Treatment of orbital fractures: the case for reconstruction with autogenous bone

PDS Plate Versus Bone Graft in Orbital Floor Reconstruction: A Prospective Study to Identify the Better Alternative

The objective of this study is to compare the effect and outcome of orbital floor reconstruction with bone graft and PDS plate. A prospective cohort study was conducted at B J Medical College, Civil Hospital, Ahmedabad from 1st September 2013 to 28th February 2016 by the Department of Burns and Plastic Surgery on patients (N = 35) who reported with orbital floor fracture. Diplopia, enophthalmos, infection rate, hospital stay, and donor site complications were considered. The above variables were assessed as predictors of outcome in the management (PDS vs. bone graft). Inferential statistics was done by chi-square test. The significance level was kept at 5%. Follow-up of 35 patients (2 years), 26 male, and 9 females aged 26-65 years were made. Diplopia and enophthalmos were the main criteria's in the study and neither of them showed any statistical significance. Donor site morbidity was noted in 3 patients among the bone graft group which was managed conservatively. Both the bone graft and PDS plate in orbital floor reconstruction is comparable in almost all aspects of our study. No statistically significant differences were found between the two groups. Pain and wound site infection are possible complications when a bone graft is used as the reconstructive option.

A Consistent, Reliable Landmark to Assist in Placement of Orbital Floor Reconstruction Plates After Blowout Fractures

OBJECTIVE

To define a reliable and consistent landmark, the superior posterior wall of the maxillary sinus, and to describe how this landmark can be used when repairing orbital floor fractures.

METHODS

Retrospective chart review. Patients >18 years old diagnosed with unilateral orbital floor and/or zygomaticomaxillary complex fractures.

MAIN OUTCOMES

The distance from the inferior orbital rim to the superior posterior wall of the maxillary sinus (landmark distance), and the distance from the landmark to the entrance of the optic canal were reported.

RESULTS

Eighty patients were included in the study. Each had unilateral isolated orbital floor fractures (n = 46) or unilateral zygomaticomaxillary complex fractures with an orbital floor component (n = 34). The contralateral eye in all patients was uninjured, and was used as an internal control. In orbital floor fractures, the mean landmark distance was 38.8 ± 1.4 mm, with a mean distance on the normal side of 38.8 ± 1.6 mm (P = 0.49). Distance to the optic canal on the injured side in isolated orbital floor fracture patients was 9.0 ± 0.8 mm with the same measurement on the normal side being 8.8 ± 0.7 (P = 0.21). In the setting of zygomaticomaxillary complex fracture, the orbital floor length was 38.2 ± 1.3 mm with a mean normal floor length of 37.8 ± 1.1 mm (P = 0.18). The mean distance from the superior posterior wall to optic canal in zygomaticomaxillary complex fractured orbits was 9.2 ± 1.1 mm with a normal side mean length of 9.5 ± 1.0 mm (P = 0.23). No significant difference was found between the measured distances in the fractured orbit and its normal counterpart for both fracture groups.

CONCLUSIONS AND RELEVANCE

The superior posterior wall of the maxillary sinus is a reliable landmark that can be used to assist in placement of an orbital floor reconstructive plate. The landmark is unchanged despite the presence of an orbital floor or zygomaticomaxillary sinus fracture.

Combined Endoscopic and Trans Palpebral Orbital Reconstruction for Silent Sinus Syndrome

