

RESULTS

The morphological variants of the superior orbital fissureare represented in Fig. 3. In our research, the superior

ing optic canal and superior orbital fissure with the types ‘‘a’’ and ‘‘b’’ptic canal wall, (b) distance from the optic nerve centre to the medial poleral pole of the superior orbital fissure, (d) distance from the optic nervee point lying in the middle of line between lateral and medial pole of theoptic canal.

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orbital fissure had very different shapes: from a classicalfissure-like shape (Fig. 3f), through different triangularvariations and finally, on egg-shaped fissure (Fig. 3I).The morphological types of the superior orbital fissuredid not present any statistically important variants withregard to sex and body side. The general rule was thatthe shape of the fissure remained the same on both sidesof the skull, the differences in a particular skull relatedonly to the size of the fissure only.

The size of the superior orbital fissure did not show sta-tistically important differences regarding sex, side or themorphological type of the fissure. Analysis showed thatgenerally there are only two morphologically differenttypes of the superior orbital fissure. Types FeI (Fig. 3)share the same characteristics: they do not have a clear nar-rowing, therefore it was impossible to measure the small-est width of the fissure as both of its edges meet at oneoutermost point (Fig. 2b). On the other hand, types AeEhad a noticeable narrowing that indicates a more or lessclear borderline between the middle broaden part andthe lateral narrow part. In such cases, it was always possi-ble to find a point at which the fissure was narrowed(Fig. 2a). This type of fissure was also characterised by

Fig. 3 e Scheme of morphological forms of the superior orbital fissurewith percentage in brackets.

Table 1 e Distances between the optic nerve and certain points in optic cana

Measured distances (inmm) of the optic nervefrom reference points

M (N¼ 50)

L R

a 1.76 (0.92) 1.70 (0.98)0.7e3.3 1.1e4.0

b 11.02 (1.18) 10.74 (1.12)8.1e7.6 4.4e13.5

c 16.81 (2.26) 17.23 (2.45)11.5e21.2 9.3e24.6

d 8.89 (1.45) 9.12 (1.24)4.1e12.2 4.2e13.5

Arithmetic means are expressed in bold letters, SDs are in parentheses, an

relatively greater length and width. Fissures AeE weregrouped into one type and named type ‘‘a’’; fissures FeIwere grouped as the morphological type ‘‘b’’. Type ‘‘a’’occurred in 63 preparations and type ‘‘b’’ in 37. Type‘‘a’’ had a mean length of 17.47 mm (SD¼ 2.26) and7.31 mean width (SD¼ 2.34). Type ‘‘b’’ measured12.48 mm (mean length, SD¼ 3.15) and 7.86 (mean)width (SD¼ 2.45). Both types ‘‘a’’ and ‘‘b’’ differed sig-nificantly in the maximal length of the fissure. Regardingthe maximum width of the fissure, the differences weresmall and irrelevant. The next research aim was to observeif there was any connection between the two fissure types‘‘a’’ and ‘‘b’’ regarding the arrangement of the contents thefissure and the orbital apex.

The results of measurements between the optic nerveand its neighbouring structures show no important differ-ences (Table 1). This encouraged further analysis focusedon the type of fissure. Therefore the data were calculatedseparately for the orbital fissures of types ‘‘a’’ and ‘‘b’’(Table 2). Except for the distance measured from the supe-rior edge of the optic canal, all other results varied signif-icantly (they were considerably smaller in type ‘‘b’’). Thedistances from the optic nerve to the narrowing as well asfrom the lateral rim of the fissure are of great clinical valuefor surgeons. They should consider the position of the op-tic nerve and other adjacent structures closer to the fissurerim. It is particularly important when the orbit and the cra-nial cavity are accessed laterally.

In the research material, the following variants of theorbital apex structures were distinguished. The typicalor ‘‘classical’’ arrangement was based on a clear distinc-tion of an area limited by the tendinous annulus of Zinn.The superior ophthalmic vein was situated in the supero-lateral area, often in the narrow part of the superiororbital fissure.

