Reconstruction of Post-traumatic Internal Orbital Wall Defects with Titanium Mesh

Matrixmidface Preformed Orbital Implants for Three-Dimensional Reconstruction of Orbital Floor and Medial Wall Fractures: A Prospective Clinical Study

Study Design

Prospective Interventional study.

Objective

To evaluate the efficiency of Matrixmidface preformed Orbital plates for three-dimensional reconstruction of orbital floor and medial wall fractures.

Methods

This prospective institutional clinical study was conducted on a group of 14 patients who underwent repair of orbital floor and medial wall fracture defects using Matrixmidface Preformed Orbital plates and open reduction and internal fixation of associated fractures. The following parameters were studied preoperative and postoperative enophthalmos, hypoglobus, orbital volume; correction of diplopia, intraoperative and postoperative complications.

Results

All 14 patients were males aged between 19 and 42 years. The most common mode of injury was found to be road traffic accidents (RTAs) followed by self-fall and trauma at workplace. Orbital fractures were associated with other concomitant maxillofacial fractures in 12 patients (85.7%) while 2 patients (14.3%) had pure blowout fractures. Significant improvement of enophthalmos was noted from preoperative period to 1 week, 6 weeks, and 6 months postoperatively (P value .02, .01, and .01, respectively). Out of 11 patients with preoperative hypoglobus, 5 patients (45.45%) had persistent hypoglobus in the immediate postoperative period which reduced to 4 patients (36.36%) at 6 weeks postoperatively (p value .00). The postoperative orbital volume of fractured side ranged from 20.3 cm3 to 26.76 cm3 with a mean of 23.50 cm3 ± 1.74. The mean difference between the volumes of the repaired and uninjured sides was found to be .27 cm3 ± .39 (P value .02) denoting that the reconstruction of the orbit closely approximated that of the uninjured side.

Conclusions

The Matrixmidface Preformed Orbital plate provides exceptional reconstruction of the orbital blowout fracture defects and ensures satisfactory results clinically and radiographically. The plate ensures an approximate recreation of topographical anatomy of the orbit and adequately restores the orbital volume. It provides adequate correction of asymmetry, hypoglobus, enophthalmos and attempts to restore eye movements, without causing any significant postoperative complication.

Ultra-High Molecular Weight Polyethylene (marPOR) is a Suitable Material for the Reconstruction of Orbital Floor Fracture Defects in Human Cadavers

Purpose

Despite there being different materials for orbital floor reconstruction available today, outcomes are still not satisfying. In recent years, ultra-high molecular weight polyethylene (UHMWPE) has gained popularity in the field of orthopedic surgery due to its good biocompatibility and low infection rate. With its three-dimensional compound structure, it combines high stability and ductility, making it a potential material to be used for orbital floor reconstruction.

Methods

In a cadaver study, an overall of eighteen orbits were included. Fractures of the inferior wall were induced and then reconstructed using Polyglactin 910/PDS composite (Ethisorb) and UHMWPE (marPOR). Orbits were scanned by cone-beam CT in each condition: Intact, fractured and reconstructed with Ethisorb, marPOR 0.85 mm and marPOR 1.5 mm. Segmented orbital volumes were calculated by specialized software (Disior bonelogic CMF).

Results

All materials led to sufficient reconstruction of the initial orbital volumes (Ethisorb: p < 0.001; marPOR 0.85 mm: p = 0.003; marPOR 1.5 mm: p < 0.001). Orbits that were reconstructed with marPOR 0.85 mm showed the least mean volume difference from intact orbital volumes.

Conclusion

UHMWPE (marPOR) offers reliable reconstruction of orbital floor fractures combined with good stability, ductility and biocompatibility.

Role of Navigation in Oral and Maxillofacial Surgery: A Surgeon's Perspectives

Surgeries related to the maxillofacial area deal with an intricate network of anatomical structures. With the complexity of the vital structures, it necessitates a surgical team to respect each anatomical boundary. In the past, there was an exceptionally high number of cases with surgical errors. These errors were not because of flaws in the surgeon’s skills or techniques but owing to lack of resources. Visualisation is one of the key factors that determines the precision of any surgical outcome. Advances in surgical planning have led to the introduction of a “Navigation” system that helps surgeons to see more, know more and ultimately do more for their patients. The usefulness of the navigation system in oral surgeries has been indicated by its surgical applications in craniomaxillofacial trauma, orthognathic surgeries, head and neck pathological resections, complex skull base surgeries and surgery involving temporomandibular joint. A vast majority of research literature has suggested remarkable improvement in surgical outcomes under the guidance of 3d planning and navigation. However, with such an inordinate advancement, financial expenses and a gradual learning curve are always a constraining factor in surgical navigation. This article overviews indication of navigation in craniofacial surgeries with a focus on applied aspect, planning and solution to the future problem.

Transnasal Endoscopic Approach for the Treatment of Medial Orbital Wall Fractures

The aim of this study is to report a case series of blowout fractures of the medial orbital wall that were treated endoscopically. Isolated fractures of the medial orbital wall are uncommon and can be asymptomatic. Various surgical methods for repairing medial orbital wall fractures have been described. The standard approach for the treatment of medial orbital wall fractures is the transcutaneous approach or the transconjunctival with retrocaruncular approach. In the last years, the attention on the use of minimally invasive techniques such as transnasal endoscopic approach is growing. This was a retrospective study of six cases completely managed endoscopically. In the presented case series, the endoscopic endonasal approach represented a safe and effective procedure for the reduction of medial wall orbital fractures.

