Navigation-Assisted Isolated Medial Orbital Wall Fracture Reconstruction Using an U-HA/PLLA Sheet via a Transcaruncular Approach

Accuracy of surgical navigation for patient-specific reconstructions of orbital fractures: A systematic review and meta-analysis

OBJECTIVE

This systematic review and meta-analysis aimed to review the recent literature on the technical accuracy of surgical navigation for patient-specific reconstruction of orbital fractures using a patient-specific implant, and to compare surgical navigation with conventional techniques.

MATERIALS AND METHODS

A systematic literature search was conducted in PubMed (Medline), Embase, Web of Science, and Cochrane (Core Collection) databases on May 16, 2023. Literature comparing surgical navigation with a conventional method using postoperative three-dimensional computed tomography imaging was collected. Only articles that studied at least one of the following outcomes were included: technical accuracy (angular accuracy, linear accuracy, volumetric accuracy, and degree of enophthalmos), preoperative and perioperative times, need for revision, complications, and total cost of the intervention. MINORS criteria were used to evaluate the quality of the articles.

RESULTS

After screening 3733 articles, 696 patients from 27 studies were included. A meta-analysis was conducted to evaluate volumetric accuracy and revision rates. Meta-analysis proved a significant better volumetric accuracy (0.93 cm3 ± 0.47 cm3) when surgical navigation was used compared with conventional surgery (2.17 cm3 ± 1.35 cm3). No meta-analysis of linear accuracy, angular accuracy, or enophthalmos was possible due to methodological heterogeneity. Surgical navigation had a revision rate of 4.9%, which was significantly lower than that of the conventional surgery (17%). Costs were increased when surgical navigation was used.

CONCLUSION

Studies with higher MINORS scores demonstrated enhanced volumetric precision compared with traditional approaches. Surgical navigation has proven effective in reducing revision rates compared to conventional approaches, despite increased costs.

Computer-assisted navigation in oral and maxillofacial surgery: A systematic review

Background

The term "navigation" describes a device that can pinpoint critical anatomical features, the most direct path to the target, and the optimal surgical orientation. This study aimed to conduct a comprehensive literature search on computer-assisted navigation for use in oral and maxillofacial surgery.

Methods

Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement, relevant studies were retrieved from five electronic databases: Medline, Web of Science, PubMed, Google Scholar, and Saudi Digital Library (SDL). The central question was, "Does the computer-assisted navigation system improve the outcome of surgical procedures in the oral and maxillofacial region?" The Cochrane Risk of Bias 2 was used to determine the various types of bias.

Results

Post-traumatic midfacial reconstruction is one of the many fields that have benefited from the use of computer-assisted navigation because of its reliability. It can also be used to extricate difficult foreign entities from the operative zone. Locating critical anatomical components, communicating the surgical plan to the patient, and verifying surgical success can improve the function and appearance of patients with dentofacial abnormalities. In addition, it decreases the surgical error margin and duration.

Conclusion

Computer-assisted navigation is promising in surgical practice. The accuracy of surgery can be significantly enhanced by first planning the process in a virtual environment and then performing it under close supervision in real time. In addition, the time required for preoperative planning and surgery can be reduced by creating and improving software programs.

New 3D Supramolecular Framework: Photocatalytic Property and Therapeutic Activity on Orbital Wall Fracture

Coordination compounds have undergone booming development in the past 20 years for their applications as multifunctional materials in the field of catalysis and biomedicine. To create compounds with both catalytic and bioactive properties, we selected Cu(II) ion and benzimidazole (Hbim) ligand as the building blocks to fabricate a new cluster-based Cu(II) compound [Cu4OCl6(Hbim)4]n·n(H2O)·2n(EtOH) (1). The exploration of single crystal X-ray diffraction exhibits that complex 1 is a 0D isolated structure on the basis of tetrahedral {Cu4O} clusters. Moreover, such supramolecular framework not only shows excellent photocatalytic effect for the MB photodegradation under the irradiation of ultraviolet light but also has the application values against orbital wall fracture. This work gives new insights on the creation of coordination polymers which might be potentially used as photocatalytic and bioactive reagents.