The location of the ophthalmic artery varied in relationto the stem of the optic nerve. Often the artery was infe-rior to the nerve, but this was observed in only 34 cases.In 66 cases, the artery was lateral and superior, a typicalvariant on occurring when it traverses the optic nervefrom above. In a few preparations (two rights and oneleft), the artery was placed laterally, close in the superiorophthalmic vein (Figs. 4 and 5). Orbital apex nervesbranched in different ways. Often division took placeearly, posteriorly in orbit at the level of the tendinous an-nulus, the frontal nerve divided into the suprafrontal and

l and superior orbital fissure (according to Fig. 2)

F (N¼ 50) M + FL + R(N¼ 100)L R

1.68 (0.9) 1.78 (1.01) 1.73 (1.01)1.2e4.3 1.0e4.2 0.7e4.3

10.8 (1.89) 11.01 (1.99) 10.88 (2.17)6.0e12.8 7.8e14.2 4.0e17.6

17.12 (2.83) 16.92 (2.27) 16.84 (2.95)12.4e23.2 12.1e22.2 9.2e24.6

9.16 (1.35) 9.98 (1.29) 9.28 (1.51)6.8e16.0 6.4e13.8 4.1e16.0

d ranges of obtained values are given below.

Table 2 e Distances between the optic nerve and certain measurementpoints in the optic canal and superior orbital fissure (according to Fig. 2)with two types of the fissure distinguished

Measureddistances to theoptic nerve fromreference points(in mm)

Type ‘‘a’’(N¼ 63)

Type ‘‘b’’(N¼ 37)

a 1.68 (0.92) 1.81 (0.9)0.7e4.3 0.98e4.2

b 13.07 (1.18) 7.15 (1.69)8.2e17.6 4.0e13.1

c 19.43 (2.19) 12.43 (2.34)13.8e24.6 9.23e17.05

d 7.38 (2.15) 12.51 (2.1)4.1e11.3 8.2e16.0

Arithmetic means are represented in bold with SD (in parentheses) andrange is given below.

Fig. 4 e Fragment of human orbit. Right side, anterior view.Arrangement of the structures within the orbital apex. 1 mm gaugebelow. (1) Lacrimal nerve, (2) frontal nerve (with two subdivisions), (3)trochlear nerve, (4) levator palpebrae muscle, (5) short ciliary nerves, (6)optic nerve, (7) ophthalmic artery, (8) inferior branch of the oculomotornerve (subdivided into two branches), (9) abducent nerve, (10)nasociliary nerve, (11) superior ophthalmic vein, (12) lacrimal vein, (13)superior branch of the oculomotor nerve.

Fig. 5 e Fragment of human orbit. Right side, anterior view. Superiororbital fissure type ‘‘a’’. Ophthalmic artery located superiorly andlaterally to the optic nerve. 1 mm gauge below. (1) Lacrimal nerve, (2)frontal nerve (with two subdivisions), (3) trochlear nerve, (4) levatorpalpebrae muscle, (5) rectus superior muscle, (6) superior branch of theoculomotor nerve, (7) optic nerve, (8) inferior branch of the oculomotornerve (subdivided into two branches), (9) lateral rectus muscle, (10)abducent nerve, (11) nasociliary nerve, (12) superior ophthalmic vein.

Superior orbital fissure 349

the supratrochlear nerves, and the branches of the oculo-motor nerve split into its muscular ramifications. Theabducens nerve showed the greatest constancy in termsof its location. In all cases, it was found in the middlepart of the lateral rectus muscle.

On rare occasions, an unusually low position of the su-perior ophthalmic vein was observed. In such cases, thevein was the lowest structure in the orbital apex nearthe superior orbital fissure (Fig. 6). This atypical layout

occurred six times (6% of sides, two right, four left, threemales and three females). The position of the vein waseight times low and lateral to the abducens nerve, andon its level. Such a layout was observed in five maleorbits and three female (three right and five left). Thoseunusual, low locations of the superior ophthalmic veinwere observed almost exclusively in type ‘‘b’’ fissures,i.e., broad and short (12/14 type ‘‘b’’ fissures).

The layouts of the structures situated in the orbitalapex are presented in Fig. 7.

DISCUSSION

There is great variation of the superior orbital fissure asdescribed in the literature. Most of the authors distin-guish 9 or 10 morphological forms of the superior orbitalfissure (Kornblum and Kennedy, 1942; Shapiro and Jan-zen, 1960; Sharma et al., 1988; Govsa et al., 1999). Par-ticular variants occur according to different authors withthe following frequency: 1.5e40%, so the real discus-sion on frequency of occurrence of each variant is verydifficult, however our results are generally close to previ-ous observations. An entirely new finding in this researchis the proposed distinction of two substantially differenttypes of fissure: type ‘‘a’’ has a noticeable narrowingcaused mainly by a bulge (of various size or a bony sur-plus) on the inferior rim; type ‘‘b’’ has a smooth outlinewithout any noticeable narrowing. It turns out that both

Fig. 6 e Fragment of human orbit. Left side, anterior view. Atypical lowposition of the superior ophthalmic vein. (1) Optic nerve, (2) superiorbranch of the oculomotor nerve, (3) levator palpebrae muscle, (4)trochlear nerve, (5) medial branch of frontal nerve, (6) periorbita andcircle of Zinn, (7) lateral branch of frontal nerve and the lacrimal nerve,(8) long ciliary nerves. (9) nasociliary nerve, (10) superior ophthalmicvein, (11) abducent nerve, (12) opthalmic artery, (13) inferior branch ofthe oculomotor nerve.