Cost Analysis of Implants in the Surgical Repair of Orbital Floor Fractures

OBJECTIVE

Options for the management of orbital floor fractures continue to evolve offering both potential advantages as well as higher costs. To date, the effect of implant choice on the cost associated with the repair of orbital floor fractures has not been studied.

METHODS

A retrospective review at a tertiary care, level I trauma center examining all adult, uncomplicated orbital floor fractures that underwent open reduction and internal fixation from 2013 to 2016. Patients with concurrent operative facial fractures were excluded. The main outcomes were overall cost of care from injury to last follow-up and operating room-related costs. Costs were determined using computerized records of charges as well as the hospital Charge Description Master. Kruksal-Wallis rank sum tests were used to analyze for differences between groups.

RESULTS

Twenty-eight patients fulfilled the inclusion criteria. Eight different stock, non-patient specific, implants were used for repair. The cost of individual types of implants ranged from $70.25 to $7 718.00. Total cost of care per patient across all implant types averaged $35 585.57 (range $25 586.26 to $49 985.74, P = .34). Operation-related charges accounted for the vast majority (94.4%) of the total cost of care. One complication occurred requiring operative re-positioning of the implant with an additional $13 042.41 in charges.

CONCLUSIONS

In the setting of uncomplicated orbital floor fractures, surgeons should select an implant that allows them to carry out the repair in a safe, timely fashion. Additional large-scale studies would help to further delineate cost differences.

Periorbital Reconstruction by "Periorbital Patch" Technique Using a Pericardium-Based Collagen Membrane and Titanium Mesh

OBJECTIVE

Titanium mesh is a commonly used material for the reconstruction of orbital floor fractures. However, in some instances, a subsequent inflammatory reaction can occur that causes the adhesion of orbital tissue to the titanium mesh. The adhesion of the orbital soft tissue to the mesh causes diplopia, lid rigidity and extraocular movements restriction. This study was performed to determine if the placement of a collagen membrane over a titanium mesh can prevent the adhesion of orbital soft tissue for an improved clinical outcome. Clinical considerations: A case study was performed investigating 106 patients undergoing a periorbital restoration. Seventy-two patients received a titanium mesh without a barrier membrane, 12 patients received a barrier membrane composed of autologous auricular cartilage to provide a barrier function and 22 patients received a pericardium collagen membrane and titanium mesh.

CONCLUSIONS

Titanium has been shown to generate an intense inflammatory reaction in host tissues, which can cause fibrosis to adjacent structures. Fibrosis is an essential factor in the repair of fracture sites, however this can lead to adverse effects in the orbital socket. Fibrosis can cause cicatrization and lower eyelid retraction when induced along the lower orbital rim. An improved outcome can be achieved by using a barrier between the titanium mesh and the soft tissue, such as autogenous auricular cartilage, however, only patients treated with a resorbable collagen membrane to act as a soft tissue barricade during site regeneration, prevented the fibrosis reaction and related problems from occurring.

Repair of Orbital Post-Traumatic Wall Defects by Custom-Made TiNi Mesh Endografts

Repairs of orbital post-traumatic and extensive malignant defects remain a major surgical challenge, in view of follow-up outcomes. Incorrect surgical management of injured facial structures results in cosmetic, ophthalmic, and social aftereffects. A custom-made knitted TiNi-based mesh (KTNM) endograft was employed to overcome post-surgical complications and post-resected lesions of the orbital area. Preoperative high-resolution computed tomography (CT) imaging and CAD modelling were used to design the customized KTNM in each case. Twenty-five patients underwent surgery utilizing the suggested technique, from 2014 to 2019. In all documented cases, resolution of the ophthalmic malfunction was noted in the early period. Follow-up observation evidenced no relapsed enophthalmos, hypoglobus, or diplopia as late complications. The findings emanating from our clinical observations allow us to claim that the KTNM indicated a high level of biocompatibility. It is simply modified intraoperatively to attach any desired shape/size for implantation and can also be screw-fixed, providing a good supporting ability. The KTNM precisely renders orbitozygomatic outlines and orbital floor, thus recovering the anatomical structure, and is regarded as an attractive alternative to Ti-based meshes and plates. Additionally, we report one of the studied cases, where good functional and cosmetic outcomes have been achieved.

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

The bony naso-orbital-ethmoid (NOE) complex is a 3-dimensional delicate anatomic structure. Damages to this region may result in severe facial dysfunction and malformation. The management and optimal surgical treatment strategies of NOE fractures remain controversial. For a patient with NOE trauma, doctors should perform comprehensive clinical examination and radiographic analysis to assess the type and extent of fracture. The results of assessment will assist doctors to make a patientspecific program for the sake of reducing post-operation complications and restoring normal appearance and function as much as possible. This review focuses on the advancement of management of NOE fractures including symptoms, classifications, diagnosis, approaches, treatment and new techniques in this field.