Silent Sinus Syndrome is defined as a painless spontaneous and progressive enophthalmos and hypoglobus with maxillary sinus hypoplasia and orbital floor resorption. It is caused by maxillary sinus atelectasis in a setting of ipsilateral chronic maxillary sinus hypoventilation. The syndrome was first described in 1964 by Montgomery, but the term "Silent Sinus Syndrome" was not coined until 1994 by Soparkar. The aetiology is still controversial: some authors postulate a basal hypoplastic sinus, other suggest an acquired process due to an obstruction of the ostium in the medium meatus. Silent Sinus Syndrome presents in the third to fifth decades of life, very rarely in childhood with no gender predilection and it is usually a unilateral disorder. The symptoms are not shown to be related to chronic sinuses disease. The clinical signs are: enophthalmos, hypoglobus, upper lid retraction secondary to dystopia of the globe, sinking of the eye and orbital asymmetry, deepened upper lid sulcus, disappearance of the palpebral fold line, lagophthalmos, vertical diplopia, malar depression, and facial asymmetry. Extraocular muscle function is generally preserved and usually there is no visual impairment. The diagnosis is confirmed by computed tomography scan of the orbits and paranasal sinuses. The treatment consists of orbital reconstruction and functional rehabilitation of the maxillary sinuses.

Effects of low-level laser therapy on autogenous bone graft stabilized with a new heterologous fibrin sealant

Autogenous bone grafts are used to repair bone defects, and the stabilization is needed for bone regeneration. Laser photobiomodulation is a modality of treatment in clinical practice for tissue regeneration, and it has therapeutic effects as an anti-inflammatory, analgesic and modulating cellular activity. The aim of the present study was to evaluate the effects of low-level laser therapy (LLLT) on an autogenous bone graft integration process stabilized with a new heterologous fibrin sealant. Forty rats were divided into two groups: Autogenous Fibrin Graft (AFG, n=20), in which a 5mm dome osteotomy was conducted in the right parietal bone and the graft was adhered to the left side using fibrin sealant; and Autogenous Fibrin Graft Laser (AFGL, n=20), which was subjected to the same procedures as AFG with the addition of LLLT. The treatment was performed immediately following surgery and then three times a week until euthanasia, using an 830nm laser (30mW, 6J/cm(2), 0.116cm(2), 258.6mW/cm(2), 2.9J). Five animals from each group were euthanized at 10, 20, 30 and 40days postoperative, and the samples were submitted to histomorphological and histomorphometric analysis. Partial bone regeneration occurred, with new bone tissue integrating the graft to the recipient bed and small areas of connective tissue. Comparative analysis of the groups at the same intervals revealed minor interfaces in group AFGL, with statistically significant differences (p<0.05) at all of the analyzed intervals (10days p=0.0087, 20days p=0.0012, 30days p<0.0001, 40days p=0.0142). In conclusion, low-level laser therapy stimulated bone regeneration and accelerated the process of integration of autogenous bone grafts.

Inaugural Survey on Practice Patterns of Orbital Floor Fractures for American Oral and Maxillofacial Surgeons

PURPOSE

In recent years, several studies have reported on practitioners' preferences for the treatment of orbital floor fractures, showing widely varying practice patterns. The purpose of the present study was to identify the practice patterns among oral and maxillofacial surgeons involved in the management of orbital floor fractures in the United States and compare them with the available published data.

MATERIALS AND METHODS

An anonymous survey was created and electronically mailed to surgeons. We also reviewed the published data on orbital floor fractures using a PubMed and MEDLINE search. The responses to the survey were analyzed using descriptive statistics.

RESULTS

The factors that had the greatest influence on the surgeon's decision to operate were a defect size > 2 cm2, enophthalmos, entrapment, and persistent diplopia. The most common surgical approach reported was a preseptal transconjunctival approach (32.0%), followed by the subciliary (27.9%) and postseptal transconjunctival (26.2%) approaches. The most commonly reported implant for orbital reconstruction was titanium (65.4%), followed by Medpor (43.7%) and composite Medpor and titanium (26.4%). The review of the published data showed a consensus among many of the operative indications mentioned, including a large defect size, enophthalmos, clinical entrapment, and persistent diplopia.

