THE DIRECT APPROACH TO ACUTE FRACTURES OF THE ZYGOMATIC-MAXILLARY COMPLEX AND IMMEDIATE PROSTHETIC REPLACEMENT OF THE ORBITAL FLOOR

Semiautomatic Procedure for Individual Preforming of Titanium Meshes for Orbital Fractures

BACKGROUND

Three-dimensional reconstruction of the orbital floor is a key procedure in primary or secondary orbital deformity. A new procedure for individually bending and preforming implants preoperatively for the reconstruction of orbital fractures is presented.

METHODS

By using diagnostic computed tomographic scan data, the topography of the orbital floor and wall structures can be recalculated. After mirroring the unaffected side onto the affected side, the defect can be reconstructed virtually. Data of the individual virtual model of the orbital cavity are sent to a template machine that reproduces the surface of the orbital floor and medial walls automatically. A titanium mesh can then be adjusted preoperatively for exact three-dimensional reconstruction. Twelve patients with orbital fractures were treated using individually preformed titanium implants.

RESULTS

All patients treated with this procedure showed normal eye mobility and function after primary reconstruction. The accuracy of the preformed implants lies in the range of 1 mm.

CONCLUSIONS

This procedure offers an individual anatomical reconstruction of the orbital cavity true to original, especially when the deep orbital cone is affected. Navigation-aided procedures guarantee intraoperatively an exact placement of the preformed mesh even for precise reconstruction of extensive orbital defects.

Safety of titanium mesh for orbital reconstruction

During the past several decades, the standard of care for orbital reconstruction after trauma has been autogenous bone grafts. Complications of bone grafts, including donor site morbidities such as scar alopecia and graft resorption with delayed enophthalmos, have inspired an interest in the use of alloplastic substitutes such as titanium. Titanium's role in orbital reconstruction was limited originally to small orbital defects, and as an adjunct to bone grafts. More recently, clinical studies have documented the sole use of titanium mesh to reconstruct large orbital defects. This study sought to document further the safety and efficacy of titanium mesh in reconstructing large orbital defects after facial trauma, with more extensive follow-up compared with previous studies. In the current study, 55 patients with 67 orbital fractures underwent orbital reconstruction with titanium mesh over a 5-year period. Associated fractures were reduced anatomically and fixed rigidly. For the analysis, 44 patients with 56 orbital fractures had adequate follow-up (mean, 44 months). An abscess developed in one patient who received high-dose steroids for 72 hours before reconstruction. She was treated with broad-spectrum intravenous antibiotics and bedside incision and drainage, and did not require removal of the titanium mesh. No patient in the current series required removal of the titanium mesh. A single case of uncorrected enophthalmos was treated with bone grafting rather than mesh revision. Large orbital defects can be reconstructed using titanium mesh with good functional results and minimal risk for infection. This study covered the authors' first 5 years using titanium. They have now used titanium mesh in orbital reconstructions for more than 10 years, without any additional cases of infection.

Complications and toxicities of implantable biomaterials used in facial reconstructive and aesthetic surgery: a comprehensive review of the literature

The use of implantable biomaterials has become an integral part of aesthetic and reconstructive surgery of the face. Metals are used for fracture fixation devices, whereas polymers are used primarily for bone or soft-tissue substitution. This review of the scientific literature examines the risks and complications of these materials. First, we present an overview of commonly used materials. Second, we address general considerations of toxicity relevant to all biomaterials. Third, we present data from a large number of clinical series on the incidence of complications for individual materials used in specific applications.

Reconstruction of orbital floor with polydioxanone plate

The use of a polydioxanone (PDS) plate for orbital reconstruction was evaluated in 20 patients with various traumatic defects of the orbital floor. The follow-up time was 9 to 45 months (mean 20.4 months). A CT scan was obtained in 13 patients. Radiographic analysis showed that in 12 of the 13 patients there was new bone in the orbital floor. Clinically, most patients had transitory postoperative diplopia (lasting for a mean of 29 days) because of overcorrection. Only 2 patients, however, suffered from persistent diplopia. In one patient, abducens nerve paresis was the cause. It is concluded that PDS is suitable for orbital floor reconstruction, at least in cases in which defects do not exceed 1-2 cm in diameter. Overcorrection seems necessary. The material is well tolerated, is totally absorbed and appears to be replaced by bone in nearly all cases.

