Late reconstruction of orbital and naso-orbital deformities

Assessment of quality of life in patients treated for orbital fractures

PURPOSE

This study aimed to assess the quality of life (QOL), before and after surgery, of patients who underwent open reduction and internal fixation for orbital fractures.

STUDY DESIGN

A prospective study.

PARTICIPANTS AND SETTING

The self-report outcome measures of 50 patients treated at the Department of Oral and Maxillofacial Surgery of the Second Affiliated Hospital of Jiamusi University from January 2016 to June 2019 were prospectively collected.

MAIN MEASURES

The quality of life was assessed using four patient-reported outcome measures (PROMs): the 15D questionnaire, Oral Health Impact Profile-14 (OHIP-14), Hospital Anxiety and Depression Scale (HADS), and 36-item Short Form Survey (SF-36). Both descriptive and comparative data analyses were calculated.

RESULTS

Zygomaticomaxillary complex fractures were the most encountered (40.3%). The total OHIP-14 scores before and after treatment were 1.72 and 1.68, respectively. Vision, breathing, sleeping, eating, usual activities, discomfort and symptoms, and vitality showed minimal changes in the 15D questionnaire. The HADS scores were ranged from 0 to 7, indicating no anxiety or depression. The comparison of SF-36 scores after 3 months and after ≥6 months of treatment revealed no significant difference.

CONCLUSIONS

Patients' QOL was minimally impacted by orbital fractures and their treatments. The severity of the negative impact can be minimized if appropriate management strategies are taken.

Late patient-fitted total orbital reconstruction for facial gunshot wound sequelae

Late reconstructions of gunshot wounds (GSWs) in the orbital area are a true challenge to the oral and maxillofacial surgeon. Usually, the wall defects are large in size and commonly present loss of orbital volume, which can cause ocular dystopia. The only exceptions are when there is an explosion of the orbital walls-that is, blow-out fractures. We encountered a patient with a two-year sequelae after GSW in the face that caused the destructed orbit to have a 2.5 bigger size than the contralateral orbit, requiring meticulous planning of a patient-specific implant (PSI) to correctly reconstruct the orbit volume and bone projection. The PSI was developed using titanium and it had three pieces that could reconstruct all four walls of the orbit. After surgery, the patient regained orbital volume and malar projection, allowing him to benefit from facial symmetry. The PSI can be used to reconstruct all the orbital walls in cases of complex bone defects.

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

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

Low-Cost 3D Printing Orbital Implant Templates in Secondary Orbital Reconstructions

PURPOSE

Despite its increasing use in craniofacial reconstructions, three-dimensional (3D) printing of customized orbital implants has not been widely adopted. Limitations include the cost of 3D printers able to print in a biocompatible material suitable for implantation in the orbit and the breadth of available implant materials. The authors report the technique of low-cost 3D printing of orbital implant templates used in complex, often secondary, orbital reconstructions.

METHODS

A retrospective case series of 5 orbital reconstructions utilizing a technique of 3D printed orbital implant templates is presented. Each patient's Digital Imaging and Communications in Medicine data were uploaded and processed to create 3D renderings upon which a customized implant was designed and sent electronically to printers open for student use at our affiliated institutions. The mock implants were sterilized and used intraoperatively as a stencil and mold. The final implant material was chosen by the surgeons based on the requirements of the case.

RESULTS

Five orbital reconstructions were performed with this technique: 3 tumor reconstructions and 2 orbital fractures. Four of the 5 cases were secondary reconstructions. Molded Medpor Titan (Stryker, Kalamazoo, MI) implants were used in 4 cases and titanium mesh in 1 case. The stenciled and molded implants were adjusted no more than 2 times before anchored in place (mean 1). No case underwent further revision.

CONCLUSIONS

The technique and cases presented demonstrate 1) the feasibility and accessibility of low-cost, independent use of 3D printing technology to fashion patient-specific implants in orbital reconstructions, 2) the ability to apply this technology to the surgeon's preference of any routinely implantable material, and 3) the utility of this technique in complex, secondary reconstructions.

Three dimensional reconstruction of late post traumatic orbital wall defects by customized implants using CAD-CAM, 3D stereolithographic models: A case report

Aim

Purpose of this case report is to highlight the precision and accuracy obtained with patient specific implants for orbital reconstruction designed on the basis of volumetric analysis of orbital computed tomographic scan (CT) scans using virtual planning, computerised designing and manufacturing and stereolithographic models to correct late post-traumatic orbital deformities such as enophthalmos and diplopia.

Material and methods

This case report describes a patient who visited our outpatient clinic for correction of enophthalmos and persistent diplopia in upward gaze, seven months post trauma. Three dimensional (3D) virtual treatment planning was carried out by using the 3D CT data. The unaffected orbit of the contralateral side was superimposed on the deformed orbit to highlight the defect and a customized implant was designed in the desired size and shape on the virtual model using computer aided designing and manufacturing (CAD-CAM) and milled in titanium mesh for precise anatomic orbital reconstruction.

Results

There was a marked improvement in both the diplopia in upward gaze and enophthalmos post surgery when the customized patient specific orbital implant was used.

