Orbital floor reconstruction with flexible Ethisorb patches: a retrospective long-term follow-up study

Case Report: Facial fracture sequelae: the importance of using a specific customized implant (PSI) for orbital reconstruction

The reconstruction of orbital fracture sequelae is a major challenge due to concerns regarding surgical approach and implant stability. Few anatomical sites of such minute size have presented with as much variation in treatment as the orbital floor fractures and related sequelae. Our patient developed sequelae of an orbital fracture over the last 3 years, presenting with dystopia, ophthalmoplegia, and diplopia in the supra- and lateroversion and aesthetic impairment. The variety of implant materials for reconstruction after orbital fractures is extensive, and the decision as to which material to use continues to be debated. The continuing development of computer-aided diagnosis and management and the construction of stereolithographic models offer comparable reproduction of anatomical detail. This technology is described in relation to the planning of trauma surgery and sequelae and the planning of ablative surgery for malignant neoplasms of the head and neck. The use of specific 3D printed titanium implants for bone defects was first reported in cranial reconstruction in 2012, and several studies have reported their use in orbital fractures. The advantages of this implant were increased stiffness, preventing shape loss during placement, a precise fit, and decreased surgical time. However, in the existing literature, the one-piece implant done in this way was a precise fit; therefore, it is possible that navigation between intraoperative anatomical landmarks is lost. However, in cases where reconstruction is difficult, such as extensive orbital wall fractures and large orbital sequelae, the 3D printed implant has been helpful in decreasing surgical time and can be accessed by a limited surgical approach with a precise fit. Our clinical case involved a 37-year-old male patient who experienced severe physical aggression in 2020, amid the COVID-19 pandemic. At the time, due to the overwhelming healthcare demands and resource constraints imposed by the pandemic, immediate surgical intervention for the correction of the fracture was not feasible. As a result of this delay, the patient developed sequelae of the orbital fracture over the last 3 years.

Current Guidelines and Opinions in the Management of Orbital Floor Fractures

Orbital floor fractures are a common manifestation of facial trauma that is encountered by ophthalmology, otolaryngology, and oral maxillofacial specialists. Surgical intervention is required emergently in cases of tissue entrapment and less urgently in cases of presenting with persistent diplopia, enophthalmos greater than 2 mm, and/or fractures involving greater than 50% of the orbital floor. Surgical management is a debated topic with differing opinions among surgeons regarding timing of repair, type of implant, and surgical approach.

Newly Developed Resorbable Magnesium Biomaterials for Orbital Floor Reconstruction in Caprine and Ovine Animal Models-A Prototype Design and Proof-of-Principle Study

BACKGROUND

orbital floor fractures have not been reconstructed using magnesium biomaterials.

METHODS

To test technical feasibility, ex vivo caprine and ovine heads (n = 5) were used. Head tissues were harvested from pubescent animals (n = 5; mean age: 3.2 years; mean mass: 26.3 kg) and stored below 11 degrees for 7-10 days. All procedures were performed in a university animal resource facility. Two experienced maxillofacial surgeons performed orbital floor procedures in both orbits of all animals in a step-by-step preplanned dissection. A transconjunctival approach was chosen to repair the orbital floor with three different implants (i.e., magnesium implants; titanium mesh; and polydioxanone or PDO sheets). The position of each implant was evaluated by Cone-beam computed tomography (CBCT).

RESULTS

Axial, coronal, and sagittal plane images showed good positioning of the magnesium plates. The magnesium plates had a radiographic visibility similar to that of the PDO sheets but lower than that of the titanium mesh.

CONCLUSIONS

The prototype design study showed a novel indication for magnesium biomaterials. Further testing of this new biomaterial may lead to the first resorbable biomaterial with good mechanical properties for extensive orbital wall defects.

Management of Orbital Floor Fractures: Our Experience in 10 Years

Purpose

Orbital floor Fractures are the most common fractures involving the facial skeleton and usually occurs after traumatic events. The reconstruction of the orbital floor can be performed with different biocompatible materials. The aim of our retrospective study is to analyze the short- and long-term outcomes of surgically treated patients based on the material used to repair the orbital floor.

Methods

We enrolled 146 patients hospitalized for orbital floor fractures in the Maxillofacial Surgery Unit of the Federico II University of Naples from 1 to 2010 to July 2020. All the fractured orbital floors were reconstructed with non-resorbable (Titanium Mesh, SynPor, SuPor and MedPor implants) or resorbable (collagen membrane, bovinum pericardium membrane, autologous bone graft) materials.

Results

We utilized non-resorbable materials in 56% (82 cases) and resorbable implants in 44% (64 cases). An improvement of the preoperative symptomatology and an aesthetical good outcome was achieved in most cases.

Conclusions

Data obtained supports that both resorbable and non-resorbable materials for orbital floor reconstruction are a safe and effective alternatives and offer satisfactory results in functional and aesthetic evaluations.

