鼻骨-眶-筛骨及相邻颌面骨骨折所致畸形的整体修复

目的 不断改进和完善鼻骨-眶-筛骨（NOE）及相邻颌面骨骨折所致畸形的修复方法.方法 对76例NOE及伴有相邻颌面骨骨折患者采用多个隐蔽切口进行手术复位、固定.同时修复外伤性鼻畸形、眶壁缺损、矫正眼球内陷、修复伴发的相邻颌面骨骨折.结果 经术后3～6个月随访,所有NOE及伴有相邻颌面骨骨折患者术后外形和功能均得到整体的改善或恢复.3例术前眼球内陷明显,术后仍有轻度内陷;2例术后复视未完全恢复;5例陈旧性骨折,术后面中部突度及宽度恢复不理想,经二次整形修复,效果满意.结论 NOE及伴有相邻部位骨折要予以整体修复才能取得良好的手术效果.     

外伤后颧眶畸形的手术复位及植骨修复

目的：探讨外伤后颧眶畸形的临床特点，治疗方法及修复材料选择。方法：通过病案记录研究13例颧眶复合体骨折患者的临床资料。复位质量及面部外观评价依据临床观察及影像学检查。随访3－12个月。结果：13例颧眶畸形患者中12例为男性。颧面畸形，眼球内陷，复视发生率分别为92．3％，46．2％，38．5％。所有患者均行外科手术及植骨修复。手术进路多选用冠状切口＋前庭沟切口，根据治疗需要还可附加睑下缘切口或内眦切口。重建技术包括颧骨，眶骨切开术，眶、鼻及颧部植骨术，眦韧带重建术。应用最多的植骨材料是异体脱矿骨（n=8)，其它为髂骨（n=3)，颅骨（n=2)，肋骨（n=1)等自体骨。1例患者术后仍有轻度复视及眼球内陷，另1例患者眼球内陷未恢复正常。3例患者颧眶外形改善但未达到充分对称。结论：手术复位及移植修复及纠正晚期颧眶畸形的理想方法。自体骨仍然是最理想的修复材料。同种异体脱矿骨也是一种安全有效的植入材料。     

外伤后颧眶畸形的手术复位及植骨修复

目的 :探讨外伤后颧眶畸形的临床特点、治疗方法及修复材料选择。方法 :通过病案记录研究 13例颧眶复合体骨折患者的临床资料。复位质量及面部外观评价依据临床观察及影像学检查。随访 3～ 12个月。结果 :13例颧眶畸形患者中 12例为男性。颧面畸形、眼球内陷、复视发生率分别为 92 .3 % ,4 6.2 % ,3 8.5 %。所有患者均行外科手术及植骨修复。手术进路多选用冠状切口 +前庭沟切口 ,根据治疗需要还可附加睑下缘切口或内眦切口。重建技术包括颧骨、眶骨切开术 ,眶、鼻及颧部植骨术 ,眦韧带重建术。应用最多的植骨材料是异体脱矿骨 (n =8) ,其它为髂骨 (n =3 )、颅骨 (n =2 )、肋骨 (n =1)等自体骨。 1例患者术后仍有轻度复视及眼球内陷 ,另 1例患者眼球内陷未恢复正常。 3例患者颧眶外形改善但未达到充分对称。结论 :手术复位及移植修复是纠正晚期颧眶畸形的理想方法。自体骨仍然是最理想的修复材料。同种异体脱矿骨也是一种安全有效的植入材料。     

