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Sivam A, Enninghorst N. The Dilemma of Reconstructive Material Choice for Orbital Floor Fracture: A Narrative Review. MEDICINES 2022; 9:medicines9010006. [PMID: 35049939 PMCID: PMC8778999 DOI: 10.3390/medicines9010006] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/04/2021] [Revised: 01/06/2022] [Accepted: 01/10/2022] [Indexed: 11/26/2022]
Abstract
The aim of this study is to present a narrative review of the properties of materials currently used for orbital floor reconstruction. Orbital floor fractures, due to their complex anatomy, physiology, and aesthetic concerns, pose complexities regarding management. Since the 1950s, a myriad of materials has been used to reconstruct orbital floor fractures. This narrative review synthesises the findings of literature retrieved from search of PubMed, Web of Science, and Google Scholar databases. This narrative review was conducted of 66 studies on reconstructive materials. Ideal material properties are that they are resorbable, osteoconductive, resistant to infection, minimally reactive, do not induce capsule formation, allow for bony ingrowth, are cheap, and readily available. Autologous implants provide reliable, lifelong, and biocompatible material choices. Allogenic materials pose a threat of catastrophic disease transmission. Newer alloplastic materials have gained popularity. Consideration must be made when deliberating the use of permanent alloplastic materials that are a foreign body with potential body interactions, or the use of resorbable alloplastic materials failing to provide adequate support for orbital contents. It is vital that surgeons have an appropriate knowledge of materials so that they are used appropriately and reduce the risks of complications.
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Affiliation(s)
- Akash Sivam
- Oral and Maxillofacial Surgery Department, Royal Hobart Hospital, Hobart, TAS 7000, Australia
- Correspondence: ; Tel.: +61-43-322-9835
| | - Natalie Enninghorst
- School of Medicine and Public Health, Faculty of Health and Medicine, University of Newcastle, Callaghan, NSW 2308, Australia;
- Royal Newcastle Centre, John Hunter Hospital, Newcastle, NSW 2310, Australia
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Guillaume O, Geven MA, Varjas V, Varga P, Gehweiler D, Stadelmann VA, Smidt T, Zeiter S, Sprecher C, Bos RRM, Grijpma DW, Alini M, Yuan H, Richards GR, Tang T, Qin L, Yuxiao L, Jiang P, Eglin D. Orbital floor repair using patient specific osteoinductive implant made by stereolithography. Biomaterials 2019; 233:119721. [PMID: 31954958 DOI: 10.1016/j.biomaterials.2019.119721] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Revised: 12/20/2019] [Accepted: 12/20/2019] [Indexed: 12/11/2022]
Abstract
The orbital floor (OF) is an anatomical location in the craniomaxillofacial (CMF) region known to be highly variable in shape and size. When fractured, implants commonly consisting of titanium meshes are customized by plying and crude hand-shaping. Nevertheless, more precise customized synthetic grafts are needed to meticulously reconstruct the patients' OF anatomy with better fidelity. As alternative to titanium mesh implants dedicated to OF repair, we propose a flexible patient-specific implant (PSI) made by stereolithography (SLA), offering a high degree of control over its geometry and architecture. The PSI is made of biodegradable poly(trimethylene carbonate) (PTMC) loaded with 40 wt % of hydroxyapatite (called Osteo-PTMC). In this work, we developed a complete work-flow for the additive manufacturing of PSIs to be used to repair the fractured OF, which is clinically relevant for individualized medicine. This work-flow consists of (i) the surgical planning, (ii) the design of virtual PSIs and (iii) their fabrication by SLA, (iv) the monitoring and (v) the biological evaluation in a preclinical large-animal model. We have found that once implanted, titanium meshes resulted in fibrous tissue encapsulation, whereas Osteo-PMTC resulted in rapid neovascularization and bone morphogenesis, both ectopically and in the OF region, and without the need of additional biotherapeutics such as bone morphogenic proteins. Our study supports the hypothesis that the composite osteoinductive Osteo-PTMC brings advantages compared to standard titanium mesh, by stimulating bone neoformation in the OF defects. PSIs made of Osteo-PTMC represent a significant advancement for patients whereby the anatomical characteristics of the OF defect restrict the utilization of traditional hand-shaped titanium mesh.