Controversies and Contemporary Management of Orbital Floor Fractures

Substantial controversy exists regarding the timing of intervention and management of patients with orbital floor fractures. Recent advances in computer-aided technology, including the use of 3-dimensional printing, intraoperative navigational imaging, and the use of novel implants, have allowed for improvement in prospective management modalities. As such, this article aims to review the indications and timing of repair, surgical approaches, materials used for repair, and contemporary adjuncts to repair. Indications for orbital floor fracture repair remain controversial as many of these fractures heal without intervention or adverse sequelae. Intraoperative navigation and imaging, as well as endoscopic guidance, can improve visualization of defects mitigating implant positioning errors, thereby reducing the need for secondary corrective procedures. Patient-specific implants may be constructed to fit the individual patient's anatomy using the preoperative CT dataset and mirroring the contralateral unaffected side and have been shown to improve pre-operative efficiency and minimize postoperative complications. With increased data, we can hope to form evidence-based indications for using particular biomaterials and the criteria for orbital defect characteristics, which may be best addressed by a specific surgical approach.

A comparative study of porous polyethylene versus absorbable polydextro- and polylevolactic-lactide plate in reconstruction of isolated medial orbital wall fracture

BACKGROUND

Several materials for medial orbital wall reconstruction have been mentioned in the literature. Our main purpose was to investigate postoperative enophthalmos and diplopia after medial orbital wall reconstruction with polydextro- and polylevolactic (poly-_L/_DL) acid (P[_L/_DL]LA) mesh plates and porous polyethylene plates.

METHODS

Using a retrospective study design, we enrolled a cohort of isolated medial blowout fracture patients treated during a 58-month interval. The predictor variable was medial orbital wall reconstruction materials (P(_L/_DL)LA mesh plate and porous polyethylene plate. The main outcome variables included the occurrence of postoperative enophthalmos and diplopia at 1 week, 1, 3, 6, and 12 months post-surgery. Appropriate descriptive, uni- and bivariate statistics were computed, and P < 0.05 was considered significant.

RESULTS

Three hundred-two isolated medial blowout fracture patients were included (24.5% females, 67% treated with P(_L/_DL)LA mesh plate). Exophthalmos measured highest in both groups 1 week after surgery and decreased steadily for 6 months postoperatively. Statistically significant differences were observed between both groups at 1 week, 1 month, and 3 months after surgery, with a higher incidence of exophthalmos observed in the P(_L/_DL)LA mesh plate group (P < 0.001). No significant differences were observed at 6 and 12 months after surgery.

CONCLUSION

The occurrence of enophthalmos after medial blowout fracture reconstruction with P(_L/_DL)LA mesh plate is comparable with the use of porous polyethylene plate. Both P(_L/_DL)LA mesh and porous polyethylene plates are, therefore, reliable implants for medial orbital wall reconstruction.

Clinical evaluation of the efficacy of materials used for primary reconstruction of orbital floor defects: Meta-analysis

BACKGROUND

The aim of this network meta-analysis (NMA) was to compare the clinical results obtained after primary reconstruction of orbital floor fractures (OFF) using different materials.

METHODS

PubMed, Cochrane, and Google Scholar databases were screened from 1989 to 2019. For a study to be eligible, it had to evaluate two or more materials and report the following clinical parameters: diplopia and/or enophthalmos and/or other complications.

RESULTS

Nine studies involving 946 patients presenting with an OFF were included. After the surgical procedure, 105 patients (11%) had diplopia, while 43 patients (4.5%) suffered from enophthalmos. The NMA revealed that less postoperative diplopia and enophthalmos were obtained either by using polydioxanone (PDS), or a polymer of l-lactic acid and dl-lactic acid (P[L/DL]LA), or porous polyethylene, or titanium mesh compared with the use of autologous bone grafts.

CONCLUSION

P(L/DL)LA and PDS seem to be the best options for small and intermediate defects, whereas the association of porous polyethylene and titanium should be preferred for larger defects.

Clinical Outcome Following Surgical Repair of Small Versus Large Orbital Floor Fractures Using Polyglactin 910/Polydioxanone (Ethisorb®)

The aim of this retrospective study was to evaluate the clinical outcome of surgical management of small versus large, isolated orbital floor fractures (OFFs) using polyglactin 910/polydioxanone (Ethisorb®). Covering a four-year period (2010-2013), all records concerning midfacial fractures with involvement of the orbit were screened. Isolated fractures of the orbital floor as well as combined injuries of the orbital floor and medial wall that had been treated surgically using polyglactin 910/polydioxanone (Ethisorb®) were included. Patients underwent a preoperative, a postoperative, and a late ophthalmologic assessment. The clinical outcomes of surgically managed small OFFs up to 2 cm2 were statistically analyzed and compared to clinical results in larger defects. The final sample included 61 patients (25 women, 36 men). Fractures up to 2 cm2 were found in 33 patients (54.1%), whereas 28 patients (45.9%) suffered from OFFs larger than 2 cm2. The clinical outcomes did not significantly differ between both sample categories, and statistical analysis showed a power of 0.91 to detect a potentially existing difference. On final examination, 52 patients were free of any clinical symptoms, whereas minor issues were found in seven subjects, and two patients suffered from severe impairment. In conclusion, polyglactin 910/polydioxanone (Ethisorb®) seems to be a suitable material for surgical repair of both small and large OFFs.

Resorbable Implants for Orbital Fractures: A Systematic Review

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.