A Narrative Review of u-HA/PLLA, a Bioactive Resorbable Reconstruction Material: Applications in Oral and Maxillofacial Surgery

The advent of bioresorbable materials to overcome limitations and replace traditional bone-reconstruction titanium-plate systems for bone fixation, thus achieving greater efficiency and safety in medical and dental applications, has ushered in a new era in biomaterial development. Because of its bioactive osteoconductive ability and biocompatibility, the forged composite of uncalcined/unsintered hydroxyapatite and poly L-lactic acid (u-HA/PLLA) has attracted considerable interest from researchers in bone tissue engineering, as well as from clinicians, particularly for applications in maxillofacial reconstructive surgery. Thus, various in vitro studies, in vivo studies, and clinical trials have been conducted to investigate the feasibility and weaknesses of this biomaterial in oral and maxillofacial surgery. Various technical improvements have been proposed to optimize its advantages and limit its disadvantages. This narrative review presents an up-to-date, comprehensive review of u-HA/PLLA, a bioactive osteoconductive and bioresorbable bone-reconstruction and -fixation material, in the context of oral and maxillofacial surgery, notably maxillofacial trauma, orthognathic surgery, and maxillofacial reconstruction. It simultaneously introduces new trends in the development of bioresorbable materials that could used in this field. Various studies have shown the superiority of u-HA/PLLA, a third-generation bioresorbable biomaterial with high mechanical strength, biocompatibility, and bioactive osteoconductivity, compared to other bioresorbable materials. Future developments may focus on controlling its bioactivity and biodegradation rate and enhancing its mechanical strength.

Bioactive Regeneration Potential of the Newly Developed Uncalcined/Unsintered Hydroxyapatite and Poly-l-Lactide-Co-Glycolide Biomaterial in Maxillofacial Reconstructive Surgery: An In Vivo Preliminary Study

Uncalcined/unsintered hydroxyapatite (HA) and poly-l-lactide-co-glycolide (u-HA/PLLA/PGA) are novel bioresorbable bioactive materials with bone regeneration characteristics and have been used to treat mandibular defects in a rat model. However, the bone regenerative interaction with the periosteum, the inflammatory response, and the degradation of this material have not been examined. In this study, we used a rat mandible model to compare the above features in u-HA/PLLA/PGA and uncalcined/unsintered HA and poly-l-lactic acid (u-HA/PLLA). We divided 11 male Sprague–Dawley rats into 3- and 16-week groups. In each group, we assessed the characteristics of a u-HA/PLLA/PGA sheet covering the right mandibular angle and a u-HA/PLLA sheet covering the left mandibular angle in three rats each, and one rat was used as a sham control. The remaining three rats in the 16-week group were used for a degradation assessment and received both sheets of material as in the material assessment subgroup. At 3 and 16 weeks after surgery, the rats were sacrificed, and mandible specimens were subjected to micro-computed tomography, histological analysis, and immunohistochemical staining. The results indicated that the interaction between the periosteum and u-HA/PLLA/PGA material produced significantly more new bone regeneration with a lower inflammatory response and a faster resorption rate compared to u-HA/PLLA alone. These findings may indicate that this new biomaterial has ideal potential in treating maxillofacial defects of the midface and orbital regions.

Facial Reconstruction: A Systematic Review of Current Image Acquisition and Processing Techniques

Introduction: Plastic and reconstructive surgery is based on a culmination of technological advances, diverse techniques, creative adaptations and strategic planning. 3D imaging is a modality that encompasses several of these criteria while encouraging the others. Imaging techniques used in facial imaging come in many different modalities and sub-modalities which is imperative for such a complex area of the body; there is a clear clinical need for hyper-specialized practice. However, with this complexity comes variability and thus there will always be an element of bias in the choices made for imaging techniques. Aims and Objectives: The aim of this review is to systematically analyse the imaging techniques used in facial reconstruction and produce a comprehensive summary and comparison of imaging techniques currently available, including both traditional and novel methods. Methods: The systematic search was performed on EMBASE, PubMed, Scopus, Web of Science and Cochrane reviews using keywords such as "image technique/acquisition/processing," "3-Dimensional," "Facial," and "Reconstruction." The PRISMA guidelines were used to carry out the systematic review. Studies were then subsequently collected and collated; followed by a screening and exclusion process with a final full-text review for further clarification in regard to the selection criteria. A risk of bias assessment was also carried out on each study systematically using the respective tool in relation to the study in question. Results: From the initial 6,147 studies, 75 were deemed to fulfill all selection criteria and selected for meta-analysis. The majority of papers involved the use of computer tomography, though the use of magnetic resonance and handheld scanners using sonography have become more common in the field. The studies ranged in patient population, clinical indication. Seminal papers were highlighted within the group of papers for further analysis. Conclusions: There are clearly many factors that affect the choice of image acquisition techniques and their potential at being ideal for a given role. Ultimately the surgical team's choice will guide much of the decision, but it is crucial to be aware of not just the diagnostic ability of such modalities, but their treatment possibilities as well.

