Do Racial Differences in Orbital

Volume Influence the

Reconstruction of Orbital
Trauma
Dina Amin, DDS,* James Jeong, DM, DMD,y Andrew J. Manhan, MPH,z
Gary F. Bouloux, DDS, MD, MDSc,x and Shelly Abramowicz, DMD, MPH║
Purpose: Successful orbital reconstruction relies on an accurate restoration of orbital volume (OV).
The purpose of this study was to determine if the OV of African American (AA) subjects differs from that
of Caucasian subjects.
Methods: The authors implemented a retrospective observational study of successive subjects who
received a maxillofacial computed tomography (CT) scan at a level I trauma center between 2017 and
2020. The primary predictor variable was race (AA/Caucasian). The primary outcome variable was orbital
volume. Two independent examiners calculated OV with an open access OsiriX MD software version
10.0.5 (Pixmeo, Switzerland). Inter-rater reliability was calculated. Differences between races, genders,
and sides were tested using independent samples t test with a significance of P < .05.
Results: Sixty subjects (120 orbits) were included in the study. The mean age was 36.7 (SD § 13.2)
years with a range of 22 to 78 years. Gender distribution was equal with 30 male (50%) and 30 female
(50%) subjects. Inter-examiner reliability was 0.973. The mean OV of AA and Caucasians was 22.38 and
23.23 cm3, respectively (P = .07). The mean OV of AA and Caucasian males was 23.92, and 24.17cm3,
respectively (P = .71). The mean OV in AA and Caucasian females was 20.84 and 22.28cm3, respectively
(P = .013).
Conclusions: African-American female subjects appear to have a smaller OV when compared with Cau-
casians which may influence orbital reconstruction. Laterality does not appear to be associated with any
differences in OV.
Ó 2021 Published by Elsevier Inc. on behalf of The American Association of Oral and Maxillofacial
Surgeons.
J Oral Maxillofac Surg 80:121−126, 2022

*
Assistant Professor in Oral and Maxillofacial Surgery, Depart-
ment of Surgery, Emory University School of Medicine, Director of
Oral and Maxillofacial Surgery Outpatient Clinic, Grady Memorial
Hospital, Atlanta, GA.
yResident-in-training, Oral and Maxillofacial Surgery, Depart-
ment of Surgery, Emory University School of Medicine, Atlanta, GA.
zMedical Student Researcher, Department of Surgery, Emory
University School of Medicine, Atlanta, GA.
xProfessor in Oral and Maxillofacial Surgery, Department of Sur-
gery, Emory University School of Medicine, Atlanta, GA.
║Associate Professor in Oral and Maxillofacial Surgery and Pedi-
atrics, Department of Surgery, Emory University School of Medi-
cine, Chief of Oral and Maxillofacial Surgery, Children’s Healthcare
of Atlanta, Atlanta, GA.
Conflict of Interest Disclosures: None of the authors have any
relevant financial relationship(s) with a commercial interest.
Address correspondence and reprint requests to Dr Dina Amin:
Department of Surgery, Emory University School of Medicine,
Atlanta, GA.; e-mail: dina.amin@emory.edu
Received June 1, 2021
Accepted July 29, 2021.
© 2021 Published by Elsevier Inc. on behalf of The American Association of Oral
and Maxillofacial Surgeons.
0278-2391
https://doi.org/10.1016/j.joms.2021.07.030