Clinical outcome after orbital floor fracture reduction with special regard to patient's satisfaction

PURPOSE

Primary reconstruction via transconjunctival approach is a standardized treatment option for orbital floor fractures. The aim of this study was to compare the findings of specific ophthalmologic assessment with the patient's complaints after fracture reduction.

METHODS

A retrospective medical chart analysis was performed on patients who had undergone transconjunctival orbital floor fracture reduction for fracture therapy with resorbable foil (ethisorb sheet or polydioxanone foil). A follow-up assessment including ophthalmological evaluation regarding visual acuity (eye chart projector), binocular visual field screening (Bagolini striated glasses test) and diplopia (cover test, Hess screen test) was conducted. Additionally, a questionnaire was performed to assess patients' satisfaction.

RESULTS

A total of 53 patients with a mean follow-up of 23 months (ranging from 11 to 72) after surgical therapy were included. Diplopia was present preoperatively in 23 (43.4%) and reduced in follow-up examination (n = 12, 22.6%). Limitations in ocular motility reduced from 37.7% to 7.5%. The questionnaire about the patient's satisfaction revealed excellent outcomes in relation to the functional and esthetical parameters.

CONCLUSION

Transconjunctival approach is a safe approach for orbital fracture therapy. Postoperative diplopia is nearly never perceptible for the individual and differs to pathologic findings in the ophthalmic assessment.

Enhanced radiographic visualization of resorbable foils for orbital floor reconstruction: A proof of principle

PURPOSE

Despite the advantages and broad applications of alloplastic resorbable implants, postoperative radiological control is challenging due to its radiolucency. The aim of the present study was to evaluate the radiographic visibility of newly developed materials for orbital floor reconstruction.

MATERIALS AND METHODS

The radiographic visibility of four different material combinations consisting of poly-(L-lactic acid)/poly-glycolic acid (PLLA/PGA) or poly(D,L-lactic acid) (PDLLA) enriched with magnesium (Mg), hydroxyapatite (HA) or β-tricalcium phosphate (β-TCP) with various layers of thicknesses (0.3, 0.6, and 1 mm), surgically placed above the orbital floor of a human head specimen, was evaluated using computed tomography (CT) and cone beam computed tomography (CBCT). The visibility was rated on a scale of 0-10 in CT/CBCT and by Hounsfield Units in CT for each subject.

RESULTS

All of the materials were clearly detectable in CT scans. Visibility was significantly higher (p < 0.001) in the standard soft tissue window (mean score: 7.3, ranging from 2 to 10) in comparison to the standard bone window (mean score: 5.2, ranging from 1 to 10). In CBCT (mean score: 3.3, ranging from 0 to 7), there was significantly lower but still sufficient visibility of the materials compared to the CT soft tissue window (p < 0.001) and CT bone window (p < 0.001). Comparing the different materials' visibility among the group of same layer thicknesses with each other, in the majority of cases, PDLLA enriched with β-TCP appeared to be most visible in both CT and CBCT.

CONCLUSION

The incorporation of radiopaque elements to PLLA/PGA and PDLLA polymers is a promising strategy to improve their visibility in CT and CBCT. Our data suggest that the reconstruction of the orbital floor with these new materials could provide an advantageous postoperative radiographic control.

Resorbable Material for Pediatric Orbital Floor Reconstruction

INTRODUCTION

The use of resorbable materials is becoming more popular for pediatric orbital floor reconstruction. The purpose of this systematic review is to evaluate the effectiveness and safety of the various materials used in pediatric orbital floor reconstruction.

METHODS

A systematic literature search was performed to identify all relevant articles reporting complications following pediatric orbital floor reconstruction. The search included published articles in three electronic databases-Ovid MEDLINE, EMBASE, and PubMed starting from database establishment to July 2017. Primary endpoints were enophthalmos, diplopia, and infection. Resorbable material was compared to autologous grafts and nonresorbable material.

RESULTS

A total of 14 studies containing 248 patients were included in this review. Fifty-four (21.8%) patients had reconstruction performed with autologous grafts, 72 (29.0%) patients with resorbable material, and 122 (49.2%) patients with nonresorbable material. Resorbable materials had the lowest rate of postoperative enophthalmos (3/52; 5.8%) and the highest rate of postoperative diplopia (19/72; 26.4%). In contrast, nonresorbable materials had the lowest rate of postoperative diplopia (5/122; 4.1%), the highest rate of postoperative enophthalmos (14/102; 13.7%). Autologous reconstruction was associated with an 11.1% (4/36) rate of postoperative enophthalmos and a 22.2% (12/54) rate of postoperative diplopia. Nine cases (8.8%) of postoperative infection were documented with nonresorbable materials. No cases of infection were reported with autologous grafts or resorbable materials.

CONCLUSION

Newer resorbable implants are safe and have a similar complication profile as traditional autologous grafts in pediatric orbital floor reconstruction.

