Comparison of the Outcomes of Blowout Fracture Repair According to the Orbital Implant:

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.

Correlation between surgical timing and postoperative ocular motility in orbital blowout fractures

PURPOSE

The study reports the correlation between surgical timing and postoperative ocular motility in orbital blowout fractures.

METHODS

This was a retrospective study of 191 patients that underwent surgical repair for unilateral orbital fractures. All patients included in the study had symptomatic diplopia from the fracture. Patients were classified into one of three groups according to the time of surgery after injury: (1) Early (within 14 days of surgery), (2) intermediate (between 15 and 30 days), and (3) late (greater than 30 days). Ocular motility was measured presurgery and at 3 and 6 months postsurgery by Hess chart with calculation of the Hess area ratio (HAR%).

RESULTS

Surgery was conducted at a mean of 24.7 ± 45.0 days (range: 1-283 days) postinjury. There were 120 patients in the early surgery group (surgery at 6.8 ± 3.8 days), 38 in the intermediate surgery group (20.7 ± 4.1 days), and 33 in the late surgery group (95.1 ± 75.0 days). Overall the HAR% improved significantly from a mean of 74.2% preoperatively to 90.8% at 6 months postoperatively (p < 0.01). In the early and intermediate groups, the postoperative HAR% improved significantly with all fracture regions (orbital floor, medial wall, and combined orbital medial wall and floor) (p < 0.05). However, in the late groups, the postoperative HAR% only improved significantly with orbital floor fractures.

CONCLUSION

Pre- and postoperative the HAR% give objective evidence of ocular motility improvement with early orbital floor fracture repair surgery. However, observation can be deployed, as a significant improvement in ocular motility can also be achieved with reconstructive surgery conducted 30 days or more after depressed floor-fragment fractures. Early intervention should be prioritized for symptomatic medial wall fractures, as late surgery does not improve motility.

A Multi-Criteria Assessment Strategy for 3D Printed Porous Polyetheretherketone (PEEK) Patient-Specific Implants for Orbital Wall Reconstruction

Pure orbital blowout fractures occur within the confines of the internal orbital wall. Restoration of orbital form and volume is paramount to prevent functional and esthetic impairment. The anatomical peculiarity of the orbit has encouraged surgeons to develop implants with customized features to restore its architecture. This has resulted in worldwide clinical demand for patient-specific implants (PSIs) designed to fit precisely in the patient's unique anatomy. Material extrusion or Fused filament fabrication (FFF) three-dimensional (3D) printing technology has enabled the fabrication of implant-grade polymers such as Polyetheretherketone (PEEK), paving the way for a more sophisticated generation of biomaterials. This study evaluates the FFF 3D printed PEEK orbital mesh customized implants with a metric considering the relevant design, biomechanical, and morphological parameters. The performance of the implants is studied as a function of varying thicknesses and porous design constructs through a finite element (FE) based computational model and a decision matrix based statistical approach. The maximum stress values achieved in our results predict the high durability of the implants, and the maximum deformation values were under one-tenth of a millimeter (mm) domain in all the implant profile configurations. The circular patterned implant (0.9 mm) had the best performance score. The study demonstrates that compounding multi-design computational analysis with 3D printing can be beneficial for the optimal restoration of the orbital floor.

Comparison of Nasoseptal Cartilage Graft Versus Titanium Mesh in Reconstruction of Pure Orbital Blowout Fractures

PURPOSE

To compare the efficacy of nasoseptal cartilage grafts versus titanium mesh implants in pure orbital blowout fractures.

METHODS

A retrospective review was performed on 48 patients who had surgical repair of an orbital fracture. Patients who underwent pure orbital blowout fracture repair with either nasoseptal cartilage grafts or titanium mesh implants and at least 1 year postoperative follow-up were included in the study. The clinical features and treatment outcomes were analyzed.

