Treatment Of Orbital Floor Fractures Research Articles

Tratamento cirúrgico de fratura orbitária Blow-out com tela de titânio: Relato de caso

Blow-out fractures are known to affect the floor or medial wall of the orbit, an anatomical region located in the middle third of the face. For an accurate diagnosis of this fracture, a thorough clinical examination associated with imaging is necessary, among them, multi-slice computed tomography is considered the “gold standard” for diagnosis and planning the approach to this type of fracture, as it allows visualization all structures without interferences, and also allowing the degree of bone comminution to be measured. Among the tomographic planes, the coronal section stands out for enabling a better assessment of the orbital floor and medial wall. Signs and symptoms are usually diplopia, enophthalmos, malar changes, restricted ocular mobility, infraorbital nerve paresthesia, periorbital ecchymosis. There are several types of surgical approaches for treating this type of trauma and to reconstruct blow-out fractures, alloplastic materials, autogenous or heterogenous grafts are chosen. The objective of this paper is to report a clinical case of blow-out orbital fracture, the surgical approach, reduction and fixation with a 1.5mm system mini-plate on the left infra-orbital rim and reconstruction of the left orbital floor with a titanium mesh, giving emphasis on the treatment of orbital floor fractures, with titanium mesh and the good prognosis without signs of contamination or postoperative foreign body reaction. Adequate clinical and anamnestic examination, plus imaging examination, followed by convergent planning, increases the chances of a good prognosis, always with the aim of achieving, when possible, the reconstruction of the form, function and aesthetics of the traumatized area.

Treatment of orbital floor fractures in a reference center in Mexico city

Background: Orbital trauma accounts for approximately 3% of all emergency department visits, with approximately 4.4 million annual visits in the United States alone. We aim to describe the treatment of adult patients with orbital floor fractures between 2016 and 2021. Methods: A retrospective, descriptive, cross-sectional, and observational study was conducted on the medical records of adult patients with orbital floor fractures between 2016 and 2021 in a referral center in Mexico city. Results: The study included 53 patients, 5 females (8%) and 48 males (92%), with a median age of 37 years at the time of diagnosis. Among the reported trauma mechanisms, falls and violence were the most common. 4 patients (7.5%) had impure right unilateral fractures, 4 patients (7.5%) had impure left unilateral fractures, 18 patients (33.9%) had pure left unilateral fractures, 22 patients (41.5%) had pure right unilateral fractures. Five patients (9.4%) had pure bilateral fractures. Six (11.3%) received non-surgical treatment, while 47 (88.6%) underwent surgical treatment. The most common surgical approach was the transconjunctival with lateral extension. Conclusions: There was a predominance of male patients and physical aggression as the primary trauma mechanism. Automated vehicle accidents were associated with more complex fractures. The most common type of orbital floor fracture was pure right unilateral. Most patients underwent open reduction with internal fixation.

Decision-Making in Treatment of Orbital Floor Fractures

Decision-Making in Treatment of Orbital Floor Fractures

Endoscopic Endonasal Orbital Floor Fracture Repair With Mucosal Preservation to Reinforce the Fractured Bone.

Treatment of orbital floor fracture is often needed to cure diplopia and enophthalmos. However, the available surgical methods have many limitations. An endoscopic endonasal reduction is a familiar approach for otolaryngologists; however, reconstruction of the orbital floor may pose certain problems. Here, the authors developed the endoscopic endonasal orbital floor fracture repair with mucosal preservation procedure (mucosal preservation procedure). This study aims to evaluate outcomes after the mucosal preservation procedure. The authors analyzed 18 patients who had their orbital floor repaired using the mucosal preservation procedure. Pre- and post-operative ocular motility range was measured with a Hess screen test, and the percentage of Hess area ratio (HAR%) was used for all statistical comparisons. The distance between the fractured bone and orbital floor (DBFO) on computed tomography was measured before and four months after surgery. Overall, diplopia, and pain improved after surgery in all patients. Diplopia and pain completely disappeared in 17 patients, while only mild diplopia remained in one. HAR% increased significantly, whereas DBFO reduced significantly after the operation. In conclusion, the outcome of the mucosal preservation procedure was favorable without any major complications. Further studies with larger numbers of patients are needed to verify our technique.