Use of Acellular Allogenic Dermal Matrix (MegaDerm) in Orbital Wall Reconstruction: A Comparison With Absorbable Mesh Plate and Porous Polyethylene

The selection of materials for orbital wall reconstruction has been a matter of debate. This study aimed to evaluate the effectiveness of an acellular allogenic dermal matrix (ADM) as an orbital wall reconstruction material and to compare the results of orbital wall reconstruction with the ADM to those of reconstruction with the more widely used absorbable mesh plate and porous polyethylene. We retrospectively reviewed the clinical charts and computed tomography images of 73 patients who underwent orbital reconstruction at 1 institution between March 2013 and February 2014. In the ADM group, the mean defect size of 29 patients was 2.89 cm. After orbital wall reconstruction with ADM, patients with preoperative enophthalmos (7 patients), limited range of eyeball movement (6 patients), and diplopia (12 patients) showed improvements. In the comparative study, the 3 groups showed no significant differences with respect to age distribution (P = 0.522), defect size (P = 0.455), and preoperative findings such as enophthalmos (P = 0.811), diplopia (P = 0.357), and limited range of eyeball movement (P = 0.795). All the preoperative symptoms improved in every group, and in the ADM group, no complication was observed during the postoperative follow-up. ADM is a biocompatible material that combines the flexibility and rigidity required to support the orbital soft tissue. Therefore, it could be an excellent alternative material for orbital wall reconstruction.

Orbital reconstruction with a partially absorbable mesh (monofilament polypropylene fibre and monofilament poliglecaprone-25): Our experience with 34 patients

Purpose

To evaluate the effectiveness and complications related to the use of a partially absorbable mesh for the reconstruction of orbital floor fractures.

This is a retrospective review of 34 consecutive patients who suffered orbital trauma from August 2007 to March 2013 treated with a partially absorbable mesh for orbital reconstruction. Data collected included gender, age, nationality, cause of injury, date of admission, date of surgery, date of discharge, type of fracture, signs and symptoms such as diplopia, enophthalmos, and sensory disturbance related to the infraorbital nerve, complications before and after surgery, and follow-ups at 1 week, 1 month, 6 months, and after 1 year.

Results

Since January 2007, 34 patients were treated in our department with orbital fractures: 28 males (82.4%) and 6 females (17.6%). The mean age was 31 years (minimum 14, maximum 45). The main causes of trauma were road traffic accidents (20 patients, 58.8%), followed by work-related accidents (9 patients, 26.5%), aggressions (3 patients, 8.8%), and sports (2 patients, 6%). Posttraumatic Diplopia was present in 20 patients (58.8%), and enophthalmos was in 9 (26.5%). The incidence of postoperative diplopia was present in 8 patients (23.5%), which decreased to 1 (2.9%) after one year. Paresthesia due to trauma was first noticed in 8 patients (20.6%) and completely disappeared after 12 months. Post surgical enophthalmos was noticed in 3 patients (7.5%). There was one case of migration of the mesh and one case of adherence in the lower lid. Both required surgery and resolved completely. Time from trauma to surgery was on average 5.5 days (min 0, max 27, SD 5.15), and the number of days before discharge was 3.5 days (min 1, max 16, SD 2.61).

Conclusions

This study describes the results of the first series of orbital floor reconstructions with a partially absorbable mesh (Monofilament polypropylene fibre and monofilament poliglecaprone-25) to date. Although there are a wide variety of materials for treatment, we believe it is a suitable option with an acceptable rate of complications.

Is there an ideal implant for orbital reconstructions? Prospective 64-case study

The aim of this study was to compare the effectiveness of porous polyethylene, titanium mesh, and castor oil-derived biopolymer randomized in orbital reconstructions of defects larger than 1 cm in length on the inferior and medial walls. A total of 63 patients (64 orbits) were evaluated to determine the presence of diplopia, enophthalmos ocular motility, and infraorbital nerve paraesthesia in both the preoperative and postoperative periods. The surgeons' opinions of the ease in handling the implants were also obtained after each procedure. The patients were divided into 3 groups: 17 received porous polyethylene, 21 received castor oil-derived biopolymer, and 26 received titanium mesh. In the preoperative period, 30 patients experienced enophthalmos, 11 experienced diplopia, and 12 experienced ocular motility. Ninety days after the orbital reconstruction, 6 cases of enophthalmos persisted, as did 2 cases of diplopia and 2 cases of ocular motility. Ten patients developed some type of postoperative complication. Material removal was required in only 1 case. Regardless of the size of the defect, the materials used were found to be effective for reconstructing orbital volume; they were also found to offer ease in handling and stabilization.

Delayed onset porous polyethylene implant-related inflammation after orbital blowout fracture repair: four case reports

Background

Porous polyethylene implants are commonly used in orbital blowout fracture repair because of purported biocompatibility, durability, and low frequency of complications. Delayed inflammation related to porous polyethylene sheet implants is very rare and no case series of this condition have been reported.

Case Presentation

This is a retrospective review of clinical presentations, radiographic findings, histopathological findings, treatments, and outcomes of patients who developed delayed complications in orbital blowout fracture repair using porous polyethylene sheets. Four male patients were included with a mean age of 49 years (range 35–69 years). Blowout fracture repair was complicated with implant-related inflammation 10 months, 2 years, 3 years, and 8 years after surgery. Chronic and subacute orbital inflammatory signs were noted in two patients and acute fulminant orbital inflammation was found in two patients. Three patients developed peri-implant abscesses and one patient had a soft tissue mass around the implant. All patients underwent implant removal and two of these patients with paranasal sinusitis had sinus surgery. Histopathological findings revealed chronic inflammatory changes with fibrosis, and one patient had foreign body granuloma with culture positive Staphylococcus aureus.