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Affiliation(s)
- Olivier Guillaume
- AO Research Institute Davos, Clavadelerstrasse 8, CH 7270, Davos, Switzerland
| | - Mike A Geven
- MIRA Institute for Biomedical Engineering and Technical Medicine, Department of Biomaterials Science and Technology, University of Twente, P.O. Box 217, 7500, AE Enschede, the Netherlands
| | - Viktor Varjas
- AO Research Institute Davos, Clavadelerstrasse 8, CH 7270, Davos, Switzerland
| | - Peter Varga
- AO Research Institute Davos, Clavadelerstrasse 8, CH 7270, Davos, Switzerland
| | - Dominic Gehweiler
- AO Research Institute Davos, Clavadelerstrasse 8, CH 7270, Davos, Switzerland
| | | | - Tanja Smidt
- AO Research Institute Davos, Clavadelerstrasse 8, CH 7270, Davos, Switzerland
| | - Stephan Zeiter
- AO Research Institute Davos, Clavadelerstrasse 8, CH 7270, Davos, Switzerland
| | - Christoph Sprecher
- AO Research Institute Davos, Clavadelerstrasse 8, CH 7270, Davos, Switzerland
| | - Ruud R M Bos
- University Medical Center Groningen, Groningen, the Netherlands
| | - Dirk W Grijpma
- MIRA Institute for Biomedical Engineering and Technical Medicine, Department of Biomaterials Science and Technology, University of Twente, P.O. Box 217, 7500, AE Enschede, the Netherlands
| | - Mauro Alini
- AO Research Institute Davos, Clavadelerstrasse 8, CH 7270, Davos, Switzerland
| | - Huipin Yuan
- - Xpand Biotechnology BV, Professor Bronkhorstlaan 10-d, 3723, MB Bilthoven, the Netherlands
| | - Geoff R Richards
- AO Research Institute Davos, Clavadelerstrasse 8, CH 7270, Davos, Switzerland
| | - Tingting Tang
- Shanghai Key Laboratory of Orthopaedic Implants, Department of Orthopaedic Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai, China
| | - Ling Qin
- Innovative Orthopaedic Biomaterial and Drug Translational Research Laboratory of Li Ka Shing Institute of Health, Department of Orthopaedics and Traumatology, The Chinese University of Hong Kong, Hong Kong, China
| | - Lai Yuxiao
- Innovative Orthopaedic Biomaterial and Drug Translational Research Laboratory of Li Ka Shing Institute of Health, Department of Orthopaedics and Traumatology, The Chinese University of Hong Kong, Hong Kong, China
| | - Peng Jiang
- General Hospital of People's Liberation Army- Beijing 301 Hospital, Beijing, China
| | - David Eglin
- AO Research Institute Davos, Clavadelerstrasse 8, CH 7270, Davos, Switzerland.
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Abstract
BACKGROUND Orbital fractures are one of the most common sequelae of facial trauma. OBJECTIVE The objective of this study was to summarize published data for resorbable implants in orbital reconstruction, including polymer composition, degradation characteristics, osteoconductivity, and complications such as enophthalmos, diplopia, and peri-implant inflammation. A literature search of the National Library of Medicine was performed via PubMed using the keyword resorbable orbital implant. A total of 27 studies were reviewed. Strength of data was assessed according to the Oxford Centre criteria. RESULTS Most commercially available implants provide adequate tensile strength for up to 6 months (with the exception of polydioxanone, which loses strength within 1 month, and poly(D,L-lactide) within 3 months). This is sufficient for the isolated orbital floor or medial wall (tensile strength, ~300 MPa) but insufficient for reconstruction of load-bearing areas (eg, the inferior orbital rim with tensile strength of ~1.2 GPa). Thicker products (>1 mm) have increased risk for delayed inflammation than thinner products. Postoperative complications including delayed inflammation (0%-9%), eyelid malposition (0%-5%), enophthalmos (5%-16%), diplopia (0%-16%), infection (0%-2%), and infraorbital nerve hypesthesia (2%-18%) are variably distributed across implants with several notable exceptions: poly(L-lactide) has an increased risk of delayed inflammation, and polydioxanone has a risk of delayed enophthalmos and hematoma. CONCLUSIONS Resorbable implants are suitable for isolated medial wall or floor fractures with intact bony buttresses and function as a barrier rather than a load-bearing support.