CONCLUSIONS

Oral and maxillofacial surgeons in the United States have a wide range of practice habits in the management of orbital floor fractures. Although the quality of the available evidence is poor, it supports a consistent approach to the management of orbital floor fractures in terms of the indications and surgical approach. The choice of reconstructive material and timing of repair remain more controversial. A clear need exists for improvement in the available data to help guide and set standards of care for the specialties managing orbital floor fractures.

Reconstruction of Orbital Floor Fractures with Porous Polyethylene Implants: A Prospective Study

PURPOSE

The main aim of our study was to assess and evaluate the efficacy, long standing outcome and infection of porous polyethylene implants in treatment of orbital floor fractures.

PATIENT AND METHODS

Twelve patients with fractures of orbital floor were included in the study. The cause of fracture was road traffic accident, self fall and cow hit respectively. They also complained of enophthalmos (n = 9), diplopia (n = 3), restricted eye movement (n = 2), impairment of infraorbital nerve (n = 3) and dystopia (n = 6). All the fractures were reconstructed with thin porous polyethylene sheets.

RESULTS

No implants were extruded and there were no signs of inflammatory reactions against porous polyethylene implant. In all nine patients with pre-op enophthalmos it was corrected post-operatively with p value = 0.000 and was statistically significant; diplopia in one patient was corrected; persistence of double vision was noted in two patients. Restricted eye movement was corrected in all patients, dystopia was corrected in four patients and in two patients have persisting dystopia. Paresthesia persisted in all three patients.

CONCLUSION

Our experience was that reconstruction of orbital floor fracture using porous polyethylene implant is reliable, safe and effective and may be used for reconstruction of the orbital floor fracture with no donor site morbidity.

Reconstruction of Orbital Floor Fractures with Autogenous Bone Graft Application from Anterior Wall of Maxillary Sinus: A Retrospective Study

INTRODUCTION

Orbital wall fracture implies a situation where disruptions of the walls or floor have occurred. It is a blowout type fracture where bone fragments with torn periosteum are pushed outside of the original bony orbit. There is no intact bone even near the defect area except the thin bone rim surrounding the blowout fracture. The purpose of this defect repair is to support orbital contents, free entrapped tissue, and, especially, restore the original orbital volume.

MATERIAL AND METHODS

Ten patients (seven males and three females) who underwent repair of orbital floor factures with maxillary sinus bone grafts were included in this study. Surgical procedure for harvesting graft and its fixation was almost same in all operated cases.

CONCLUSION

The collection in the maxillary sinus due to fracture of floor of orbit, blood and bony fragments collected in the maxillary sinus can be easily drained and removed after removal of anterior wall of maxillary sinus and through the same approach you can reduce the floor of orbit manually to the proper position which helps to decease the orbital floor defect.

Management of pure medial orbital wall fracture with autogenous bone graft

The orbit is an irregular conical cavity formed from 7 bones including the frontal, sphenoid, zygomatic, maxillary, ethmoid, lacrimal, and palatine bones. Fractures of the internal orbit can cause a number of problems, including diplopia, ocular muscle entrapment, and enophthalmos. Although muscle entrapment is relatively rare, diplopia and enophthalmos are relatively common sequelae of internal orbital fractures. Medial orbital wall fracture is relatively uncommon and represents a challenge for its anatomical reconstruction. In this context, autogenous bone graft has been the criterion standard to provide framework for facial skeleton and orbital walls. Therefore, it is possible to harvest grafts of varying size and contour, and the operation is performed through the bicoronal incision, which is the usual approach to major orbital reconstruction. Thus, this article aimed to describe a patient with a pure medial orbital wall fracture, and it was causing diplopia and enophthalmos. The orbital fracture was treated using autogenous bone graft from calvarial bone. The authors show a follow-up of 12 months, with facial symmetry and without diplopia and enophthalmos. In addition, a computed tomography scan shows excellent bone healing at the anterior and posterior parts of the medial orbital wall reconstruction.