Conclusions

Delayed complications with porous polyethylene sheets used in orbital blowout fracture repair may occur many years following the initial surgery in immunocompetent patients. Low-grade or fulminant inflammation could complicate blowout fracture repair related with the implant.

Mechanical resistance of the periorbita and the orbital floor complex--are isolated orbital floor fractures only a soft tissue problem?

The primary aims of orbital floor reconstruction are to prevent enophthalmos and herniation of the orbital contents in order to achieve correct globe position. Theoretically, the mechanical load of the orbital floor is approximately 0.0005N/mm(2) (30g orbital content onto 600mm(2) of orbital floor area). Therefore, low mechanical stress from orbital floor reconstruction materials is expected. The periorbita and orbital floor complex (bony orbital floor with periorbita) of 12 human cadavers were investigated for their mechanical resistance to distortion and compared to different absorbable pliable reconstruction materials after modification with pores (Bio-Gide, Creos, and PDS). The human periorbita resistance (approximately 1.4N/mm(2)) was comparable to that of the absorbable membranes (Creos, Bio-Gide), and the resistance of PDS (approximately 2.3N/mm(2)) was comparable to that of the orbital floor complex. The periorbita has a higher stability than the bony orbital floor. Therefore, in isolated orbital floor fractures with a traumatized bony orbital floor and periorbita, reconstruction of the soft tissue as a periorbita equivalent with a resorbable membrane appears to be adequate to prevent enophthalmos and herniation of the orbital contents.

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 the orbital floor with polydioxanone: a long-term clinical survey of up to 12 years

Fractures of the orbital floor are common in injured patients, who often require operation to prevent complications and, among other materials, polydioxanone is widely used. The aim of this study was to evaluate the long-term outcomes of fractures of the orbital floor that had been reconstructed with polydioxanone foil. A total of 101 patients (73 men and 28 women) who had reconstruction of the orbital floor for defects of 2cm(2) or smaller with polydioxanone implants, over a mean (SD) time period of 8 (2) years were evaluated. Sensitivity of the infraorbital nerve, ocular motility, and diplopia were evaluated and correlated with perioperative values. Persistent hyperaesthesia was found in 15 patients, whereas in another 15 the hyperaesthesia recovered completely over time. Three patients had double vision during follow-up. Twenty patients with preoperative diplopia had no persistent double vision postoperatively, and 15 patients with disturbed ocular motility recovered completely. Two patients had persistently disturbed motility, and one patient had enophthalmos. There was a significant association between hyperaesthesia preoperatively and postoperatively (p= 0.005). In most patients reconstruction of the orbital floor with polydioxanone was successful. Long-term complications such as diplopia, compromised bulbar motility, and hyperaesthesia of the cheek were seen in a few cases, but might not have been solely related to the use of polydioxanone.

Evidence-based medicine: Orbital floor fractures

LEARNING OBJECTIVES

After studying this article, the participant should be able to: 1. Explain the epidemiology, anatomy, and pathophysiology of orbital floor fractures. 2. Select the optimal timing of--and understand the indications for-operative repair of orbital floor fractures. 3. List advantages and disadvantages of the surgical approaches and materials available for orbital floor reconstruction. 4. Identify special considerations in treating pediatric patients presenting with orbital floor fractures.

SUMMARY

This maintenance of certification module reviews the anatomy, pathophysiology, diagnosis, and management of orbital floor fractures in addition to special considerations for pediatric patients. The shows the evidence rating scale used for the literature review in creating this maintenance of certification article.

[When should an orthoptic evaluation be prescribed in the management of orbital floor fracture? A prospective study of 47 fractures]

INTRODUCTION

We evaluated the indication of orthoptic evaluation for the management of orbital floor fractures in a prospective series.

MATERIAL AND METHOD

Forty-seven patients presenting with an orbital floor fracture were included in our prospective study. Consultations in orthoptics and maxillo-facial surgery were regularly carried out. Diplopia and motility were systematically assessed as well as a coordimetric examination according to Hess-Lees's technique.

RESULTS

Nineteen percent of coordimetric motility disorders were observed among asymptomatic patients, after trauma. No diplopia or clinical motility disorder were observed 1 and 2 months after trauma, and coordimetric examinations came back to normal 2 and 3 months after trauma respectively for non-operated (26) and operated (21) patients.

CONCLUSIONS

An orthoptic evaluation is necessary for the management of orbital floor fractures to diagnose the type of diplopia, motility disorders, and to indicate a coordimetric examination if diplopia is present. We suggest this orthoptic evaluation for patients presenting with diplopia between 5 and 10 days following trauma, 1 month after trauma for non-surgical treatment and 2 months after trauma for surgical treatment.

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.

A review of materials currently used in orbital floor reconstruction

Orbital fractures are common fractures of the midface. As such, numerous techniques and materials exist for the repair of this region, each with inherent advantages and disadvantages. But does the ideal implant material exist? Should we stop and simply use readily available materials, or should the cycle of need and discovery continue? A comprehensive review of materials used in orbital reconstruction and possible new directions in orbital floor reconstruction are presented.