Bone Regeneration Potential of Uncalcined and Unsintered Hydroxyapatite/Poly l-lactide Bioactive/Osteoconductive Sheet Used for Maxillofacial Reconstructive Surgery: An In Vivo Study

Uncalcined and unsintered hydroxyapatite/poly l-lactide (u-HA/PLLA) material has osteoconductive characteristics and is available for use as a maxillofacial osteosynthetic reconstruction device. However, its bone regeneration ability in the maxillofacial region has not been fully investigated. This study is the first to assess the bone regenerative potential of osteoconductive u-HA/PLLA material when it is used for repairing maxillofacial bone defects. A total of 21 Sprague-Dawley male rats were divided into three groups—the u-HA/PLLA, PLLA, or sham control groups. A critical size defect of 4 mm was created in the mandible of each rat. Then, the defect was covered with either a u-HA/PLLA or PLLA sheet on the buccal side. The rats in each group were sacrificed at 2, 4, or 8 weeks. The rats’ mandibles were sampled for histological analysis with hematoxylin and eosin staining, histomorphometry, and immunohistochemistry with Runx2 and osteocalcin (OCN) antibody. The amount of newly formed bone in the u-HA/PLLA group was significantly higher than that of the PLLA group. The expression of Runx2 and OCN in the u-HA/PLLA group was also significantly higher. These results demonstrate that the u-HA/PLLA material has excellent bone regenerative ability and confirm its applicability as a reconstructive device in maxillofacial surgery.

Biomechanical Loading Comparison between Titanium and Unsintered Hydroxyapatite/Poly-L-Lactide Plate System for Fixation of Mandibular Subcondylar Fractures

Osteosynthesis absorbable materials made of uncalcined and unsintered hydroxyapatite (u-HA) particles, poly-l-lactide (PLLA), and u-HA/PLLA are bioresorbable, and these plate systems have feasible bioactive osteoconductive capacities. However, their strength and stability for fixation in mandibular subcondylar fractures remain unclear. This in vitro study aimed to assess the biomechanical strength of u-HA/PLLA bioresorbable plate systems after internal fixation of mandibular subcondylar fractures. Tensile and shear strength were measured for each u-HA/PLLA and titanium plate system. To evaluate biomechanical behavior, 20 hemimandible replicas were divided into 10 groups, each comprising a titanium plate and a bioresorbable plate. A linear load was applied anteroposteriorly and lateromedially to each group to simulate the muscular forces in mandibular condylar fractures. All samples were analyzed for each displacement load and the displacement obtained by the maximum load. Tensile and shear strength of the u-HA/PLLA plate were each approximately 45% of those of the titanium plates. Mechanical resistance was worst in the u-HA/PLLA plate initially loaded anteroposteriorly. Titanium plates showed the best mechanical resistance during lateromedial loading. Notably, both plates showed similar resistance when a lateromedially load was applied. In the biomechanical evaluation of mandibular condylar fracture treatment, the u-HA/PLLA plates had sufficiently high resistance in the two-plate fixation method.

Navigation-Assisted Orbital Trauma Reconstruction Using a Bioactive Osteoconductive/Bioresorbable u-HA/PLLA System

Orbital fractures with orbital wall defects are common facial fractures encountered by oral-maxillofacial surgeons, because of the exposed position and thin bony walls of the midface. The primary goal of surgery is to restore the pre-injury anatomy and volume of hard tissue, and to free incarcerated or prolapsed orbital tissue from the fracture by bridging the bony defects with reconstructive implant material and restoring the maxillofacial-orbital skeleton. Numerous studies have reported orbital fracture repair with a wide variety of implant materials that offer various advantages and disadvantages. The ideal orbital implant material will allow conformation to individual patients' anatomical characteristics, remain stable over time, and are radiopaque, especially for the reconstruction of relatively large and/or complex bony walls. Based on these requirements, novel uncalcined and unsintered hydroxyapatite (u-HA) particles and poly-L-lactide (PLLA; u-HA/PLLA) composite sheets could be used as innovative, bioactive, and osteoconductive/bioresorbable implant materials for orbital reconstruction. In addition, intraoperative navigation is a powerful tool. Navigation- and computer-assisted surgeries have improved execution and predictability, allowing for greater precision, accuracy, and minimal invasiveness during orbital trauma reconstructive surgery of relatively complex and large orbital wall defects with ophthalmological malfunctions and deformities. This review presents an overview of navigation-assisted orbital trauma reconstruction using a bioactive, osteoconductive/bioresorbable u-HA/PLLA system.