复合性眼眶骨折整复术相关问题的分析

目的 总结复合性眼眶骨折的治疗经验,探讨治疗中的难点问题及对策.方法 回顾分析2005年1月至2010年1月中国医科大学口腔医学院口腔颌面外科诊治的89例复合性眼眶骨折患者.病例资料包括鼻-眶-筛骨折、颧-眶-上颌骨骨折、额眶骨折,其中包含复合性眼眶骨折以及创伤性眼眶骨缺损.应用冠状切口入路、经皮肤切口下睑下入路、经睑结膜切口下睑入路、眶上眉弓切口入路、上睑入路、眉间下鼻根入路、内眦内侧入路、经口腔上颌前庭沟黏膜切口入路以及小切口内镜辅助完成手术,综合应用颅颌面创伤外科、整复外科、修复重建外科、微创外科、计算机辅助和模型外科等理论和技术治疗各类型复合性眼眶骨折.对复合性眼眶骨折继发或再发眼球内陷、重度粉碎性眼眶骨折和陈旧性眼眶骨折等难点问题进行重点分析并总结疗效.结果 89例患者术后眼眶外形得以恢复,眼球内陷得以纠正,通过泪道重建恢复患者泪道系统功能.其中陈旧性眼眶骨折或眼眶骨折术后畸形的发生率为38%(34/89),经治疗后畸形得到明显改善.其中6例随访时出现眼球内陷复发,经再次或多次手术效果仍不能令人满意.结论 复合性眼眶骨折的治疗需要口腔颌面外科、眼科、神经外科、耳鼻咽喉科等多学科协作,达到修复畸形和改善功能的目的.重度眼球内陷的治疗、眼球内陷再发的防范和治疗、眶区严重软组织损伤和内眦畸形的治疗以及陈旧性眼眶损伤的治疗仍是目前所面临的挑战.     

应用自体耳甲软骨瓣重建眶底

目的研究自体耳甲软骨瓣应用于眶底重建,对眶底骨折引起的复视和眼球内陷的疗效。方法自2003年7月～2007年6月应用耳甲软骨瓣重建眶底共21例。本组患者术前均经轴位和冠状位眶部CT证实存在眶底骨折下陷,且部分眶内容物疝入上颌窦,患侧眼球突出度与健侧相差3mm以上。自患侧耳廓切取耳甲软骨瓣（保留两侧软骨膜）,经下眼睑下缘切口入路,用耳甲软骨瓣修补眶底骨质缺损。术后均随访3个月以上,观察复视和眼球内陷的治疗效果,以及供区耳廓有无畸形。结果本组21例患者术后复视消失者19例（90.5%）、明显改善者2例（9.5%）;双侧眼球突出度相差≤2mm共17例（81.0%）,2.1mm～3.0mm共3例（14.3%）,〉3mm共1例（4.7%）;无一例出现耳廓畸形和耳甲软骨瓣感染。结论对于眶底骨折伴有眶底下陷,眶内容物疝入上颌窦以及双侧眼球突度相差明显的患者,应用耳甲软骨瓣重建眶底,可显著改善复视和眼球内陷等眼功能障碍,且不会引起供区耳廓畸形。     

非单纯性眼眶骨折眶腔容积改变与眼球内陷相关性研究方法初探基于CT图像数据的计算机辅助测量

目的应用计算机辅助三维CT影像分析系统，测量分析非单纯性眼眶骨折术前术后眶腔容积变化，为定量诊断和矫治骨折继发眼球内陷探索可行性研究方法。方法2004年10月～12月北京大学口腔医院颌面创伤中心经治的7例颅颌面创伤合并单侧非单纯性眼眶骨折。投照薄断层（0．625mm）CT，将图像数据以DICOM格式输入图像分析软件，对眼眶及眶内容物进行三维重建。描述眶腔破坏特征。测量眼球突度、原骨折和虚拟恢复眶外缘后的眶腔容积，并做术前术后比较分析。结果应用该系统可形象直观地显示眼眶畸形部位、范围。定量明确眼眶体积扩大量。在该类眼眶骨折中，骨折可波及整个眶壁。与眶缘骨折相比较，眶壁骨折与眼球内陷关系密切。术前术后比较，眼球内陷得到不同程度的改善，健患侧眼眶体积之差进一步缩小。结论基于CT图像数据的计算机图像分析系统可以清晰直观的显示出骨折眶壁畸形，以及健患侧眶腔体积的差异。球前和球后眶腔容积差可以为进一步探求眼眶破坏与眼球内陷的相关关系及量化诊断提供重要参数。     