Bioabsorbable fixation devices in trauma and bone surgery: current clinical standing

Bioabsorbable fixation devices are increasingly used in trauma, orthopedic and craniomaxillofacial surgery. The devices are essentially made of polylactic acid and/or polyglycolic acid polymers. Ultra-high-strength implants are manufactured from such polymers using self-reinforcing techniques. Implants are available for stabilization of fractures, osteotomies, bone grafts and fusions, as well as for reattachment of ligaments, tendons, meniscal tears and other soft tissue structures. As these implants are completely absorbed, the need for a removal operation is overcome and long-term interference with tendons, nerves and the growing skeleton is avoided. The risk of implant-associated stress shielding, peri-implant osteoporosis and infections is reduced. Implants do not interfere with clinical imaging. Current clinical use of bioabsorbable devices is reviewed.

Evaluation of the Biodegradable Plates (PG910/PDO) for Reconstruction of Various Sizes of Orbital Floor Defects in the Blow-Out Fractures

The aim of our study was to evaluate the biodegradable plates (PG910/PDO) for reconstruction of various sizes of the orbital floor defects in the blow-out fractures. We included patients who had an impure blow-out fracture. All patients had a recent trauma and also the surgical intervention was done between 1 and 10 days after trauma. The amount of the orbital floor defect was measured in each case through computed tomography scan. In the surgical intervention, a biodegradable plate was used for the reconstruction of the orbital floor defect along with titanium miniplates used for bone fixation in orbital rim. Due to aesthetic reasons, all patients underwent secondary surgery including removal of titanium miniplates after 18 months. The orbital floor was reevaluated during the removal of the miniplates. The clinical evaluation of remnant defects and biodegradable plates (presence of complete or partial resorption) were documented for each patient. In our study a total of 15 patients (10 males and 5 females) underwent the orbital floor reconstruction using biodegradable miniplates. The size of the orbital floor defects was meanly 3.51 ± 1.29 cm(2). Results demonstrated that 4 out of 15 patients had a remnant defect after resorption of the biodegradable plate. In 10 out of 15 patients, the biodegradable plates completely replaced with fibrous tissues after 18 months. Remaining five patients had partial resorption of plates. There was not any relationship between the defect size and the remnant defects (p > 0.05). A significant relationship was seen between the defect size and the plates' resorption rate (p < 0.001). There is a significant relationship between the resorption rate and the remnant defect. The risk to have remnant defects have been increased as the plates had incomplete resorption. The use of biodegradable plates is an appropriate option for reconstruction of the orbital floor defects. The defect size does not have any effect on the stability of the plate. However, incomplete plate resorption increases the risk of remnant defects in the orbital floor. The larger defects lead to slow degradation of biodegradable plates.

Biomaterials for repair of orbital floor blowout fractures: a systematic review

PURPOSE

To evaluate the reported use and outcomes of implant materials used for the restoration of post-traumatic orbital floor defects in adults.

MATERIALS AND METHODS

A systematic search of the English literature was performed in the databases of PubMed, Cochrane Library, and EMBASE. The study selection process was adapted from the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement, and 55 articles complied with the study inclusion criteria. The primary outcome measures were diplopia, enophthalmos, graft extrusion/displacement, and infection related to the graft material. The secondary outcome measures were infraorbital paresthesia, orbital dystopia, orbital soft tissue entrapment, and donor-site complications.

RESULTS

Of 55 articles, 41 (74.5%) evaluated were retrospective case series, 9 (16.4%) were retrospective case-control studies, 3 (5.5%) were controlled trials, and 2 (3.6%) were prospective case series. Autogenous graft materials were predominantly used in 19 studies, alloplastic materials were used in 33 studies, and the remaining 3 articles reported on allogeneic materials. Overall, 19 different types of implant materials were used in 2,483 patients. Of 827 patients with diplopia before surgery, 151 (18.3%) had diplopia postoperatively. Of 449 patients with enophthalmos before surgery, 134 (29.8%) had enophthalmos postoperatively. Only 2 patients (0.1%) and 14 patients (0.6%) had graft extrusion/displacement and infection related to the graft material, respectively; alloplastic biomaterials were used in all of these cases.

CONCLUSIONS

All graft materials used were successful to variable degrees because all studies reported improvement in terms of the recorded outcome measures. A guideline for choice of implant material based on defect size was developed.

Medial orbital wall reconstruction with flexible Ethisorb patches

OBJECTIVES

The aim of this study was to analyse the long-term result after reconstruction of the medial orbital wall with a flexible, biodegradable material (Ethisorb).

MATERIALS AND METHODS

During a period of almost 8 years, 31 patients with a medial orbital wall fracture were analysed retrospectively. Inclusion criteria were patients with a maximum size fracture of the orbital medial wall measuring 1.5-2 cm(2). Exophthalmos, enophthalmos, bulbus motility, diplopia and skin sensation were investigated over a period of 6 months. In all patients, the medial orbital wall was reconstructed with Ethisorb patches.

RESULTS

No significant intraoperative complications were detected. No postoperative infection, abscess or seroma was found in any of the patients receiving an Ethisorb patch.

CONCLUSIONS

The advantage of the semiflexibility of the Ethisorb patch is that it supplies an anatomically correct fit to the orbital medial wall but does not require fixation by screws or the use of sutures.