121
122
The reconstruction of orbital anatomy represents a
challenging area in maxillofacial trauma.1,2 Recon-
struction of orbital symmetry requires a precise mea-
surement of orbital volume (OV). Incorrect OV can
cause ocular dystopia,3-6 enophthalmos,7-9 and/or
diplopia.6
Before recent technological advancements,3 sur-
geons did not calculate OV as a part of surgical plan-
ning.10 Traditionally, a patient would undergo repair
of orbital fracture when preoperative clinical exami-
nation showed enophthalmos/exophthalmos,11,12
hypoglobus,13 muscle entrapment,13 occulocardiac
reflex,13,14 persistent diplopia,11 and/or radiographic
evidence of 50% or more orbital floor fracture on a
computed tomography (CT) scan.10,15,16
However, neither clinical exam nor CT imaging
provides OV (preoperative or postoperative) data.17
Preoperative imaging,1,6 new materials,18,19
patient-specific implants,17 and computer-assisted
surgical planning have improved surgical
outcomes.1,6,17 Historical values of OV have been
extrapolated from Caucasian subjects.20,21 However,
previous studies demonstrated that OV differ among
multiple racial groups: Caucasians,20,22 Chinese,23
Korean,24 Japanese,25 Hong Kong Chinese,26 Turk-
ish,27 and Taiwanese.28 The OV of African Americans
(AA) is not known.
Knowledge of the mean OV in AA would assist pre-
operative surgical planning of orbital fracture in the
AA population resulting in more accurate and race
specific orbital reconstruction. This is particularly
important when bilateral orbital reconstruction is
required as there is no existing patient specific OV
that can be calculated from an intact orbit. The failure
to use race specific norms may result in under or over
correction of OV. This may then result in enophthal-
mos, exophthalmos, and diplopia.
The purpose of this study was to calculate OV in
AA subjects. Specific aims were to compare OV
between AA and Caucasian subjects, as well as dif-
ference between genders for both AA, and Cauca-
sian subjects.
Materials and Methods
STUDY DESIGN AND SAMPLE
The authors implement a retrospective observa-
tional study of successive subjects presenting to
Grady Memorial Hospital who required a maxillofa-
cial CT scan between 2017 and 2020. Institutional
Review Board Approval was granted. The inclusion
criteria were age over 18 years, a maxillofacial CT
scan, intact orbital anatomy, and a complete medical
record. Exclusion criteria included prior orbital
injury or surgery, midface or orbital trauma,
RACIAL DIFFERENCES IN ORBITAL VOLUME
congenital craniofacial anomaly, and the presence of
orbital pathology
STUDY VARIABLES
The primary predictor variable was race (AA vs
Caucasian). The primary outcome variable was OV.
All subjects received a CT scan per protocol (0.5mm
slice increment, 100 to 120kV, 80 to 440 mA, 200 to
220 FOV, 0.656 pitch, and a 512 £ 512 image
matrix).
SAMPLE SIZE
The sample size calculations were computed on
the basis of a mean difference in OV of 2 cm3
which is generally considered to be clinically sig-
nificant when comparing pre-traumatic and postop-
erative orbital volumes. To achieve a study power
of 90%, the study sample size was 60 patients (30
Caucasians and 30 AA) consisting of 120 orbits.
(Table 1).
CALCULATION OF ORBITAL VOLUME
Several methods previously calculated OV in-situ
(eg dried skulls using water,23,27,29-31 sand,27,30,32,33
glass beads,34 alginate impressions9) or from imaging
(eg point-counting method on CT,27 direct calculation
on CT3,20,22,28,35 or on magnetic resonance imag-
ing26). The gold standard in volumetric analysis is the
Water Displacement Method.23,27,29-31 It is based on
the Archimedean principle of fluid displacement,36
which states that an object displaces its own volume
when immersed in water.36 Earlier investigations
examined various CT analysis software programs in
calculating OV (ie Mimic, 20 Analyze,30 Eclipse Treat-
ment Planning System,35 Extended Brilliance Work-
space3). In the current study, we used OsiriX MD to
calculate OV because it is comparable to the Water
Displacement Method and its reliability and efficacy
were previously verified.37 We measured OV on a
bony window via multiple contiguous coronal views.
Orbital landmarks were chosen on the basis of previ-
ous validated studies.25,28,38,39 Boundaries were: 1)
anterior: posterior lacrimal crest,39 2) posterior: optic
Table 1. THE SAMPLE SIZE CALCULATIONS FOR OV.
The mean OV for SD The mean D Power Sample
Caucasians (cm3) (cm3) OV for AA (cm3) % size
26.9 2.3 1.0 80 166
26.9 2.3 2.0 80 42
26.9 2.3 1.0 90 222
26.9 2.3 2.0 90 56
Amin et al. Do Racial Differences in Orbital Volume Influence. J
Oral Maxillofac Surg 2022.
AMIN ET AL. 123

canal,28,39 3) lateral: lateral orbital wall,25,28,38,39 and
4) medial: medial orbital wall25,28,38,39 (Figs. 1, 2).
CALIBRATION
Two independent observers completed calibration
on 5 subjects/CT scans who were not included in the
study.
STATISTICAL ANALYSIS
Data analysis was performed with IBM SPSS Statis-
tics for Windows, version 26 (IBM Corp. Armonk,
New York). Inter-observer reliability was calculated
with a 2-way mixed-effects model, intraclass correla-
tion coefficients, 95% confidence intervals (CI), and P
values. Descriptive statistics summarized demo-
graphics of the sample.
The differences between nominal (gender, lateral-
ity) and continuous (age) outcome variables were
computed using the x2 and independent t test,
respectively. Statistical significance was P < .05.
Results
Sixty subjects (30 AAs and 30 Caucasians; 120
orbits) with a mean age of 36.7 years (range, 22 to 78)