Fig. 7 e Types of arrangement of nerves and vessels within the orbitalapex. (1) Optic nerve, (2) superior branch of the oculomotor nerve, (3)trochlear nerve, (4) frontal nerve, (5) lacrimal nerve, (6) superiorophthalmic vein, (7) nasociliary nerve, (8) abducent nerve, (9) inferiorbranch of the oculomotor nerve, (10) ophthalmic artery.

Fig. 8 e Patient in the day of discharge from hospital. (A) Lateralisationof right eyeball in looking ahead and (B) immobilisation of the righteyeball during to look upward and to the left.

350 Journal of Cranio-Maxillofacial Surgery

types of the orbital fissure differ not only with regard totheir shape but also size. Moreover, in both cases the softstructures are arranged differently. This refers first of allto the position of the superior ophthalmic vein. In type

‘‘b’’ it was placed noticeably more often in atypicallow or very low position. This observation is of greatclinical importance, as according to classical definitions,the vein lies in the farthest segment of the fissure. Al-though we do not usually expect to come across impor-tant structures passing through this area, the surgeonshould approach the lateral part of the orbit with thegreatest diligence, particularly during orbitotemporal ac-cesses. The atypically low placement of the vein mustsurely expose it to pressure from fractures of the greaterwing of the sphenoid bone. This may cause an obstruc-tion of venous blood flow within the orbit or a haematomaas an additional symptom in the superior orbital fissuresyndrome (Zachariades et al., 1985).

What is also important is the changing position ofthe ophthalmic artery in the posterior part of the orbit.In a number of cases, the artery was placed not infe-rior to the optic nerve but laterally. Govsa et al.(1999) also mention such cases. The measurementsof the superior orbital fissure indicate that it constitutesa more or less triangular field 17.3� 20.8� 9.5 mm(Govsa et al. 1999). The range of variations is how-ever large and the SD is up to 20% of the meanvalue. According to Morard’s et al. (1994) measure-ments, the size of the superior orbital fissure is on

Fig. 9 e CT scans of patient on the day of trauma. Arrows show fractures of sphenoid and maxillary bones. (AeC) Greater wing of sphenoid bone and(D) lateral wall of maxillary sinus.

Superior orbital fissure 351

average 3� 22 mm in length. This indicates there mayexist extreme differences that did not occur in the re-searched material. In our investigation the length ofthe superior orbital fissure was between 11 and21 mm. The maximum length of the fissure measuredin this research was on average 15.62 and is close tothe result of Govsa et al. (1999) which was 16.9. Sim-ilarly, one can compare the results in Table 1, the dis-tances between the optic nerve and the inferior rim ofthe superior orbital fissure; the rim fairly adequatelyrepresents the height of the superior orbital fissure. Ac-cording to our measurements, this distance was10.88 mm. According to Govsa et al. (1999), on theother hand, it was 9.0 mm as the distance betweenthe superior and inferior edges of the superior orbitalfissure. Similar results were presented by Natori andRhoton (1995). Their measurement criterion was thedistance between the lateral edge of the superior orbitalfissure and the structures lying within. Their fissurelength measurements from the outermost points ofthe fissure was 15.9 mm (SD, 3.7; range, 7.7e22.1)(Natori and Rhoton, 1995).