CLINICAL RELEVANCE

The low rate of reported bulbus motility disturbance, diplopia, exophthalmos and enophthalmos demonstrates acceptable results after medial orbital wall reconstruction using the Ethisorb patch.

Forces charging the orbital floor after fractures

The objective of this study was first to establish a method to measure forces and displacement of the orbital content in defects of the orbital floor in truncated fresh and unfixed heads and second to characterize reconstruction materials with regard to punctuation strength and compression.Orbital floor defects (10 × 20 mm and 15 × 20 mm; 3 mm behind the orbital rim) were prepared after Le Fort I osteotomy. The values of force and displacement were recorded in 6 freshly frozen human heads. In addition, the punctuation strength of 2 reconstruction materials (polydioxanone [PDS] foil and collagen membrane) was evaluated using a Zwick Z010 TN1 universal testing machine. The forces of the orbital content (28.41 [SD, 1.6] g) applied to the defects of 10 × 20 mm and 15 × 20 mm with an intact periorbita were 0.04 (SD, 0.003) N (0.0002 MPa) and 0.07 (SD, 0.02) N (0.0002 MPa), respectively, and with a split periorbita were 0.06 (SD, 0.03) N (0.0003 MPa) and 0.08 (SD, 0.06) N (0.00026 MPa), respectively. The displacement values without reconstruction materials of the 10 × 20-mm and 15 × 20-mm defects were 0.94 (SD, 0.7) mm and 1.2 (SD, 0.5) mm, respectively. The PDS foil could withstand forces of 118.9 (SD, 14.1) N (0.375 MPa), and the collagen membrane could withstand forces of 44.5 (SD, 5.3) N (0.14 MPa). This is the first study to report forces charging the orbital floor. The presented results support the use of PDS foils and collagen membranes as reconstruction materials for orbital floor defects, at least in smaller and medium-sized fractures.

Biomaterials and implants for orbital floor repair

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.

The use of absorbable polyglactin/polydioxanon implant (Ethisorb(®)) in non-surgical closure of oro-antral communication

Oro-antral communications (OAC) greater than 4-5 mm in diameter can seldom be counted on to heal spontaneously without the necessity for surgical closure. The initial experience in applying an absorbable polyglactin/polydioxanon implant (Ethisorb(®)), in non-surgical closure of OAC ranging from 5 to 7 mm in diameter, is presented. Twelve patients of varying ages with OAC up to 72 h in duration, have been treated with Ethisorb(®). Failures were not demonstrated in the form of the creation of an oro-antral fistula (OAF), and in all patients, OAC-s were closed with the epithelization of post-extraction wounds up to 21 days after implantation of Ethisorb(®). Based on these initial encouraging results, we propose that an Ethisorb(®) biopolymeric absorbable implant can be used in selected clinical cases for non-surgical closure of OAC.

Retrospective analysis of orbital floor fractures--complications, outcome, and review of literature

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.

Diagnosis and management of enophthalmos

Enophthalmos is a relatively frequent and misdiagnosed clinical sign in orbital diseases. The knowledge of the different etiologies of enophthalmos and its adequate management are important, because in some cases, it could be the first sign revealing a life-threatening disease. This article provides a comprehensive review of the pathophysiology, evaluation, and management of enophthalmos. The main etiologies, such as trauma, chronic maxillary atelectasis (silent sinus syndrome), breast cancer metastasis, and orbital varix, will be discussed. Its objective is to enable the reader to recognize, assess, and treat the spectrum of disorders causing enophthalmos.

Comparativein vitro study of the proliferation and growth of human osteoblast-like cells on various biomaterials

In vitro studies about the growth behavior of osteoblasts onto biomaterials is a basic knowledge and a screening method for the development and application of scaffolds in vivo. In this in vitro study human osteoblast-like (HOB) cells were cultured on seven different biomaterials used in dental and craniomaxillofacial surgery, respectively. The tested biomaterials were synthetic biodegradable (MacroPore, Ethisorb, PDS, Beriplast P) and nonbiodegradable polymers (Palacos) as well as calcium phosphate cement (BoneSource) and titanium. The cell proliferation and cell colonization were analyzed by scanning electron microscopy and EZ4U-test. Statistical analysis were performed. HOB-like cells cultivated on Ethisorb showed the highest proliferation rate. The proliferation rate was statistically significant compared with Palacos, MacroPore, and BoneSource. Whereas, Beriplast, PDS, and titanium yielded lower proliferation rates. However, there was no statistically significant difference compared with Palacos, MacroPore, and BoneSource. SEM analysis showed no significant difference in individual cell features and cell colonization. But an infiltration and a growth of HOB-like cells throughout the porous structure of Ethisorb, which is formed by crossing fibers, is a striking different feature (macrotopography). This feature can explain the highest proliferation rate of Ethisorb. The results showed that HOB-like cells appear to be sensitive to substrate composition and topography. Moreover, the basis for further studies with such biomaterial/osteoblast constructs in vivo are provided. Further focusing points are developing techniques to fabricate three-dimensional porous biomaterial/cell constructs, studying the tissue reaction and the bone regeneration of such constructs compared with the use of autologous bone.