Comparison of Absorbable Mesh Plate versus Titanium-Dynamic Mesh Plate in Reconstruction of Blow-Out Fracture: An Analysis of Long-Term Outcomes

Background

A blow-out fracture is one of the most common facial injuries in midface trauma. Orbital wall reconstruction is extremely important because it can cause various functional and aesthetic sequelae. Although many materials are available, there are no uniformly accepted guidelines regarding material selection for orbital wall reconstruction.

Methods

From January 2007 to August 2012, a total of 78 patients with blow-out fractures were analyzed. 36 patients received absorbable mesh plates, and 42 patients received titanium-dynamic mesh plates. Both groups were retrospectively evaluated for therapeutic efficacy and safety according to the incidence of three different complications: enophthalmos, extraocular movement impairment, and diplopia.

Results

For all groups (inferior wall fracture group, medial wall fractrue group, and combined inferomedial wall fracture group), there were improvements in the incidence of each complication regardless of implant types. Moreover, a significant improvement of enophthalmos occurred for both types of implants in group 1 (inferior wall fracture group). However, we found no statistically significant differences of efficacy or complication rate in every groups between both implant types.

Conclusions

Both types of implants showed good results without significant differences in long-term follow up, even though we expected the higher recurrent enophthalmos rate in patients with absorbable plate. In conclusion, both types seem to be equally effective and safe for orbital wall reconstruction. In particular, both implant types significantly improve the incidence of enophthalmos in cases of inferior orbital wall fractures.

Management of zygomatic complex residual deformity due to war in Iraq

INTRODUCTION

Since March 20, 2003, maxillofacial surgeons in Iraq encounter several trauma cases, part of which are zygomatic residual deformities that result from conventional war, civil unrest, crimes, and car explosions. This study aimed to determine the relationship between etiological factors and severity of posttraumatic zygomatic residual deformity and to investigate methods of surgical repairs, treatment modalities, and any complications that may have occurred during this critical time in Iraq.

PATIENTS AND METHODS

There were a total of 40 patients with posttraumatic deformity of the zygoma included in this study. Records of these patients (29 men and 11 women) who have been treated in the maxillofacial unit of a specialized surgery hospital (Medical City Hospital, Baghdad) between 2006 and 2011 were collected.

RESULTS

Of all patients, 28 (70%) had injuries from missile whereas 12 patients (30%) had injuries from other causes (aggressive social behavior). According to the causes of delayed treatment, 30 patients (60%) were untreated previously (15 patients [50%] of them had delay because severe comminution, severe damage, or loss of the overlying soft tissue; 3 patients [10%] were undiagnosed; and 12 patients [40%] had treatment delayed as a result of major damage to other body parts or medical condition), 3 patients (30%) had improper reduction, and 7 patients (70%) had improper fixation. Our definitive treatment was as follows: 13 patients (32.5%) were treated by osteotomy, 10 patients (25%) were treated by onlay bone graft, 14 patients (35 %) were treated by both methods, and 3 patients (7.5%) were untreated.

CONCLUSIONS

[corrected] We recommend that every surgeon who deals with residual deformity should clinically evaluate the residual deformity.

Alpha-tricalcium phosphate cement in the reconstruction of bone defects in rats

PURPOSE

To evaluate the ability of a mixture of α-TCP and autogenous bone (AB) vs. α-TCP alone and AB alone to promote new bone formation and tissue repair in bone defects.

METHODS

Bone defects surgically created in 15 male Wistar rats were divided into four groups: Group I (AB), Group II (α-TCP), Group III (α-TCP+AB assessed by light microscopy), and Group IV (α-TCP+AB assessed by scanning electron microscopy). Bone repair findings were assessed at 30, 60, and 120 days postoperatively.

RESULTS

The histological findings obtained in Groups I (p=0.459), II (p=0.368), and III (p=0.459) and at 30 days (p=0.717), 60 days (p=0.717), and 120 days (p=0.779) did not show statistically significant differences. Scanning electron microscopy revealed direct contact between the α-TCP+AB implant and the bone tissue at 120 days.