FIGURE 1. A-C, Boundaries of orbit. Axial A, sagittal B, and coronal C, views, (A, anterior; L, lateral; M, medial; P, posterior; I, inferior; S, superior).
Amin et al. Do Racial Differences in Orbital Volume Influence. J Oral Maxillofac Surg 2022.
124 RACIAL DIFFERENCES IN ORBITAL VOLUME

OV of AA female subjects is less than that of Cauca-

FIGURE 2. Computed 3-dimensional reconstruction of left orbit
(red arrow: anterior orbital boundary, yellow arrow: posterior
orbital boundary) (Color version of the figure is available online.).
Amin et al. Do Racial Differences in Orbital Volume Influence. J
Oral Maxillofac Surg 2022.
were included in the study. Thirty subjects were
male, and 30 subjects were female. Inter-rater reliabil-
ity was calculated and found to be excellent at 0.973
(CI [0.90 to 0.99], P value <.0001).
The mean OV of AA and Caucasian subjects
was 22.38 cm3 (§3.76) and 23.23 cm3, (§3.58),
respectively (P = .07).
The mean OV of AA and Caucasian males was 23.92
cm3 (§3.41) and 24.17 cm3 (§4.00),
respectively (P = .71). The mean OV of AA and Cauca-
sian females was 20.83 cm3 (§3.46 cm3 and 22.28
cm3 (§2.84), respectively (P = .013). (Table 2).
The mean OV for left and right orbits was 22.87
cm3 (§3.52) and 22.73 cm3 (§3.86), respectively
(P = .77). (Table 2)
Discussion
The purpose of this study was to calculate OV in AA
subjects. The results of this study show that the mean
sians whereas the mean OV in AA and Caucasian male
subjects appears to be similar.
Post-traumatic enophthalmos and dystopia is a
major complication that can develop after orbital
fracture(s).40 An increase of OV,41,42 orbital fat atro-
phy,41 and scarring of intraorbital soft tissue appear
to be the main mechanisms of post-traumatic enoph-
thalmous and dystopia.40,43 Previous studies have
shown that computer-assisted surgical planning
(CASP) and patient-specific implants (PSI) are the
most reliable method to ensure accurate OV
restoration.1,17,44 The ability to restore OV accurately
requires determining the pre-trauma volume. This is
relatively straightforward when the injury is unilat-
eral as the non−injured orbit can be used to calcu-
late the OV. When the injury is bilateral, surgeons
must rely on pre-injury CT scans, if available, or use
racial and gender specific norms. The findings from
this study provide a mean OV for AA males and
females that will allow correct determination of OV.
Interestingly, although the OV of Caucasian, and AA
males is similar, the OV of AA females is less than
that of Caucasian females. Previous studies have
shown differences between male and female OV
within several races with male OV being larger.20,45
Similarly, Japanese males have also been shown to
have larger OV than females.45 The findings from
this study appear to support current literature.20,45
The reasons for the differences in OV between gen-
ders is unclear. However, some studies hypothesized
that the differences are due to the loss of bone den-
sity as a result of menopausal osteoporosis.46 Studies
have found that perimenopausal women may lose up
to 0.3% of baseline bone mineral density (gram per
square centimeter) per year.46,47 While, older men
experience osteoporosis, studies have found that the
bone loss is far less in males when compared with
women.46-48 Another possible reason for the differen-
ces in OV between genders is the difference in bony
remodeling in response to soft tissue changes.49 In
females, fat, and muscle volume increases with age,

Table 2. MEAN ORBITAL VOLUME.