RESULTS

Twenty-five patients fulfilled our study criteria and were included in the analyses. Nasoseptal graft was used in 12 patients (48%) while titanium mesh was preferred in 13 patients (52%). Preoperative clinical features including age, size of the floor defect, and preoperative clinical findings (enophthalmos, diplopia, and restriction of ocular motility) were similar between 2 groups. Mean postoperative follow-up was 14.7 ± 2.3 months in the nasoseptal group while it was 16.1 ± 2.5 months in the titanium group (P = 0.84). Diplopia and ocular motility limitation were resolved in all patients at the last postoperative follow-up visit, while 1 patient in each group had enophthalmos (8.3% versus 7.6%, P = 1.0). No patient in the nasoseptal group experienced postoperative complications while 2 patients in the titanium group (15.3%) developed material-related complications (P = 0.48).

CONCLUSIONS

Long-term clinical results of nasoseptal cartilage grafts and titanium mesh implants in pure orbital blowout fractures with preoperative floor defects smaller than 4 cm2 were comparable. Nasoseptal cartilage grafts may be preferred in patients with septal deviation and no spurs or turbinate hypertrophy.

The trend of recovery period on postoperative eye movement in orbital blowout fractures

To investigate the trend of restoration of postoperative eye movements after orbital blowout fractures by analyzing the percentage of Hess area ratio (HAR%). This was a retrospective study of patients who underwent orbital blow out reconstruction surgery within 28-days post injury. Eye movements were measured preoperatively and 3, 6, and 12 months post operatively by Hess chart. Orbital fractures were classified into three shapes: trap-door fracture with muscle entrapment, trap-door fracture with incarcerated tissue, and depressed fracture. Correlations between fracture shapes, regions, reconstruction implant, age and HAR% were analyzed. This study involved 125 eyes (64 right eyes and 61 left eyes) of 125 isolated orbital fracture cases (95 males, 30 females, mean age: 27.2, range 4-85 years old). Of the total 125 cases, 96 patients had orbital floor fractures, 18 had orbital medial wall fractures, and 11 had combined orbital medial wall and floor fractures. Three had trap-door fractures with muscle entrapment, 42 had trap-door fractures with incarcerated tissue, and 80 had orbital depressed fractures. The overall mean HAR% improved significantly from 76.0 pre-operatively to 95.5 post-12 months (P < 0.01). The mean HAR% in orbital floor fracture improved significantly from 76.7 pre-operatively to 92.9 and 94.7 at 3, 6 months respectively. There was a non-significant improvement in the HAR% in medial wall fractures from 83.2 pre-operatively to 89.5 at 3 months and a significant improvement to 93.2 at 6 months (p < 0.05). Orbital fractures were reconstructed with either Unsintered hydroxyapatite particles/poly l-lactide composite sheet (u-HA/PLLA composite sheet) (91 patients), a silicone silastic sheet (20 patients) a combination of sheets (7 patients) or without an implant (7 patients). There was no significant difference in the HAR% improvement between the different implants. The HAR% improvement was significantly greater in patients <18 years old than in those aged 18 or over. The HAR% is an effective method of the objective assessment of recovery after orbital fracture. Patients and surgeons should be aware that the recovery after medial wall fractures is slower than after floor fractures and continues after three months post-surgery and that a longer period of observation without further intervention may be required for medial wall fractures, whilst floor fractures are likely to have achieved their maximal recovery by three months.

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.

Application of Three-Dimensional Printing Technology in the Orbital Blowout Fracture Reconstruction

The aim of this study was to investigate the clinical outcomes of orbital blowout fracture repair by using the three-dimensional (3D) printing-assisted fabrication of individual titanium mesh. Clinical and radiologic data were analyzed for 12 patients with orbital floor and/or medial wall fractures. Lower eyelid incision was used to expose the fractures. Preoperative computed tomographic data were input into an imaging software to rebuild a 3D orbit and mirror the unaffected side into the affected side to replace the demolished orbit. A resin model of the reshaped orbit was generated and used to develop an individual titanium mesh for repairing the fractured orbital. The surgical results were assessed by value of enophthalmos and a comparison of preoperative and postoperative orbital volume difference. All patients had a successful treatment outcome without any complications. Clinical significant enophthalmos were not observed after treatment, and diplopia were solved within 2 weeks postoperative. No extraocular muscle limitation was observed. Postoperative computed tomography scans demonstrated appropriate positioning of titanium mesh and there was no implant displacement. The postoperative orbital volume and enophthalmos difference between the 2 eyes decreased significantly than preoperative (P < 0.001). Three-dimensional printing-assisted fabrication of individual titanium mesh is appropriate for use in orbital blowout fracture.