Intact Periorbita Can Prevent Post-Traumatic Enophthalmos Following a Large Orbital Blow-Out Fracture.

Treatment of orbital floor fractures is predicated on the restoration of orbital volume to prevent enophthalmos or hypoglobus. Globe position is the result of a complex interplay between the bony orbital anatomy and the soft tissue envelope. Studies on orbital fractures have frequently suggested criteria for repair on the basis of bony defect size or volume change. In this report, we describe a case of a large orbital floor defect (4.8 cm2) with intact periorbita and no herniation of soft tissue contents in a young male following facial trauma. The patient was followed for 1-year clinically and did not develop enophthalmos. This case demonstrates that bony injury alone is not sufficient to produce enophthalmos, and that the interplay between the soft tissue and bony anatomy is a critical determinant of globe position following orbital trauma.

Endoscopically assisted computer-guided repair of internal orbital floor fractures: an updated protocol for minimally invasive management

BackgroundPerforming accurate anatomical reconstruction is a challenging task in the treatment of internal orbital floor fractures. Compared with traditional transcutaneous incisions, endoscopic transmaxillary approaches have the advantage of avoiding complications related to external scars, and provide direct access to the orbital floor. Autogenous bone provides the ideal material for defect reconstruction, but determination of the correct size and shape of the graft is crucial for a stable support. This study introduces a new protocol for the treatment of internal orbital floor fractures that combines endoscopy, virtual reality, and 3D printing. The authors also investigated the impact of computer-aided surgery (CAS) on the overall accuracy of reconstruction in aiming to achieve the triple objective of restoring anatomy, volume, and function. Materials and methodsFourteen patients with orbital floor fractures were recruited for this study. High-resolution CT scans provided appropriate imaging for detailed orbital floor defect visualization. A virtual reconstruction of the orbital floor defect was developed and a 3D printed template was fabricated to provide intraoperative guidance in the graft harvesting phase, according to the orbital defect. Virtual analyses were conducted to evaluate the accuracy of reconstruction both in terms of graft size and graft orientation. ResultsPostoperative CT scans showed that in all cases orbital floor reconstruction was successfully performed, resulting in restoration of the correct globe position. No intraoperative complications occurred. Correspondence of graft size was evaluated using color-coded maps and RMSE, while comparison of angular measurements allowed the authors to relate simulated and actual reconstruction. ConclusionsOrbital floor reconstruction performed via transmaxillary endoscopy is a safe technique, which allows for detailed visualization of the fracture rim, avoids external scars, and permits an easier reduction of the prolapsed orbital content into the overlying orbital cavity. Virtual planning plays an important role in defining the appropriate geometry of the bone graft and establishing the optimal reconstruction strategy. Our preliminary results indicate that virtual planning and 3D printing should become part of an integrated protocol for the endoscopic treatment of orbital floor fractures.

Flattening of the orbital lower eyelid fat as a long-term outcome after surgical treatment of orbital floor fractures

Our aim was to report the incidence of asymmetry of the lower eyelid (that manifests itself as flattening of the eyelid fat) as a long-term complication of the surgical approach of unilateral fractures of the orbital floor. We retrospectively reviewed the aesthetic appearance of the lower eyelid in 43 patients after repair of such fractures. Long-term asymmetry seen as asymmetrical flattening of the eyelid fat was evaluated and graded qualitatively as mild, moderate, and severe. We studied its relations to the surgical approach, patient’s age and sex, and postoperative time; 20 of the 43 had flattening of the lower eyelid fat. There were significantly more patients with flattening of the fat after a transconjunctival approach than after transcutaneous ones (p=0.03). We found a statistical likelihood of the development of flattening of the fat when patients were between 40 and 60 years old at the time of operation (p=0.006). Increasing age at the time of the study was related to increased severity (p=0.0019), with the greatest significance over 55 years old (p=0.006). We found no relation to patients’ sex, or duration of operation. To our knowledge this is the first time that flattening of the eyelid fat has been described as a long-term complication after a particular approach to orbital floor fractures. The transconjunctival incision was more likely to be associated with this long-term outcome. Patients over 40 years old are also at risk of developing flattening, and this is more severe when the patient is over 55. A short follow-up period is not sufficient for the evaluation of the aesthetic outcome of traditional approaches to fractures of the orbital floor in the lower eyelid.