African Americans (n = 60 orbits) Caucasian (n = 60 orbits) P value and CI

Age 29.8 (4.8) 43.5 (15.4) <.0001 (-19.67 − [-7.73])

Gender 1.00
Male 30 (50.0) 30 (50.0)
Female 30 (50.0) 30 (50.0)
OV
All 22.38 cm3 23.23 cm3 .07 (-1.78 − 0.08)
Male 23.92 cm3 24.17 cm3 .71 (-1.59 − 1.09)
Female 20.83 cm3 22.28 cm3 .013 (-2.59 − [-0.31])
Amin et al. Do Racial Differences in Orbital Volume Influence. J Oral Maxillofac Surg 2022.
AMIN ET AL.
FIGURE 3. Suggested gender and race specific mean orbital vol-
ume (OV) for Caucasian and African-Americans.
Amin et al. Do Racial Differences in Orbital Volume Influence. J
Oral Maxillofac Surg 2022.
whereas only fat volume increases in males.20 This
results in more bony remodeling in females.20,46
Previous studies have shown comparable OV
between the right and left orbits in the same
race.9,20,31 This has been reported for several racial
groups including Caucasian,9,20,31 Turkish,50 Taiwa-
nese28 and Chinese subjects.26 However, other stud-
ies have reported intra-individual volume differences
in the normal orbits, which can be 0.8 cm3 between
sides.9,50 Unilateral orbital wall fractures (floor and/or
medial wall) presents little challenge for any race as it
can be predictably restored using the OV of the con-
tralateral uninjured orbit (mirroring).42
Bilateral orbital wall fractures are (floor and/or medial
wall) often associated with other facial fractures (ie,
naso-ethmoidal (NOE), zygomatico-maxillary complex
[ZMC], and/or Le-Fort II or III fractures). Additionally,
high energy trauma (ie, firearm injuries) will increase
the complexity of reconstruction due to the loss orbital
rim continuity, and contour. OV in such cases can be
more challenging given the inability to calculate a
patient specific OV. In these situations, it becomes
important to use norms that are on the basis of race,
and gender. The results of this study suggest that the
ideal OV for reconstruction is smaller in AA females
when compared with Caucasian females. This should
be taken into consideration to reduce the likelihood of
inadvertent enophthalmos or orbital dystopia. (Fig 3)
Another utilization of racial-specific OV is forensic
and anthropological investigations.51
Recognizing racial norms in OV can help to esti-
mate the race of deceased persons.
There are some limitations to our study. As this was
the first study to calculate OV in AA patients, we
were not able to compare our values to previous stud-
ies. It is also possible that some patients had mixed
racial backgrounds despite self-declaring their race as
125
AA or Caucasian. This is a potential confounder that
may have led to an over or underestimated OV in AA
depending on their actual racial background.
In conclusion, AA female subjects appear to have a
smaller OV when compared with Caucasian females.
References
1. Novelli G, Tonellini G, Mazzoleni F, Bozzetti A, Sozzi D: Virtual
surgery simulation in orbital wall reconstruction: integration of
surgical navigation and stereolithographic models. J Cranio-
maxillofac Surg 42:2025-2034, 2014
2. Ahn HB, Ryu WY, Yoo KW, et al. Prediction of enophthalmos
by computer-based volume measurement of orbital fractures in
a Korean population. Ophthalmic Plast Reconstr Surg 24:36-
39, 2008
3. Andrades P, Cuevas P, Hern
andez R, Danilla S, Villalobos R:
Characterization of the orbital volume in normal population. J
Cranio-Maxillofac Surg 46:594-599, 2018
4. Bite U, Jackson IT, Forbes GS, Gehring DG: Orbital volume
measurements in enophthalmos using three-dimensional CT
imaging. Plast Reconstr Surg 75:502-508, 1985
5. Neuschwander TB, Chang EL, Sadun AA: Hertel curve: orbital
volume increment and proptosis in a cadaver model. Ophthal-
mic Plast Reconstr Surg 21:431-434, 2005
6. Bell RB, Markiewicz MR: Computer-assisted planning, stereoli-
thographic modeling, and intraoperative navigation for com-
plex orbital reconstruction: a descriptive study in a