A novel technique for placing titanium mesh with porous polyethylene via the endoscopic transnasal approach into the orbit for medial orbital wall fractures

Background

The endoscopic transnasal approach is widely used for reconstructing the medial orbital wall by filling it with a silicone sheet or Merocel, but this technique has the disadvantage of retaining the packing for a long time. To overcome this drawback, a method of positioning an absorbable plate in the orbit has been introduced, but there is a risk of defect recurrence after the plate is absorbed. Here, the authors report the results of a novel surgical technique of placing a nonabsorbable titanium mesh with porous polyethylene into the orbit through the endoscopic transnasal approach.

Methods

Fourteen patients underwent surgery using the endoscopic transnasal approach. Preoperative computed tomography (CT) was used to calculate the size of the bone defect due to the fracture, and the titanium mesh was designed to be shorter than the anteroposterior length of the defect and longer than its height. The titanium mesh was inserted into the orbit under an endoscopic view. The authors then confirmed that the titanium mesh supported the orbital contents by pressing the eyeball and finished the operation. Immediately after surgery, CT results were evaluated.

Results

Postoperative CT scans confirmed that the titanium mesh was well-inserted and in the correct position. All patients were discharged without any complications.

Conclusions

We obtained satisfactory results by inserting a titanium mesh with porous polyethylene into the orbit via the transnasal approach endoscopically.

Permanent Versus Bioresorbable Implants in Orbital Floor Blowout Fractures

PURPOSE

To compare the outcomes of bioresorbable and permanent implants in the reconstruction of isolated orbital floor blowout fractures.

METHODS

Retrospective series of all patients who had orbital floor fracture repair in a single tertiary trauma center from January 2005 to December 2014. The authors reviewed the case notes and CT scans of patients with orbital floor fracture repair with either bioresorbable or permanent implants. Main outcome measures were enophthalmos, diplopia, and ocular motility restriction 1.5 years after fracture repair. Implant-related complications were collected for analysis.

RESULTS

There were a total of 88 patients in our study. Bioresorbable implants were used in 48 patients (54.5%) while 40 patients had permanent implants (45.5%). The authors analyzed the implants used in various sizes of orbital fractures: small (<13.3 mm), medium (13.3-20 mm), and large (>20 mm). One and a half years after fracture repair, both groups had comparable clinical outcomes (n = 2 and n = 0 for diplopia for permanent and bioresorbable implant groups, respectively, n = 0 for enophthalmos for both groups and n = 1 for ocular motility limitation for both groups) overall and across all fracture sizes.

CONCLUSION

Bioresorbable implants degrade after fracture healing through hydrolysis and promote the gradual transfer of functional forces to healing bone during its disintegration. The clinical outcomes of diplopia, enophthalmos, and ocular motility restriction associated with the use of resorbable implants are comparable to that of permanent implants for all fracture sizes. Their study shows that bioresorbable and permanent implants are equally safe and effective for the treatment of patients with isolated orbital floor blowout fractures.

High-Density Polyethylene Material versus Autogenous Grafts in Craniofacial Augmentation Procedures

AIM

The objective was to do a comparative study and to evaluate the outcome in overall acceptance for correction of residual facial deformity with autogenous graft versus porous polyethylene implants.