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Abstract
Orbital floor injuries, alone or combination with other facial fractures, are one of the most commonly encountered midface fractures. Techniques for orbital reconstruction have migrated away from autogenous bone grafts to well-tolerated alloplasts, such as titanium and Medpor. Material for reconstructing the orbit can then be selected based on requirements of the defect matched to the mechanical properties of the material. Material selection is largely and ultimately dependent upon surgeon preference.
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Biomaterials and implants for orbital floor repair. Acta Biomater 2011; 7:3248-66. [PMID: 21651997 DOI: 10.1016/j.actbio.2011.05.016] [Citation(s) in RCA: 87] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2011] [Revised: 04/19/2011] [Accepted: 05/16/2011] [Indexed: 11/23/2022]
Abstract
Treatment of orbital floor fractures and defects is often a complex issue. Repair of these injuries essentially aims to restore the continuity of the orbital floor and to provide an adequate support to the orbital content. Several materials and implants have been proposed over the years for orbital floor reconstruction, in the hope of achieving the best clinical outcome for the patient. Autografts have been traditionally considered as the "gold standard" choice due to the absence of an adverse immunological response, but they are available in limited amounts and carry the need for extra surgery. In order to overcome the drawbacks related to autografts, researchers' and surgeons' attention has been progressively attracted by alloplastic materials, which can be commercially produced and easily tailored to fit a wide range of specific clinical needs. In this review the advantages and limitations of the various biomaterials proposed and tested for orbital floor repair are critically examined and discussed. Criteria and guidelines for optimal material/implant choice, as well as future research directions, are also presented, in an attempt to understand whether an ideal biomaterial already exists or a truly functional implant will eventually materialise in the next few years.
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Lieger O, Schaller B, Zix J, Kellner F, Iizuka T. Repair of Orbital Floor Fractures Using Bioresorbable Poly-L/DL-Lactide
Plates. ACTA ACUST UNITED AC 2010. [DOI: 10.1001/archfaci.2010.91] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Affiliation(s)
- Olivier Lieger
- Department of Cranio-Maxillofacial Surgery, Cantonal Hospital Lucerne, Lucerne, Switzerland (Dr Lieger); and Departments of Cranio-Maxillofacial Surgery (Drs Schaller, Zix, and Iizuka) and Radiology (Dr Kellner), University Bern, University Hospital, Bern, Switzerland
| | - Benoit Schaller
- Department of Cranio-Maxillofacial Surgery, Cantonal Hospital Lucerne, Lucerne, Switzerland (Dr Lieger); and Departments of Cranio-Maxillofacial Surgery (Drs Schaller, Zix, and Iizuka) and Radiology (Dr Kellner), University Bern, University Hospital, Bern, Switzerland
| | - Jürgen Zix
- Department of Cranio-Maxillofacial Surgery, Cantonal Hospital Lucerne, Lucerne, Switzerland (Dr Lieger); and Departments of Cranio-Maxillofacial Surgery (Drs Schaller, Zix, and Iizuka) and Radiology (Dr Kellner), University Bern, University Hospital, Bern, Switzerland
| | - Frauke Kellner
- Department of Cranio-Maxillofacial Surgery, Cantonal Hospital Lucerne, Lucerne, Switzerland (Dr Lieger); and Departments of Cranio-Maxillofacial Surgery (Drs Schaller, Zix, and Iizuka) and Radiology (Dr Kellner), University Bern, University Hospital, Bern, Switzerland
| | - Tateyuki Iizuka
- Department of Cranio-Maxillofacial Surgery, Cantonal Hospital Lucerne, Lucerne, Switzerland (Dr Lieger); and Departments of Cranio-Maxillofacial Surgery (Drs Schaller, Zix, and Iizuka) and Radiology (Dr Kellner), University Bern, University Hospital, Bern, Switzerland
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Gosau M, Schöneich M, Draenert FG, Ettl T, Driemel O, Reichert TE. Retrospective analysis of orbital floor fractures--complications, outcome, and review of literature. Clin Oral Investig 2010; 15:305-13. [PMID: 20165966 DOI: 10.1007/s00784-010-0385-y] [Citation(s) in RCA: 100] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2009] [Accepted: 01/20/2010] [Indexed: 01/03/2023]
Abstract