Evaluation de l’intérêt de la préformation préopératoire d’une plaque d’ostéosynthèse en titane sur modèle obtenu par impression 3D pour le traitement des fractures du plancher orbitaire : une revue systématique de la littérature et description d’un nouveau protocole

Evaluation de l’intérêt de la préformation préopératoire d’une plaque d’ostéosynthèse en titane sur modèle obtenu par impression 3D pour le traitement des fractures du plancher orbitaire : une revue systématique de la littérature et description d’un nouveau protocole

Observation on the efficacy of surgeries for the treatment of orbital floor fractures associated with inferior rectus incarceration

Objective To observe the clinical efficacy of surgery for the treatment of orbital floor fractures associated with inferior rectus incarceration. Methods The data of 6 eyes of 6 patients with orbital floor fractures and incarceration of the inferior rectus from Jun. 2013 to Jun. 2014 were analyzed retrospectively. All cases were with diplopia and restriction of upward motility, without enophthalmos, and underwent orbital fracture reduction surgery. The orbital contents protruding into the cavity of the maxillary sinus were returned, and Medpor was implanted for the reconstruction of the inferior orbital wall. Visual acuity, motility and diplopia and CT results pre-and post-operatively were observed and compared. Results All patients were followed up for 3 months. Motility recovered and diplopia disappeared in 5 cases within 2 weeks after injury and 1 patient received surgery more than 2 weeks after injury showed partial improvement of motility and diplopia. Post-operative CT showed the pavimentum orbitae was intact and the inferior rectus reduction. The visual acuity of all patients were not reduced. Conclusion Orbital floor fracture reduction surgery can effectively correct the restricted motility and diplopia of orbital floor fractures and inferior rectus incarceration. Earlier operation might bring more benefits. Key words: Orbital fractures, floor; Inferior rectus incarceration

Clinical research of absorbable bone internal fixation system for the treatment of orbital floor fractures

Objective To evaluate the clinical efficacy of absorbable bone internal fixation system for the treatment of orbital floor fractures. Methods The data of 22 cases with fracture of orbital floor from Aug.2014 to Aug. 2016 were retrospectively analyzed. They underwent absorbable bone internal fixation system treatment.The follow-up time was 6 months. The postoperative therapeutic efficacy was evaluated. Results After surgery, enophthalmos improved in 20 cases (90.91%) , diplopia completely cured in 18 cases(81.82%), diplopia symptom improved in 4 cases(18.18%). Among 19 cases of orbital nerve paresthesia, the symptom improved in 15 cases(78.95%). Conclusion Absorbable internal fixation system is better material of bone repair of orbital floor fractures. Key words: Orbital floor fracture; Internal fixation of bone system, absorbable; Treatment

The application of volumometry as an indication criterion in blow-out fractures.

In this prospective study (2014 - 2016) we treated 29 patients with blow-out fractures. 18 (62%) were treated conservatively and in 11 (38%) we proceeded surgically. We decided whether surgical or non-surgical therapy was appropriate on the basis of clinical ENT, eye examination and the total volume of prolapsed orbital soft tissue. All procedures were perfomed by the same operating team with a uniform subciliary approach and using PMR splints adapted to the correct size and shape. On the basis of the mathematical model we reassessed findings in 2 patients: in one we decided against a surgical solution and in the other a surgical approach was indicated. All 18 patients treated conservatively, fully recovered and are free of diplopia. The 11 operated patients are also free of diplopia, only 1 patient (3%) displays clinically insignificant postoperative diplopia in extreme posisitons when looking upwards. With proper selection of the optimal treatment, the rate of complete disappearance of diplopia and fully preserved motility of the eyeball ranges from 91 to 97%. Surgical treatment of orbital floor fractures is important, mainly to minimise persistent post-traumatic diplopia which significantly reduces a patient's quality of life.