MATERIALS AND METHODS

A total of 16 patients in the age group of ≥15 years irrespective of sex, caste, religion, and socioeconomic status presenting with signs and symptoms of residual facial deformities and who were declared fit for surgery were included in the study. The study patients were further divided into two groups, of eight each. Deformity correction using autogenous grafts was performed in Group A and using high-density polyethylene (HDPE) alloplastic implants was performed in Group B. During the follow-up period, patients' and doctor rating of overall acceptance between autogenous and alloplastic (HDPE) bone grafts was recorded on 100-mm visual analog scale (VAS) on the 2nd day and 7th day and at 3, 6, and 12 weeks.

RESULTS

The unpaired t-test is used for evaluation. VAS score at all the follow-up periods above stated was significantly higher in alloplastic group than in the autogenous group for both in patients and doctor evaluation.

CONCLUSION

From the present study, it can be concluded that porous HDPE implants are an effective alternative to autogenous grafts in accordance of overall acceptance for correction of residual facial deformity when proper case selection, exclusion of negative prognostic factors, and meticulous surgical procedure are followed.

Medial Orbital Wall Reconstruction With Porous Polyethylene by Using a Transconjunctival Approach With a Caruncular Extension

BACKGROUND

The reported rate of isolated medial orbital wall fractures varies widely but has been found to be as high as 55% of all orbital fractures. Identifying and repairing medial orbital wall defects by using appropriate materials improves patient outcome considerably; however, most related research has focused on orbital floor defect management rather than medial orbital wall treatment, and no consensus on repairing medial orbital wall fractures exists. Furthermore, medial orbital wall fracture is a main cause of posttraumatic enophthalmos. In this study, we introduce a modified surgical technique for repairing large medial wall fractures stably, also reviewed relevant literature and established an algorithm for managing medial orbital wall fractures.

METHODS

We reviewed the outcomes of facial trauma patients who underwent facial bone reduction and internal fixation surgery in our hospital between October 1, 2010, and October 1, 2013. The patients were all treated medial orbital wall reconstruction with porous polyethylene by using a transconjunctival approach with a caruncular extension for large medial orbital wall fractures. Medical records and radiologic images of the patients were reviewed retrospectively. The outcomes evaluated were trauma mechanism, clinical findings of ocular injury, preoperative and postoperative ocular symptoms, degree of enophthalmos, and orbital volume restoration after surgery.

RESULTS

Transconjunctival approach with a caruncular extension was performed without any complications. The incidence of diplopia was 47.4% and enophthalmos (>2 mm) was 31.6%, with no significant diplopia and enophthalmos after surgery. Patients were symptom-free on follow-up. The average enophthalmos was successfully corrected from 0.88 mm preoperatively to 0.26 mm and orbital volume was corrected from 26.22 to 22.99 cm after surgery; these results also showed P less than 0.001.

CONCLUSIONS

The current results suggest that the proposed method of medial orbital wall reconstruction, in which porous polyethylene is implanted by using a transconjunctival approach with a caruncular extension, yields favorable outcomes. The approach facilitates a wide visualization of the operative field, which provides sufficient working space for implant insertion and is consequently free from iatrogenic trauma or surgery-related complications.

Evaluation of the Retro-Orbital Fatty Tissue Volume in Delayed Orbital Blow-Out Fractures

PURPOSE

In patients where diplopia and enophthalmia are manifest, surgical intervention is usually necessary. The pathogenesis of these symptoms usually includes the prolapse of orbital tissues into the sinus or compression by the surrounding bone structures. Although the retro-orbital fatty tissue, orbital fascia, and the muscle tissue can be reduced to the original place after being incarcerated into the maxillary space, it is obvious that the procedure can lead to significant fibrosis in these structures. The authors have aimed to carry out a quantitative evaluation of the fatty tissue volumes in patients with repair delayed for more than two weeks.

METHODS

The preoperative and postoperative fatty tissue volumes and the changes in total orbital volume were evaluated by using CT on the patients (n = 9) who were consulted to the authors' clinic from other health centers.

RESULTS

Although no significant correlation was observed between the prolapsed volume and the postoperative reduction in the fatty tissue, the reduction in the retro-orbital fatty tissue was statistically significant.

CONCLUSION

Evaluating postoperative retro-orbital fatty tissue volumes may have implications for surgical intervention in the future.