全面部陈旧性骨折回顾性分析与临床分类研究

目的 回顾分析全面部陈旧性骨折所致面部畸形、功能障碍和影响疗效的多个因素,并提出全面部陈旧性骨折的临床分类.方法 39例全面部陈旧性骨折患者,男性31例,女性8例;中位年龄33岁;机动车撞击伤为主要致伤原因;35例合并全身伤.伤后时间>4周,术后复查均>6个月.分析临床体征与骨折特点的关系,根据骨折复杂因素提出临床分类.回顾性分析治疗效果,总结关键技术,提出治疗原则.结果 陈旧性骨折面部畸形率90%,其中46%存在面宽畸形,关节脱位-髁突骨折-颏(颏旁)骨折和颧弓骨折外移位是致面宽畸形的主要因素;张口受限率59%,颧骨-颧弓骨折和关节强直是致张口受限的主要原因,髁突矢状骨折伴外脱位是继发关节内强直的典型损伤类型;咬合紊乱率100%,髁突.关节+颏-颏旁+上颌矢状骨折可致最复杂的错(牙合).眼部症状率46%,鼻骨-眶-筛骨(nosal-orbital-ethmoid,NOE)骨折是主要损伤类型.全面部骨折可以分两型,Ⅰ型:颧骨复合体+上颌骨+下颌骨骨折;Ⅱ型:Ⅰ型+NOE骨折.根据是否存在关节脱位-髁突骨折和颧弓骨折将全面部骨折分3个亚型,A型:不存在关节脱位-髁突骨折和颧弓骨折;B型:关节脱位-髁突骨折(Ba),颧弓骨折(Bb);C型:关节脱位-髁突骨折和颧弓骨折同时存在.本组中,Ⅰ型占46%,Ⅱ型占54%;A亚型占41%,B亚型占41%,C亚型占18%.疗效"良"Ⅰ型24%、II型62%,与Ⅱ型NOE骨折术后遗留鼻畸形和眼球内陷-复视有关;疗效"中"、"差"主要集中在C亚型,与软组织损伤严重度和关节强直有关.结论 NOE骨折继发的鼻畸形和眼球内陷-复视、关节强直和(或)颧骨颧弓粉碎导致的张口受限、颧骨颧弓缺损或粉碎造成的面部塌陷和颌间瘢痕、髁突骨折-关节脱位+颏(颏旁)骨折+上颌矢状骨折产生的复杂错(牙合)、软组织缺损-瘢痕挛缩继发的面部畸形和器官移位是决定全面部骨折复杂性和影响治疗效果的主要因素.     

眶-上颌-颧骨复合骨折临床分类治疗探讨

目的:探讨眶-上颌-颧骨(OMZ)复合骨折三维立体结构上的分类法,以提高临床治疗水平。方法:收集69例OMZ骨折病例,通过常规X线片、螺旋CT片检查,从三维立体结构角度将骨折分为四型,总结临床治疗方法及效果。结果:术后随访2个月～4年,69例患者颧面部塌陷畸形均得到良好改善,咬合关系紊乱的患者均达到功能性咬合,通过训练后,张口度恢复满意,无面神经永久性损伤。A型骨折12例,无不良症状发生。B型骨折15例,有1例术后颧-眶外壁处仍稍显膨隆。C型骨折32例,有3例术后眶下神经麻痹症状未能恢复。D型骨折10例,术后眼球内陷1例,仍>2mm,复视未能恢复1例,眶下神经麻痹症状未恢复3例,术后切口感染1例,术后颧骨颧弓仍稍显膨隆3例。结论:眶-上颌-颧骨复合骨折四型分类法,对指导临床治疗有一定参考价值。     

114 例眼眶骨折分析

目的:探讨眼眶骨折的诊断和治疗原则。方法:回顾分析了114例眼眶骨折的患者,分类统计其临床表现和治疗方法。结果:眼球运动障碍、复视和眼球内陷发生率分别为63.2%、62.3%和59.6%;视神经损伤、泪道损伤和眼球破裂的发生率分别为15.8%、15.8%和12.3%。95.6%的患者接受了眶壁整复和人造骨植入术;72.8%的患者进行了骨折复位内固定术;部分患者进行了视神经减压术、眼球修补术和泪道手术。结论:眼球运动障碍、复视和眼球内陷是眼眶骨折的主要临床表现,视神经损伤、眼球破裂和泪道损伤亦不能忽视;眶壁整复和人造骨植入术是眼眶骨折治疗的主要术式,非单纯性眼眶骨折还需行骨折复位内固定术。     