Conclusion

The concept of using customized implant with the help of 3D virtual treatment planning, 3D stereolithographic models and CAD-CAM greatly improves the correction of extremely difficult late post-traumatic orbital deformities.

Secondary reconstruction of maxillofacial trauma

PURPOSE OF REVIEW

Craniomaxillofacial trauma is one of the most complex clinical conditions in contemporary maxillofacial surgery. Vital structures and possible functional and esthetic sequelae are important considerations following this type of trauma and intervention. Despite the best efforts of the primary surgery, there are a group of patients that will have poor outcomes requiring secondary reconstruction to restore form and function. The purpose of this study is to review current concepts on secondary reconstruction to the maxillofacial complex.

RECENT FINDINGS

The evaluation of a posttraumatic patient for a secondary reconstruction must include an assessment of the different subunits of the upper face, middle face, and lower face. Virtual surgical planning and surgical guides represent the most important innovations in secondary reconstruction over the past few years. Intraoperative navigational surgery/computed-assisted navigation is used in complex cases. Facial asymmetry can be corrected or significantly improved by segmentation of the computerized tomography dataset and mirroring of the unaffected side by means of virtual surgical planning. Navigational surgery/computed-assisted navigation allows for a more precise surgical correction when secondary reconstruction involves the replacement of extensive anatomical areas. The use of technology can result in custom-made replacements and prebent plates, which are more stable and resistant to fracture because of metal fatigue.

SUMMARY

Careful perioperative evaluation is the key to positive outcomes of secondary reconstruction after trauma. The advent of technological tools has played a capital role in helping the surgical team perform a given treatment plan in a more precise and predictable manner.

Do Radiologists and Surgeons Speak the Same Language? A Retrospective Review of Facial Trauma

OBJECTIVE

The objective of the present study is to examine the concordance of facial fracture classifications in patients with trauma who underwent surgery and to assess the epidemiologic findings associated with facial trauma.

MATERIALS AND METHODS

Patients with trauma who underwent facial CT examination and inpatient operative intervention during a 1-year period were retrospectively analyzed. Patient demographic characteristics, the mechanism of injury, the radiology report, the surgical diagnosis, and clinical indications were reviewed. Fractures were documented according to bone type and were classified into the following subtypes: LeFort 1, LeFort 2, LeFort 3, naso-orbital-ethmoidal, zygomaticomaxillary complex (ZMC), orbital, and mandibular. Concordance between the radiology and surgery reports was assessed.

RESULTS

A total of 115,000 visits to the emergency department resulted in 9000 trauma activations and 3326 facial CT examinations. One hundred fifty-six patients (4.7%) underwent facial surgical intervention, and 133 cases met criteria for inclusion in the study. The mean injury severity score was 10.2 (range, 1-75). The three most frequently noted injury mechanisms were as follows: assault (77 cases [57.9%]), a traffic accident (21 cases [15.8%]), and a fall (20 cases [15%]). The three most frequently noted facial bone fractures were as follows: mandible (100 cases [75.2%]), maxilla (53 cases [39.8%]), and orbit (53 cases [39.8%]). The five descriptors most frequently found in the radiology and surgery reports were the mandibular angle (25 cases), the orbital floor (25 cases), the mandibular parasymphysis (22 cases), the mandibular body (21 cases), and ZMC fractures (19 cases). A classification was not specified in 31 of the radiologic impressions (22.5%), with 28 of 31 radiologists expecting the surgeon to read the full report. The descriptors used in the radiology and surgery reports matched in 73 cases (54.9%) and differed in 51 cases (38.3%). No classifications were used by one or both specialties in nine cases (6.8%).

CONCLUSION

For 38.3% of patients needing facial surgery, descriptors used in the radiologic and surgery reports differed. Speaking a common language can potentially improve communication between the radiology and surgery services and can help expedite management of cases requiring surgery.

A Novel Method of Orbital Floor Reconstruction Using Virtual Planning, 3-Dimensional Printing, and Autologous Bone

Fractures of the orbital floor are often a result of traffic accidents or interpersonal violence. To date, numerous materials and methods have been used to reconstruct the orbital floor. However, simple and cost-effective 3-dimensional (3D) printing technologies for the treatment of orbital floor fractures are still sought. This study describes a simple, precise, cost-effective method of treating orbital fractures using 3D printing technologies in combination with autologous bone. Enophthalmos and diplopia developed in a 64-year-old female patient with an orbital floor fracture. A virtual 3D model of the fracture site was generated from computed tomography images of the patient. The fracture was virtually closed using spline interpolation. Furthermore, a virtual individualized mold of the defect site was created, which was manufactured using an inkjet printer. The tangible mold was subsequently used during surgery to sculpture an individualized autologous orbital floor implant. Virtual reconstruction of the orbital floor and the resulting mold enhanced the overall accuracy and efficiency of the surgical procedure. The sculptured autologous orbital floor implant showed an excellent fit in vivo. The combination of virtual planning and 3D printing offers an accurate and cost-effective treatment method for orbital floor fractures.