CONCLUSION

The α-TCP implant is effective alternative bone substitutes for the treatment of critical size bone defects.

Traumatic orbital floor fractures: repair with autogenous bone grafts in a tertiary trauma center

PURPOSE

To evaluate the outcome of autologous bone grafts in the reconstruction of orbital floor fractures. A retrospective interventional case series was performed at a tertiary trauma center.

MATERIALS AND METHODS

All patients with traumatic orbital floor fractures that had been reconstructed using calvarial or iliac autogenous bone grafts from August 2006 to January 2010 were included in the present study. The operations were performed by the same team of maxillofacial and oculoplastic surgeons. The patients were evaluated pre- and postoperatively for the presence of enophthalmus and diplopia. The surgical technique was tailored to best fit the patient's clinical characteristics, with attention to the cosmetic and functional outcomes and the preferred use of a sutureless transconjunctival technique, when applicable. The main outcome measures were residual enophthalmus, diplopia, and the complication rate.

RESULTS

A total of 16 patients (11 males and 5 females), with an average age of 34.4 years, underwent orbital floor reconstruction using an autologous bone graft. Calvarial and iliac bone grafts were used in 11 and 5 patients, respectively. A transconjunctival approach was applied in 10 patients. All patients achieved good cosmetic and functional outcomes, with improvement in enophthalmus. Three patients had residual diplopia postoperatively that was probably due to traumatic muscular injury. No significant perioperative or long-term complications were noted during a mean follow-up of 12.5 months.

CONCLUSION

Reconstruction of orbital floor fractures after trauma using autologous bone grafts is safe and associated with a low rate of complications. Combining the appropriate surgical approach with multidisciplinary teamwork results in excellent cosmetic and functional outcomes and allows for efficient and comprehensive postoperative management.

Treatment of orbital fractures: evaluation of surgical techniques and materials for reconstruction

Reconstruction of the fractured orbit serves to prevent functional and aesthetic posttraumatic sequels. In 2004, the surgical protocol at our unit was modified with respect to techniques for surgical access, types, and materials for reconstruction. The modifications were as follows: (a) introduction of medial orbital wall reconstructions through a bicoronal approach, (b) transconjunctival approach instead of the subciliary approach, and (c) porous polyethylene or porous polyethylene-titanium instead of autologous bone grafts. To evaluate the different surgical techniques and materials used, orbital reconstructions performed at our unit from 2000 to 2007 were retrospectively studied. In total, 177 primary or first-time secondary reconstructions were performed in 176 patients. The overall rate of early complications requiring medical or surgical intervention was 6.4%, and the reoperation rate was 3.4%. There were no statistically significant differences in the frequency of cicatricial eyelid complications between the subciliary and the transconjunctival approaches. There was a reduction in operative time with the use of implants compared with the use of bone. The overall rate of infections was 2%; however, there were no infections in the group treated with implants. Seven patients had secondary surgery for persistent enophthalmos, 4 of them due to defects in the medial orbital wall that had not been corrected at the time of primary reconstruction of the orbital floor. In conclusion, porous polyethylene/porous polyethylene-titanium is a safe material for orbital reconstructions. Reconstruction of the medial orbital wall is important to prevent posttraumatic enophthalmos, particularly in combined medial wall-orbital floor fractures.

Efficacy of Iliac Crest vs. Medpor in Orbital Floor Reconstruction

AIM

The present study is to compare the effectiveness of iliac crest graft and medpor implant, for repairing traumatic orbital floor defects.

MATERIALS AND METHODS

A total of 20 patients were included in the study. Autogenous iliac crest graft and medpor implant was used in 10 patients of the each group. Patients were evaluated for the presence or absence of diplopia, enophthalmos, infraorbital nerve paresthesia, and ocular motility disorders. Surgical indications for orbital exploration included entrapment of orbital tissues, large orbital defect (greater than 50% of the orbital floor or more than 8 mm), or orbital floor defects with involvement of other zygomaticofrontal complex fractures.