Postoperative Complications in Craniomaxillofacial Reconstruction With Medpor

Bone reconstruction in craniofacial surgery is a challenge for surgeons, who most commonly adopt the autogenous bone grafting and alloplastic implants in such procedures. Among the alloplastic materials, the high-density porous polyethylene is highlighted-Medpor (Medpor, Porex Surgical Inc, Newman, GA), considered to be pure polyethylene, with only 1 manufacturing process and standard pore size. The purpose of the current study has been to present through a review of literature and the types of complications derived from the use of Medpor in craniomaxillofacial bone surgery. A specific and sensitive database was initially created via PubMed, focusing on studies published in English peer-reviewed journals between 2004 and 2014, including case reports, experimental studies in humans, and prospective and retrospective studies. Forty articles were found at PubMed database. After analyzing their abstracts, 19 were selected, totaling 1453 patients and 121 complications, being the most commonly reported diplopia with 56 patients and infection with 6 patients. Most of the complications reported in the articles used for the development of the current review are not directly related to the use of the Medpor implant. The only complications directly related to the use of this biomaterial were cases of infection.

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.

Ocular Motility After Repair of Combined Medial and Inferior Orbital Wall Fractures With Extended Conjunctival Incision With Inferior Oblique Reattachment

PURPOSE

To describe ocular motility and effectiveness of an extended conjunctival incision with reattachment of the inferior oblique muscle to repair combined orbital medial and inferior wall fractures.

METHODS

The authors retrospectively studied 20 eyes from 20 patients who underwent combined orbital medial and inferior wall fractures surgery with reattachment of the inferior oblique muscle from January 2007 to December 2011. Single large L-shaped implant was inserted into the fracture site. All patients were evaluated preoperatively and postoperatively at 1, 3, and 6 months, by computed tomography, Hertel exophthalmometry, the Hess test of ocular motility, and the Goldmann diplopia test.

RESULTS

Sixteen patients (80%) had no significant enophthalmos or diplopia after surgery. Inferior oblique motility was not changed in 12 patients (60%) after reattachment of the inferior oblique muscle. After 1 month, inferior oblique underaction was presented in 8 patients (40%) and in 4 patients (20%) after 6 months. Finally, only 2 patients (10%) had the inferior oblique underaction remained, it was not improved.

CONCLUSIONS

The extended conjunctival incision with reattachment of the inferior oblique muscle for combined orbital wall fracture repair offers a wide surgical field and space for a single large implant insertion and corrects the enopthalmos. The reattachment of the inferior oblique muscle does not contribute to the development of inferior oblique underactions or diplopia that was resolved spontaneously within 6 months after surgery.

Medial Wall Orbital Reconstruction using Unsintered Hydroxyapatite Particles/Poly L-Lactide Composite Implants

Background

Poly-L-lactide materials combined with hydroxyapatite (u-HA /PLLA) have been developed to overcome the drawbacks of absorbable materials, such as radiolucency and comparably less implant strength. This study was designed to evaluate the usefulness of u-HA/PLLA material in the repair of orbital medial wall defects.

Methods

This study included 10 patients with pure medial wall blow-out fractures. The plain radiographs were taken preoperatively, immediately after, and 2 months after surgery. The computed tomography scans were performed preoperatively and 2 months after surgery. Patients were evaluated for ease of manipulation, implant immobility, rigidity and complications with radiologic studies.

Results

None of the patients had postoperative complications, such as infection or enophthalmos. The u-HA/PLLA implants had adequate rigidity, durability, and stable position on follow-up radiographic studies. On average, implants were thawed 3.4 times and required 14 minutes of handling time.

Conclusion

The u-HA/PLLA implants are safe and reliable for reconstruction of orbital medial wall in terms of rigidity, immobility, radiopacity, and cost-effectiveness. These thin yet rigid implants can be useful where wide periosteal dissection is difficult due to defect location or size. Since the u-HA/PLLA material is difficult to manipulate, these implants are not suitable for use in complex 3-dimensional defects.