preliminary cohort. J Oral Maxillofac Surg 67:2559-2570, 2009
7. Raskin EM, Millman AL, Lubkin V, della Rocca RC, Lisman RD,
Maher EA: Prediction of late enophthalmos by volumetric anal-
ysis of orbital fractures. Ophthalmic Plast Reconstr Surg 14:19-
26, 1998
8. Whitehouse RW, Batterbury M, Jackson A, Noble JL: Prediction
of enophthalmos by computed tomography after 'blow out'
orbital fracture. Br J Ophthalmol 78:618-620, 1994
9. Tandon R, Aljadeff L, Ji S, Finn RA: Anatomic variability of the
human orbit. J Oral Maxillofac Surg 78:782-796, 2020
10. Glassman RD, Manson PN, Vanderkolk CA, et al. Rigid fixation
of internal orbital fractures. Plast Reconstr Surg 86:1103-1109,
1990
11. Scawn RL, Lim LH, Whipple KM, et al. Outcomes of orbital
blow-out fracture repair performed beyond 6 weeks after
injury. Ophthalmic Plast Reconstr Surg 32(4):296-301, 2016
12. Jazayeri HE, Khavanin N, Yu JW, et al. Does early repair of
orbital fractures result in superior patient outcomes? A system-
atic review and meta-analysis. J Oral Maxillofac Surg 78:568-
577, 2020
13. Burnstine MA: Clinical recommendations for repair of isolated
orbital floor fractures: an evidence-based analysis. Ophthalmol-
ogy 109:1207-1210, 2002
14. Kim BB, Qaqish C, Frangos J, Caccamese JF Jr: Oculocardiac reflex
induced by an orbital floor fracture: report of a case and review of
the literature. J Oral Maxillofac Surg 70:2614-2619, 2012
15. Manson PN, Grivas A, Rosenbaum A, Vannier M, Zinreich J, Iliff
N: Studies on enophthalmos: II. The measurement of orbital
injuries and their treatment by quantitative computed tomogra-
phy. Plast Reconstr Surg 77:203-214, 1986
16. Cole P, Boyd V, Banerji S, Hollier LH Jr: Comprehensive man-
agement of orbital fractures. Plast Reconstr Surg 120(7 Suppl
2):57s-63s, 2007
17. Schlittler F, Vig N, Burkhard JP, Lieger O, Michel C, Holmes S:
What are the limitations of the non-patient-specific implant in
titanium reconstruction of the orbit? Br J Oral Maxillofac Surg,
2020
18. Scolozzi P, Momjian A, Heuberger J, et al. Accuracy and
predictability in use of AO three-dimensionally preformed tita-
nium mesh plates for posttraumatic orbital reconstruction: a
pilot study. J Craniofac Surg 20:1108-1113, 2009
19. Gunarajah DR, Samman N: Biomaterials for repair of orbital
floor blowout fractures: a systematic review. J Oral Maxillofac
Surg 71:550-570, 2013
126
20. Regensburg NI, Wiersinga WM, van Velthoven ME, et al. Age
and gender-specific reference values of orbital fat and muscle
volumes in Caucasians. Br J Ophthalmol 95(12):1660-1663,
2011
21. Parsons GS, Mathog RH: Orbital wall and volume relationships.
Arch Otolaryngol 114:743-747, 1988
22. Regensburg NI, Kok PH, Zonneveld FW, et al. A new and vali-
dated CT-based method for the calculation of orbital soft tissue
volumes. Invest Ophthalmol Vis Sci 49:1758-1762, 2008
23. Ji Y, Qian Z, Dong Y, Zhou H, Fan X: Quantitative morphome-
try of the orbit in Chinese adults based on a three-dimensional
reconstruction method. J Anat 217:501-506, 2010
24. Ye J, Kook KH, Lee SY: Evaluation of computer-based volume
measurement and porous polyethylene channel implants in
reconstruction of large orbital wall fractures. Invest Ophthal-
mol Vis Sci 47:509-513, 2006
25. Sicurezza E, Palazzo G, Leonardi R: Three-dimensional comput-
erized tomographic orbital volume and aperture width evalua-
tion: a study in patients treated with rapid maxillary
expansion. Oral Surg Oral Med Oral Pathol Oral Radiol Endod
111:503-507, 2011
26. Chau A, Fung K, Yip L, Yap M: Orbital development in Hong
Kong Chinese subjects. Ophthalmic Physiol Opt 24:436-439,
2004
27. Acer N, Sahin B, Erg€ ur H, Basaloglu H, Ceri NG: Stereological
estimation of the orbital volume: a criterion standard study. J
Craniofac Surg 20:921-925, 2009
28. Shyu VB-H, Hsu C-E, Chen C-H, Chen C-T: 3D-assisted quantita-
tive assessment of orbital volume using an open-source soft-