Previously undescribed palpebral branch from the infraorbital canal: Application to surgery of the eyelid and treatment of orbital floor fractures.

The sensory innervation of the inferior eyelid is mainly derived from the inferior palpebral branch (IPb) of the infraorbital nerve (ION). This study aimed to investigate another, to our knowledge, previously unknown branch, and elucidate its location and distribution. Twelve sides from seven fresh frozen cadaveric Caucasian heads were used in this study. The specimens were derived from two male and four female adult cadavers age. The diameter of the IPb of the ION (D1) and branch arising from the upper wall of the infraorbital canal (D2), and distance between the branching points of this branch and the anterior border of the orbit floor (L1) was measured. A branch to the lower eyelid was found arising from the infraorbital canal on the majority of sides. D1 ranged from 0.4 to 1.1 mm. The branch arising from the upper wall of the infraorbital canal was found 10 sides (83%). D2 ranged 0.6 to 1.0 mm. L1 ranged from 10.2 to 19.8 mm. All of the branches arising from the upper wall of the infraorbital canal (10 sides) primarily innervated to the inferior eyelid. We suggest this branch should be named the "posterior IPb" of the ION. Knowledge of this branch might decrease sensory loss following invasive procedures of the lower orbit. Clin. Anat. 30:835-838, 2017. © 2017Wiley Periodicals, Inc.

Concept of patient-specific shape memory implants for the treatment of orbital floor fractures.

We will aim to develop implants made of a Ni-Ti shape memory alloy which can be applied for the treatment of midface fractures, such as isolated orbital floor fractures. These can then be implanted in a compressed form and unfold automatically in the body. With the help of newly developed application instruments, the implants can be applied along transnasal and transantral approaches into the maxillary sinus. Our objective is to evaluate the operation process and the functionality of these implants, already in a pre-investigation by an experienced surgeon on a phantom. The functionality of the surgical procedure and an implant prototype were both evaluated with the help of a realistic phantom. The minimally invasive application was carried out using the transnasal and transantral approach. Instruments and implant were rated individually on a scale, from -2 (not at all) to +2 (very good) for vaious criteria, such as the implants functionality or the ergonomics of the entire procedure. For a geometric comparison between the manufactured implant and the planned target geometry, the implants were scanned by micro-computed tomography. CAD models were derived from the scans by using reverse engineering. Both the implants and the application procedure were assessed as good; thus, the implant concept is suitable for further development. Implants made of shape memory alloys could allow in the future and allow less invasive access to treat orbital floor fractures. The implant design has to be modified that the implant can be stabilized and fixed with screws or a suture to avoid dislocation or implant loosening. The complication rates and risks of conventional orbital reconstructions should be lowered by this new method.

Treatment of orbital floor fracture with conchal cartilage

Treatment of orbital floor fracture with conchal cartilage

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 invivo. The combination of virtual planning and 3D printing offers an accurate and cost-effective treatment method for orbital floor fractures.

Development of Patient-specific Orbital Floor Implants Made of Shape Memory Alloys

The shape memory alloy NiTi has successfully proved in many areas of medical technology. This paper describes the innovative idea and development of orbital floor implants made of NiTi. Pseudoelastic NiTi has the peculiarity to withstand large mechanical deformations of up to 8% without being plastically deformed, i.e. it returns to its original shape with relief of the strain. This material property can be used to produce flexible, yet stable implants. The NiTi implants can be implanted into the body in compressed form through relatively small approaches. Arriving at the fracture position, they develop self-reliantly in the previously memorized shape. The perioperative trauma is reduced. The treatment of orbital floor fractures is often done surgically by use of implants made of rigid materials such as titanium, which are inserted in the eye socket through an open approach on the lower eyelid. Implants made of a pseudoelastic shape memory alloys can help to reduce the required incision length of the approach. It is even possible to insert the implant in a minimally invasive procedure via endoscopic access routes and to completely avoid open approach. In this paper first design variants of pseudoelastic orbital floor implants are presented and considerations on the manufacturing process are made.