数字外科技术在眼眶重建中的应用

目的 探讨数字外科技术在眼眶损伤重建中的临床应用价值.方法 对7例眼眶缺损患者采用CT扫描获取眶区数据,通过反求与快速原型、计算机辅助设计-计算机辅助制作(CAD-CAM)数字外科技术进行术前设计,在手术达到骨折精确复位的同时完成眼眶重建,并结合坚固内固定及Medpor 填充方法解决眶骨折变形、眼球内陷及复视等问题.结果 7例眼眶缺损患者均重建了眼眶形态,获得了理想的眶周轮廓恢复,4例眼球内陷得到矫治,2例复视术后无复发.结论 数字外科技术为眼眶重建的手术设计与实施提供了精确手段,可有效减少并发症,明显改善面部形态.     

Ageing increases risk of lower eyelid malposition after primary orbital fracture reconstruction

Lower eyelid malposition (LEM) is a common sequela after orbital fracture reconstruction. This study aimed to analyse the development of LEM, specifically ectropion and entropion, following primary orbital fracture reconstruction, to identify predictive factors for LEM, and to assess the effect of the eyelid complication on patients’ daily lives. The retrospective cohort comprised patients who had undergone orbital floor and/or medial wall fracture reconstruction for recent trauma. Demographics, fracture type and site, surgery and implant-related variables, follow-up time and number of visits, type and severity of LEM, subsequent surgical correction, and patient satisfaction, were analysed. The overall occurrence of LEM was 8%, with ectropion in 6% and entropion in 2% of patients. Older age, complex fractures, transcutaneous approaches, preoperative traumatic lower lid wounds, and implant material were associated with the development of LEM. Of all patients, 3% needed surgical correction of LEM. Six of the 13 patients (46%) who developed LEM required surgical correction. The transconjunctival approach and patient-specific implants should be preferred, especially in elderly patients and those with more complex fractures. LEM often requires subsequent surgical correction, and the treatment period is substantially prolonged, with multiple extra visits to the clinic.     

Reconstruction of the orbital walls in surgery of the skull base for benign neoplasms

Surgery for benign neoplasm extending into the orbital roof requires immediate reconstruction to avoid complications, which include transmission of the cerebral pulse to the globe, bulbar dystopia, diplopia, and fibrosis of the oculomotor muscles. Many alloplastic materials have been employed for such reconstruction, but currently most authors agree that autologous bone graft is the best option. Using calvarial bone in adults and split ribs in children, we have operated on eight patients for fibrous dysplasia (five cases), neurofibroma (two cases), or meningioma (one case). After a median follow-up period of two years and six months, good morphology of the orbit was maintained with no ocular symptoms.     

冠状切口在颧骨复合体骨折中的应用

目的探讨颧骨复合体骨折复位和固定术中应用冠状切口入路的手术适应证、手术方法及减少并发症的措施。方法84例颧骨复合体骨折的患者应用单纯冠状切口为36.9%、冠状切口 下睑缘切口为32.1%、冠状切口 下睑缘切口 前庭沟切口为16.7%和冠状切口 前庭沟切口为14.3%。术中患者均使用微型钛板或小型钛板坚强内固定。对于眶底骨折出现眼球内陷的患者以羟基磷灰石人工骨进行眶底重建。结果84例患者均未发生手术后切口感染,术后随访3个月到2年,无面神经永久性损伤,术后所有咬合关系紊乱的患者均达到功能性咬合。通过训练后张口度得到满意恢复。8例患者术后患侧颧弓处仍稍显膨隆。术后眼球内陷只有1例仍大于3mm,其余均恢复满意。结论颧骨复合体骨折使用头皮冠状切口时,熟练掌握颞部的解剖层次是至关重要的,仔细保护神经及血管结构可减少手术并发症。     

Late reconstruction of the complex orbital fractures with computer-aided design and computer-aided manufacturing technique