RESULTS

All patients were successfully treated by restoration of the orbital wall continuity. Follow-up was done at 1-12 weeks. One patient had postoperative infection. There was no graft extrusion.

CONCLUSIONS

Both the groups showed satisfactory results, but group II was better than group I, as there was no donor site morbidity. Porous polyethylene (Medpor) is a biocompatible and high-density polyethylene implant. It is well tolerated by surrounding tissue, and its porous structure is rapidly infiltrated by host tissue. It is a highly stable and somewhat flexible porous alloplast that has rapid tissue in growth into its pores.

Options in orbital floor reconstruction in blowout fractures: a review of ten cases

OBJECTIVE

The purpose of this case series was to assess the aesthetic and functional outcome of orbital floor reconstruction performed with calvarial bone graft, titanium mesh or prolene mesh.

METHODS

Ten cases of orbital blowout fractures treated at our centre from October 2006 to July 2008 were considered for this study. Clinical examination, patient satisfaction and radiographic investigations were used to assess repaired fractures.

RESULTS

Prolene mesh was used in four cases, titanium mesh was used in four cases and calvarial graft used in two cases. Nine patients had significant improvement in their esthetic appearance. Symmetry was restored in all cases. All ten cases had a noticeable improvement in the function. Of total ten cases six had diplopia, three recovered completely during the six months after the surgery. Three cases showed improvement later. All ten cases with enopthalmos recovered completely. Of the nine patients with infraorbital numbness, all recovered completely during the six months following surgery. One patient where the reconstruction was done with calvarial bone graft showed mild discrepancy in the ocular level.

CONCLUSION

For small, linear defects measuring less than 2cm with enopthalmos and restricted ocular movements, prolene mesh (four cases) was used. For larger defects and impure blowout fractures involving the infraorbital rim, calvarial graft (two cases) or titanium mesh (four cases) was used. The outcome of surgery with all three materials was satisfactory. No postoperative complications were seen except for mild hypoglobus in a case reconstructed with calvarial graft. All three materials, calvarial graft, titanium mesh, prolene mesh, have the potential to be useful reconstructive materials in orbital floor blowout fractures.

Bioresorbable poly-L/DL-lactide (P[L/DL]LA 70/30) plates are reliable for repairing large inferior orbital wall bony defects: a pilot study

PURPOSE

The purpose of this study was to share our clinical experience on the use of bioresorbable poly-L/DL-lactide implants (P[L/DL]LA) 70/30 (PolyMax; Synthes, Oberdorf, Switzerland) to repair, large (> or =2 cm2), inferior orbital wall defects and to evaluate whether P(L/DL)LA 70/30 implants adequately support the orbital soft tissue contents.

PATIENTS AND METHODS

Thirteen patients who suffered orbital blowout fractures, with > or =2 cm2 bony defects in the inferior orbital wall, took part in the study. The inferior orbital wall was explored via subconjunctival approach. After repositioning of orbital content, each inferior orbital wall was reconstructed using a round plate of P(L/DL)LA 70/30. Computed tomography and magnetic resonance imaging coronal sections were undertaken before the operation and 2 and 36 weeks postoperatively.

RESULTS

The magnetic resonance imaging studies showed no abnormal tissue foreign body reactions in the orbital region. The material showed adequate strength to stabilize bone segments during the critical period of bone healing. The bone healing seems to take place along the bone fragments. The clinical outcome was excellent in 11 of the 13 cases (85%). At the end of the study, only one patient had mild enophthalmos.

CONCLUSIONS

Bioresorbable P(L/DL)LA 70/30 implants are safe and reliable for the repair of large defects (> or =2 cm2) in the inferior orbital wall. It seems that this is the first reported biodegradable material, in the literature, to promote bone healing along the bone fragments of the inferior orbital wall.