An analysis of 2,067 cases of zygomatico-orbital fracture

A ten-year review of 2,067 cases of zygomatico-orbital fractures is presented. The age and sex distribution, anatomical types of fractures, associated maxillofacial and nonmaxillofacial trauma, and causes of the injuries are described. The majority of fractures were sustained by males and resulted from trauma inflicted in altercations. The most common associated facial fractures were mandibular; the most common associated nonmaxillofacial trauma was extremity fractures. Motorcycle accidents caused the most significant amount of associated trauma, followed by motor vehicle accidents in which no seat restraint was used by the victim. Treatment, when indicated, consisted of elevation via a temporal approach followed by fixation where necessary. The fixation methods used are presented and discussed.

Orbital floor fractures and their treatment

Orbital floor fractures can occur with or without any associated fractures of the middle third of the facial skeleton. Fifty-one patients with a unilateral "black eye" after motor vehicle accidents were reviewed. The fractures involving the orbital floor were analysed. The clinical signs and symptoms, with results of radiological examination, are discussed. The various treatment modalities and their postoperative complications are discussed.

Fractures of the orbital floor: indications for exploration and for the use of a floor implant

Fractures of the orbital floor are frequently treated by exploratory surgery and by the insertion of a floor implant, because of the possibility of late diplopia and enophthalmos. The findings of this study would suggest that this fear is not justified and that there is no indication for an early diagnostic exploration of the fractured orbital floor, if there are no clinical or radiological signs of orbital floor fracture within 14 days of the accident. The significance of the status of the periorbita in the method of treatment of the fractured orbital floor is stressed. The suggestion is made, contrary to what is generally found in the literature, that a linear or a comminuted floor fracture and an orbital floor with a defect do not require a floor implant, if the periorbita is intact.

An unusual late complication of orbital floor fracture repair

Three patients developed unilateral proptosis 13, 16, and 20 years after repair of blow-out fracture with orbital floor Teflon implants. In one patient trauma preceded the onset of proptosis. In all three cases, the cause of the proptosis was probably hemorrhage of the capillaries in a fibrous capsule that surrounded the implant and that was evident on orbital CT scan. In two cases on CT scan, a retrobulbar cyst-like structure surrounded the implant, which was confirmed on ultrasonography. In the third case, an irregular soft-tissue density surrounded the implant. Histologically, a fibrous capsule surrounded the implant in all three cases, and in one case, the inner lining of the fibrous capsule was respiratory epithelium. The contents of the cyst-like structure, in two cases, were fresh blood and disintegrating red blood cells and blood products. In the third case, no cyst-like structure or "cyst" contents were identified; however, fibrous tissue containing hemosiderin-laden macrophages suggested the presence of an organized hemorrhage. The patients' proptosis resolved almost completely after surgical removal of the implant, decompression of the "cyst," and partial removal of the "cyst" wall in two cases. The same result followed removal of the implant and part of the fibrous capsule in the third case.

Gelfilm and blowout fractures

A variety of alloplastic and natural substances have been utilized for support of the orbital floor following a blowout fracture. The employment of Gelfilm is herein recommended for the smaller floor defects. Sterile Gelfilm is manufactured from denaturated collagen, is 0.075 mm. thick, and is known to be tolerated well by ocular tissues. Complete absorbsion of Gelfilm occurs in two to three months, obviating the need for removal of a prosthetic material or the lifetime presence of an alloplast in the orbit. In contrast to autografts no additional surgery is required for its preocurement.

Chrome cobalt and gold implant for the reconstruction of a traumatized orbital floor

Diplopia and enophthalmos were two sequelae of injuries to the orbital floor. These have been corrected by chrome cobalt and gold implants in the reconstruction of the orbital-floor defect after the inferior rectus and inferior oblique muscles and the orbital structures were freed from the area of blowout. An infraorbital approach was used for access.

Blowout fracture of the orbit. Diagnosis and treatment

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