This retrospective study aimed at investigating indications, surgical approaches, and the materials used for orbital floor reconstructions, as well as the clinical follow-up, particularly with regard to postoperative complications. This study comprised 189 patients who underwent surgery for fractures of the orbital floor between 2003 and 2007. Diagnosis and treatment were based on both physical examination and computed tomography scan of the orbit. Patients were retrospectively analyzed for data, such as mechanism of injury, classification of fracture, and complications. The most common cause of injury was physical assault followed by traffic accidents. Surgery was conducted with a mean delay of 2.9 days after the incident. Mid lower eyelid incision was the most common surgical approach to the orbital floor. For orbital floor reconstruction, polydioxanone sheets (70.5%) were mainly used, followed by Ethisorb Dura (23.3%) and titanium mesh (6.2%). There were 19.0% of patients who showed postoperative complications: 5.8% suffered from persisting motility impairment, 3.7% from enophthalmos, 3.2% from consistent diplopia, 2.6% from ectropion, and 0.5% from orbital infection. Intraorbital hematoma (3.2%) represented the most severe complications, one patient suffered lasting impairment of sight and another one, complete blindness of the affected eye. If postoperative impairment of vision becomes evident, immediate surgical intervention is mandatory. Retrobulbar hematoma is more likely to occur in heavily traumatized patients with comminuted fractures and also in patients taking anticoagulative medication. The subciliary approach to the orbit and repeated operations by the same approach are associated with a higher risk of developing ectropion.
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Affiliation(s)
- Martin Gosau
- Department of Oral and Maxillofacial Surgery, University Medical Center Regensburg, 93042 Regensburg, Germany.
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Affiliation(s)
- Jason K Potter
- University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390-9109, USA
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Ellis E, Messo E. Use of nonresorbable alloplastic implants for internal orbital reconstruction. J Oral Maxillofac Surg 2004; 62:873-81. [PMID: 15218569 DOI: 10.1016/j.joms.2003.12.025] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Edward Ellis
- University of Texas Southwestern Medical Center, Dallas, TX 75390-9109, USA.
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Rohner D, Hutmacher DW, Cheng TK, Oberholzer M, Hammer B. In vivo efficacy of bone-marrow-coated polycaprolactone scaffolds for the reconstruction of orbital defects in the pig. J Biomed Mater Res B Appl Biomater 2003; 66:574-80. [PMID: 12861610 DOI: 10.1002/jbm.b.10037] [Citation(s) in RCA: 134] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Alloplastic materials offer a number of advantages over bone autografts in the reconstruction of craniofacial defects. These include: lack of donor site morbidity, unlimited quantities of available material, and the possibility to conform exactly to the defect. An ideal bioresorbable material would degrade slowly, and have osteoconductive properties to allow replacement and remodeling by osseous tissue. This is seldom observed, the materials instead being replaced by fibrous tissue. Polycaprolactone (PCL), an FDA-approved bioresorbable polymer, has several properties that might make it suitable for reconstruction of craniofacial defects. The technique of fused deposition modeling (FDM) allows for the fabrication of highly reproducible bioresorbable 3D scaffolds. The nature of the fully interconnected pore network might enhance vascular ingrowth and osteoconductive properties. It was hypothesized that coating the scaffolds in bone marrow might enhance bone formation due to the osteoinductive nature of the bone-marrow mesenchymal cells. This study aimed to test these hypotheses in the pig model. Defects measuring 2 x 2 cm were surgically created in each orbit of eight Yorkshire pigs. The orbits were divided into three groups: Group 1 (n=4), no reconstruction (control); Group 2 (n=6), reconstruction with no coated PCL scaffolds; and Group 3 (n=6) reconstruction with bone-marrow-coated PCL scaffolds. The results were evaluated at 3 months by histological and histomorphometric analyses. The defects in Group 1 were covered with fibrous scar tissue. The shape of the reconstructed area was insufficient. The defects in Groups 2 and 3 were reconstructed correctly. In Group 2 the noncoated scaffolds showed 4.5% of new bone formation compared with 14.1% in Group 3, which is statistically significant (p<0.05). The entirely interconnected 3D polycaprolactone scaffold seems to be a promising material. It induces the bone ingrowth required for reconstructing craniofacial and orbital defects. Further long-term evaluations of these PCL scaffolds must be made in order to confirm these conclusions.
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Affiliation(s)
- Dennis Rohner
- Department of Plastic Surgery, Singapore General Hospital, Outram Road, Singapore 169608.
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