Clinical application of self-developed fracture reduction fixator in the treatment of severe blow-out orbital floor fracture

Objective To investigate how to effectively reposit and fix the displaced tissues of severe blow-out orbital floor fracture.Methods The self-developed fracture reduction fixators were applied to nine cases of orbital floor fracture by maxillary sinus route.Results The operation method was simple,and the good curative effects were obtained in all patients,such as fracture reduction,no tissue incarceration,diplopia eliminated or even disappeared,enophthalmos less than 2 mm.Conclusion The self-developed fracture reduction fixator is a reasonable and effective approach in the treatment of severe blow-out orbital floor fracture. Key words: Fracture, blow-out, orbital floor; Operation; Fixator, reduction, fracture

Poly(trimethylene carbonate) and biphasic calcium phosphate composites for orbital floor reconstruction: a feasibility study in sheep

In the treatment of orbital floor fractures, bone is ideally regenerated. The materials currently used for orbital floor reconstruction do not lead to the regeneration of bone. Our objective was to render polymeric materials based on poly(trimethylene carbonate) (PTMC) osteoinductive, and to evaluate their suitability for use in orbital floor reconstruction. For this purpose, osteoinductive biphasic calcium phosphate (BCP) particles were introduced into a polymeric PTMC matrix. Composite sheets containing 50 wt% BCP particles were prepared. Also laminates with poly(D,L-lactide) (PDLLA) were prepared by compression moulding PDLLA films onto the composite sheets. After sterilisation by gamma irradiation, the sheets were used to reconstruct surgically-created orbital floor defects in sheep. The bone inducing potential of the different implants was assessed upon intramuscular implantation. The performance of the implants in orbital floor reconstruction was assessed by cone beam computed tomography (CBCT). Histological evaluation revealed that in the orbital and intramuscular implantations of BCP containing specimens, bone formation could be seen after 3 and 9 months. Analysis of the CBCT scans showed that the composite PTMC sheets and the laminated composite sheets performed well in orbital floor reconstruction. It is concluded that PTMC/BCP composites and PTMC/BCP composites laminated with PDLLA have osteoinductive properties and seem suitable for use in orbital floor reconstruction.

Complications of Orbital Floor Repair With Silastic Sheet

Treatment of orbital floor fracture is a subject of great interest in maxillofacial surgery. Many materials have been described for its reconstruction.In this article, the authors report a case of a patient who, 7 years from a previous orbital floor fracture and treatment with silastic sheet, presented herself to their clinic for the failure of the material used for its reconstruction and a skin fistula.Orbital floor repair with silastic sheet is an old method that no one uses anymore, but we still observe cases of late complications with this material. So a fine knowledge of silastic sheet complications is needed for young surgeons.The authors report the case and perform a literature review about the use of more modern biomaterials for orbital floor reconstruction.

Radiologic and Facial Morphologic Long-Term Results in Treatment of Orbital Floor Fracture With Flexible Absorbable Alloplastic Material

Although orbital floor fractures are frequently treated by the Ethisorb patch or polydioxanone foil, the utility of these treatments in extensive fractures remains controversial. The purpose of this study was to examine objectively the extent to which such flexible absorbable materials can restore orbital geometry in comminuted and defect fractures. Twenty-one patients with isolated comminuted or defect fractures of the orbital floor (mean, 4.32 cm(2)) were recruited for this retrospective study. Using an infraorbital approach, 15 patients received an Ethisorb patch, whereas polydioxanone foil (0.25 mm) was used in the remaining cases. Follow-up examinations with cone-beam computed tomography and 3-dimensional facial scanning occurred on average 27.4 months postoperatively. Orbital heights and volumes were measured on the fracture side and compared with the unaffected side. Based on 3-dimensional facial scan data, the ocular bulb position was assessed in the sagittal and vertical directions. For all parameters, the difference between the left and right sides was calculated, which was statistically significant compared with the side difference of an age- and gender-matched control group using unpaired t test (P < .05). No statistically significant differences were observed in any variable between the surgical and control cohorts. A decreased diplopia rate of 38.14% was attained by the surgical intervention. The reconstruction of moderate to extensive orbital floor fractures can be provided with polydioxanone foil or the Ethisorb patch without significant changes in orbital geometry.