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.

A new option for the reconstruction of orbital floor defects with heterologous cortical bone

BACKGROUND

The orbital floor is one of the most frequently injured areas of the maxillofacial skeleton during facial trauma. A retrospective analysis of patients who have undergone treatment of orbital floor fractures with heterologous cortical bone is presented.

METHODS

This retrospective study was carried out with 21 patients over a period of 4 years between 2010 and 2014. All patients with a traumatic orbital floor defect who underwent reconstruction with heterologous cortical bone were included. The operations were carried out under general anesthesia for all patients. A subciliary incision was used in 20 patients and an infraorbital approach was used in one patient. All patients underwent follow-up examinations clinically as well as radiologically, at 1, 3, 6 and 12 months postoperatively. Computed tomographic scans were taken at the postoperative 6th month, and at the first postoperative year if needed.

RESULTS

Preoperatively, the physical examination revealed diplopia in 17 patients (80.9%), gaze restriction in 14 patients (66.6%), enophthalmos in six patients (28.5%), and infraorbital nerve paresthesia in two patients (9.5%). None of the patients showed impaired visual acuity preoperatively or postoperatively. Diplopia and gaze restriction resolved postoperatively in all of the patients. All patients had a negative intraoperative forced duction test demonstrating free globe movement. Enophthalmos showed complete resolution in the postoperative period. In one of the two patients with preoperative infraorbital nerve paresthesia, this resolved at the postoperative fifth month. Scleral show appeared in six patients but resolved completely within 3-8 weeks with massage. There was no graft extrusion, resorption or displacement during the follow-up period.

CONCLUSIONS

Tecnoss Semi Soft Lamina is a good alternative for the reconstruction of blowout fractures due to its plasticity and biocompatible structure. Without donor site morbidity, it is a safe and appropriate heterologous bone graft material for maxillofacial applications such as orbital floor reconstruction. We cannot recommend its use for near-total, wide orbital floor defects as it may not provide enough support in such circumstances.

A Novel Bioresorbable Implant for Repair of Orbital Floor Fractures

PURPOSE

To describe clinical, radiologic, and safety outcomes of orbital floor fracture repair using a novel bioresorbable polycaprolactone (PCL) mesh implant (Osteomesh™, Osteopore International, Singapore).

METHODS

This is a prospective interventional case series of orbital floor fractures repaired using a novel PCL mesh implant. Clinical evaluation was conducted at presentation and postoperatively at 1, 4, 12, 24 and 48 weeks. Computed tomography (CT) of the orbits was performed 1 year postoperatively.

RESULTS

A total of 20 patients were recruited. Mean follow up was 50.4 ± 31.88 weeks. The majority of the patients were male (60%) and of Chinese ethnicity (75%), and the mean age was 39.35 (range 13-69) years. The most common mechanism of injury was assault. The average fracture size was 21.9 mm (range 12-32 mm) in the anteroposterior meridian and 18.65 mm (range 6-27 mm) in the horizontal meridian. Fifty percent of the patients were classified as having a large orbital defect (horizontal width ≥20 mm). The binocular single vision (BSV) score improved from 72.1% preoperatively to 90.8% postoperatively (P < 0.05) for 17 patients who had pre and postoperative charts. BSV improvement did not differ significantly between those with large and small orbital fracture sizes. There were features of neobone formation on CT scan performed 1.5 years after implantation.

CONCLUSION

This bioresorbable implant is a promising material for the repair of both small and large orbital floor fractures, giving good functional and aesthetic outcomes.

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.

Foreign Body Granuloma Following Orbital Reconstruction with Porous Polyethylene

Porous polyethylene is commonly used in the orbit for fracture repair and anophthalmic reconstruction; it reportedly has a good safety profile and integrates well into host tissue. Foreign body reaction to porous polyethylene has been reported in facial tissue, but to our knowledge, not in the orbit. The authors report 2 cases of foreign body inflammatory giant cell reaction in patients who underwent orbital fracture repairs with porous polyethylene implants.

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.