Reconstruction of Internal Orbital Wall Fracture with Iliac Crest Free Bone Graft: Clinical, Computed Tomography, and Magnetic Resonance Imaging Follow-Up Study

BACKGROUND

The purpose of this study was to clinically and radiologically assess the outcome of internal orbital reconstruction with an iliac bone graft.

METHODS

Twenty-four consecutive patients with unilateral orbital wall fractures were enrolled in this prospective study. A medial cortical wall from the anterior ilium was used for reconstruction. At each follow-up visit, globe posture, diplopia, and eye movements were assessed. Coronal and sagittal computed tomography and magnetic resonance imaging were used to observe graft posture, bone defects, and intraorbital soft-tissue changes.

RESULTS

Most fractures (46 percent) were pure orbital floor fractures. The mean follow-up was 7.8 months. One patient with medial wall and floor fractures required reoperation because of insufficient bone graft. At the last follow-up, this was the only patient (4 percent) with both enophthalmos (2 mm) and hypophthalmos (3 mm). Five patients (21 percent) had hypophthalmos (> 1 mm) at the end of the study. Resorption and remodeling were detected in all grafts, but no grafts were totally resorbed. Sagittal or coronal bone graft postures were assessed as good in 18 orbits (75 percent). Bone defects (> 10 mm) at reconstructed areas were detected in 13 orbits (54 percent). Scar tissue was observed only in three reconstructed orbits (13 percent). Diplopia in central field of vision was registered in seven patients preoperatively but in none at the end of the study.

CONCLUSIONS

The resorption rate was high, but most of it was advantageous remodeling. Overall outcome was good. Secondary operations led to poor outcomes. Thin computed tomography and magnetic resonance imaging sections (< or = 2 mm) are needed to evaluate accurately bone graft placement and posture and orbital volume.

Anatomical 3-dimensional Pre-bent Titanium Implant for Orbital Floor Fractures

PURPOSE

This cadaver study evaluates the use of pre-bent 3-dimensional titanium mesh implants for orbital floor and medial wall reconstruction.

DESIGN

Nonrandomized comparative study.

PARTICIPANTS

Eight human cadaveric heads (n = 16 orbits).

METHODS

Transcutaneous incisions were used to expose both orbital floors in each cadaveric head. Unilateral orbital floor and medial wall fractures were generated in each specimen. The contralateral orbit remained uninjured. The fractures then were repaired with pre-bent titanium mesh fan plates molded from aluminum templates presenting different sizes. The templates were generated from topographical computed tomography (CT) data previously obtained from normal subjects. The accuracy of orbital reconstruction was evaluated with postoperative CT scans.

MAIN OUTCOME MEASURES

The mean value of the distances between the implant and the bony orbit was evaluated.

RESULTS

The mean distance between all 16 plates and their respective orbital floors/medial walls was 0.81+/-0.74 mm. Mean values were 0.68+/-0.63 mm for the unfractured side and 0.93+/-0.82 mm for the fractured side. No significant differences were found between orbits when evaluated for side of injury, gender, or size of defect.

CONCLUSION

Pre-bent 3-dimensional titanium mesh implants provide accurate reconstruction of orbital floor and medial orbital wall fractures. The mean implant error was <1 mm for all orbits studied.

A 3-month preclinical trial to assess the performance of a new TVT-like mesh (TVTx) in a sheep model

The objective of this study was to evaluate in a sheep model the performance of a new polypropylene mesh (TVTx), which is intended as a less invasive treatment for female stress urinary incontinence. Eight female sheep were used in this study, each one being implanted with eight TVTx samples. At each time-point (weeks 1, 2, 4, and 12) seven TVTx were pulled out, while one TVTx was carefully dissected for histological investigations. One TVTx and one TVT, moreover, were inserted and immediately pulled out for obtaining the initial pullout forces in all sheep. The initial pullout values of TVT and TVTx were overlapping. The pullout forces of TVTx were >5 N (500 g) and increasing from weeks 1 to 12 (p<0.001). Histology revealed good tissue integration of TVTx in the tissue within 12 weeks after implantation. No abnormal histological findings were observed. This data could support the realization of a clinical trial with the TVTx mesh.

Individual CAD/CAM Fabricated Glass-Bioceramic Implants in Reconstructive Surgery of the Bony Orbital Floor

BACKGROUND

The aim of the study was to present a set of preliminary cases from an ongoing program of reconstructive procedures using a new technique in the treatment of severe enophthalmos and diplopia after the primary treatment of orbital floor fractures had rendered insufficient results.

METHODS

Glass-bioceramic implants were shaped from computed tomography coordinates with computer-assisted design and computer-assisted manufacturing. In this prefabrication process, the implants were milled individually out of a solid block of Bioverit II (3di Gmbh, Jena, Germany). The adequacy of this reconstruction for treating malfunction and aesthetic deficits was evaluated.

RESULTS

Eight patients with orbital floor fractures underwent successful surgery. The results were encouraging, with all patients showing a good functional and aesthetic outcome.

CONCLUSIONS

Computer-assisted design/computer-assisted manufacturing implants made of Bioverit II can be used for a very accurate and successful secondary reconstruction of the orbital floor. However, it addresses only a few aspects of the treatment of orbital floor fractures and should be considered as an equal alternative to other reconstruction methods.