However, the length of the superior orbital fissurevaries greatly when the shape of the fissure is takeninto account, but only regarding the division into types‘‘a’’ and ‘‘b’’ (Table 2). Such an approach allows us tosingle out the oval shape fissure with smooth and regularoutline which at times may resembles an egg or a roundedisosceles triangle. These fissures are generally character-

ised by shorter length and a considerable width. Thewidth does not however compensate for the shortnessof the fissure. In consequence, the area of the type ‘‘b’’fissure is significantly smaller than the area of the type‘‘a’’ fissure. This fact has not been mentioned in the lit-erature. This information seems to be important as itallows the surgeon to anticipate the topography and toknow what distances should be considered intraopera-tively, before a standard skull radiograph is performed.It should be emphasised that the nerves which are mostclosely connected to the optic nerve are the nasociliarynerve and the superior branch of the oculomotor nerve.Importantly, any careless operation in the proximity ofthe optic nerve may lead to injury of those delicate nervebranches. According to Govsa et al. (1999), the follow-ing structures lie in the greatest proximity to each other:the superior branch of the oculomotor nerve and the me-dial rim of the fissure, the trochlear nerve and the supe-rior rim, the abducens nerve and the inferior edge. Ourobservations confirm that such a layout is also presentin the apex of the orbit. However, a common phenome-non in this area of the orbit (contrary to the orbital fis-sure) is the division of the inferior and sometimessuperior branch of the oculomotor nerve into thebranches to successive external eye muscles. The frontalnerve and the nasociliary nerve can also produce such de-rivative stems (Fig. 4e6). In this area, long ciliary nervesand supraorbital nerve and the supratrochlear nervealready can be noticed.

Fig. 10 e 3-D reconstruction of CT scans. (A) Antero-lateral view: (1)fractures of zygomatic bone, (2) destruction of orbital roof, (3) bonyfragment in lateral part of superior orbital fissure. (B) Lateral view: (1)fractures of zygomatic bone, (2) destruction of lateral wall of orbit(greater wing of sphenoid bone).

352 Journal of Cranio-Maxillofacial Surgery

CASE REPORT

Case history (no. 17332/07): a 31-year-old man was ad-mitted to the Maxillofacial Surgery Ward of Radom Hos-pital in 2007after a bicycle accident. On admission, thepatient was alert but he showed signs of concussionincluding headache and vertigo. Physical examination re-vealed numerous facial cuticle abrasions, right upper andlower eyelid haematomas (Fig. 8). Bilateral orbital ec-chymosis predominantly on the right, right subconjuncti-val haemorrhage, right blepharoptosis, exophthalmia andophthalmoplegia with the slight abduction were alsopresent. The sensation of touch in the right frontal areawas disturbed. The CT scan (Figs. 9 and 10) revealedpresence of a small amount of intracranial gas in thebasal cisterns, frontal lobes, and on the brain convexity,as well as focal haemorrhagic contusion in the postero-basal part of the right frontal lobe. The other brain struc-tures were normal. The ventricular system was stillcentered, not widened. There was also extensive subcuta-neous emphysema of the right face, right lower eyelid,and both orbits, blood in both maxillary, sphenoid andethmoid sinuses. There was an oblique fracture cleft ofthe right orbital roof and some infraorbitally, fracturesin squamas of both temporal bones and wings of thesphenoid bones. The examination also revealed fractureof the lateral wall of the right sphenoid sinus, commi-nuted fracture of the right maxillary sinus walls withslight intussusception of the anterior sinus wall. An out-fractured angularly orientated large bone chip was seenin the lateral wall of the right maxillary sinus. Fracturesof the frontal process of the right zygoma and arch,

and the posterior osseous nasal septum were also visible.Ophthalmological consultation confirmed bilateralecchymoses, predominantly in the right eye, rightblepharoptosis and exophthalmia with the slight abduc-tion and total right ophthalmoplegia. The left eye wasnormal. Neurological examination confirmed irregularityof the pupils R . L and right eye immobility. Based onthe physical examination and radiological findings the di-agnose of superior orbital fissure syndrome and orbitalapex syndrome were established. Anti-oedema andanti-inflammatory treatments were initiated. The patientwas offered surgery to which he did not consent. After10 days he was discharged from the hospital in good con-dition (with recommendation of periodic follow up).

CONCLUSIONS

1. The superior orbital fissure has two basic morpho-logical types, which differ according to size parame-ters as well as the location of the structures withinthe fissure.

2. The superior ophthalmic vein sometimes is the elementwithin the orbital apex which is placed most inferiorly.

3. Cranio-maxillofacial surgeon in his everyday prac-tice has to manage the most complex posttraumaticlesions, including superior orbital fissure syndrome.Thorough knowledge of anatomy with topographicalvariants enables quick diagnosis as well as appropri-ate treatment.

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Dr. Jaros1aw WYSOCKIInstitute of Physiology and Pathology of HearingZgrupowania AK Kampinos Str. 1, 01-943 WarsawPoland

Tel./Fax: +48 22 835 52 14E-mail: j.wysocki@ifps.org.pl

Paper received 30 May 2007Accepted 2 November 2007