ware platform in a Taiwanese population. PLoS One 10:
e0119589, 2015
29. Deveci M, Ozturk S, Sengezer M, Pabuscu Y: Measurement of
orbital volume by a 3-dimensional software program: an experi-
mental study. J Oral Maxillofac Surg 58:645-648, 2000
30. Koppel DA, Foy RH, McCaul JA, Logan J, Hadley DM, A Ayoub:
The reliability of "Analyze" software in measuring orbital vol-
ume utilizing CT-derived data. J Craniomaxillofac Surg 31:88-
91, 2003
31. Forbes G, Gehring DG, Gorman CA, Brennan MD, Jackson IT:
Volume measurements of normal orbital structures by computed
tomographic analysis. AJR Am J Roentgenol 145:149-154, 1985
32. P'An TH: Measurement of the Chinese orbit. J Anat 67:596-598,
1933
33. Alexander JC, Anderson JE, Hill JC: The determination of
orbital volume. Trans Can Opthalmolog Soc 24:105-111, 1961
34. Osaki TH, de Castro DK, Yabumoto C, et al. Comparison of
methodologies in volumetric orbitometry. Ophthalmic Plast
Reconstr Surg 29:431-436, 2013
35. Wi JM, Sung KH, Chi M: Orbital volume restoration rate after
orbital fracture'; a CT-based orbital volume measurement for
evaluation of orbital wall reconstructive effect. Eye (Lond)
31:713-719, 2017
RACIAL DIFFERENCES IN ORBITAL VOLUME
36. Wikipedia. Archimedes' principle. Accessed June 4, 2021.
https://en.wikipedia.org/wiki/Archimedes%27_principle
37. Yamauchi T, Yamazaki M, Okawa A, et al. Efficacy and reliabil-
ity of highly functional open source DICOM software (OsiriX)
in spine surgery. J Clin Neurosci 17:756-759, 2010
38. Kreshanti P, Bangun K: Computer aided volume measurement
using osirix, a free 3D-rendering software, in preplanned cor-
rection of enophthalmos with diced cartilage graft. J Plastik
Rekonstruksi 1:54-60, 2012
39. Sugiura K, Yamada H, Okumoto T, Inoue Y, Onishi S: Quantita-
tive assessment of orbital fractures in Asian patients: CT mea-
surement of orbital volume. J Craniomaxillofac Surg 45:1944-
1947, 2017
40. Zhang Z, Zhang Y, He Y, An J, Zwahlen RA: Correlation
between volume of herniated orbital contents and the amount
of enophthalmos in orbital floor and wall fractures. J Oral Max-
illofac Surg 70:68-73, 2012
41. Lee HB, Lee SH: A Straightforward method of predicting
enophthalmos in blowout fractures using enophthalmos esti-
mate line. J Oral Maxillofac Surg 74:2457-2464, 2016
42. Sn€all J, Narjus-Sterba M, Toivari M, Wilkman T, Thor
en H:
Does postoperative orbital volume predict postoperative
globe malposition after blow-out fracture reconstruction? A
6-month clinical follow-up study. Oral Maxillofac Surg
23:27-34, 2019
43. Harris GJ, Garcia GH, Logani SC, Murphy ML, Sheth BP, Seth
AK: Orbital blow-out fractures: correlation of preoperative
computed tomography and postoperative ocular motility.
Trans Am Ophthalmol Soc 96:329-353, 1998
44. Gander T, Essig H, Metzler P, et al. Patient specific implants
(PSI) in reconstruction of orbital floor and wall fractures. J Cra-
niomaxillofac Surg 43:126-130, 2015
45. Furuta M: Measurement of orbital volume by computed tomog-
raphy: especially on the growth of the orbit. Jpn J Ophthalmol
45:600-606, 2001
46. Ugradar S, Lambros V: Orbital volume Increases with age: a
computed tomography-based volumetric study. Ann Plast Surg
83:693-696, 2019
47. Bainbridge KE, Sowers MF, Crutchfield M, Lin X, Jannausch M,
Harlow SD: Natural history of bone loss over 6 years among
premenopausal and early postmenopausal women. Am J Epide-
miol 156:410-417, 2002
48. Cawthon PM, Shahnazari M, Orwoll ES, Lane NE: Osteoporosis
in men: findings from the osteoporotic fractures in men study
(MrOS). Ther Adv Musculoskelet Dis 8:15-27, 2016
49. Hadjidakis DJ, Androulakis II: Bone remodeling. Ann N Y Acad
Sci 1092:385-396, 2006
50. Ozyazgan I, Erdogan N, Sahin B: Stereologic orbital volume
measurements in zygomatic fractures. J Oral Maxillofac Surg
67:2605-2608, 2009
51. Lundy JK: Forensic anthropology: what bones can tell us. Labo-
ratory Med 29:423-427, 1998