BACKGROUND: To construct three-dimensional (3D) imaging and computer generated models of complex orbital fractures, and develop a Computer-Aided Design/Computer-Aided Manufacture (CAD/CAM) system to help improve the surgical planning of complex orbital fracture and promote its outcome. METHODS: A prospective study was carried out on 17 patients with unilateral complex orbital fractures from Mar 2003 to Mar 2006 at the Shanghai ninth people's hospital. The utilization of a CAD/CAM technique based on Helical computer tomography data, with stereolithographical (SLA) modelling as intermediate step, enabled surgeons to plan for the surgical progress of osteotomy, movement, reposition, fixation and material implanting.Orbital volume was calculated pre and post-operatively. Orbital fracture reconstruction and globe repositioning was performed and followed up 3-9 months post-treatment. Ocular function and aesthetic deformities such as enophthalmos, diplopia and extraocular motility problems were accessed.The data was processed with SAS 6.17 statistical software. RESULTS: 17 patients with complex orbital fractures underwent successful orbital fracture reconstruction surgery. The deformities of orbit, medial canthus, nose, zygomata, maxillary and frontal bone were well corrected. The volume of reconstructed orbit was approximately symmetrical with respect to the contralateral orbit. Enophthalmos was corrected and diplopia, extraocular movement were improved. CONCLUSIONS: CAD/CAM system enables the surgeon to predict reconstructive surgical steps before the operation, and can help to improve the outcome of surgery. This technique may be proved as one of the most useful clinical tools for orbital surgery.     

Posttraumatic obstruction of lacrimal pathways: a retrospective analysis of 58 consecutive naso-orbitoethmoid fractures

Posttraumatic dacryostenosis represent a troublesome sequela for patients who have sustained centrofacial trauma and can determine complexity in diagnosis and treatment. This article, based on a retrospective analysis of 58 patients with naso-orbitoethmoidal (NOE) trauma, reports the incidence of posttraumatic dacryostenosis and the evolution of such impairments in consideration of fracture type. Experience in diagnosis and treatment is illustrated, and surgical outcomes 6 months after external dacryocystorhinostomy (DCR) are reported. Posttraumatic epiphora was observed in 27 patients with NOE fractures (46.5%). In 10 cases, temporary epiphora was encountered and spontaneous recovery of lacrimal drainage within 5 months was observed. In the remaining 17 cases, permanent epiphora was registered and a frequent association with delayed treatment of facial fracture repair or bone loss in the lacrimal district was found. Surgical reconstruction of lacrimal pathways was performed 6 months after primary surgery, with external DCRs in all 17 patients with epiphora and the presence of nasolacrimal duct obstruction observed with dacryocystorhinography. External DCR with a large rhinostomy achieved a success rate of 94% in the reconstruction of lacrimal drainage. Such a technique proved to be effective in the treatment of posttraumatic dacryostenosis, although patients considered the temporary presence of external scars and stenting material to be a major problem.     

Reconstruction of Orbital Floor Fractures with Porous Polyethylene Implants: A Prospective Study

Purpose

The main aim of our study was to assess and evaluate the efficacy, long standing outcome and infection of porous polyethylene implants in treatment of orbital floor fractures.

Patient and methods

Twelve patients with fractures of orbital floor were included in the study. The cause of fracture was road traffic accident, self fall and cow hit respectively. They also complained of enophthalmos (n = 9), diplopia (n = 3), restricted eye movement (n = 2), impairment of infraorbital nerve (n = 3) and dystopia (n = 6). All the fractures were reconstructed with thin porous polyethylene sheets.

Results

No implants were extruded and there were no signs of inflammatory reactions against porous polyethylene implant. In all nine patients with pre-op enophthalmos it was corrected post-operatively with p value = 0.000 and was statistically significant; diplopia in one patient was corrected; persistence of double vision was noted in two patients. Restricted eye movement was corrected in all patients, dystopia was corrected in four patients and in two patients have persisting dystopia. Paresthesia persisted in all three patients.

Conclusion

Our experience was that reconstruction of orbital floor fracture using porous polyethylene implant is reliable, safe and effective and may be used for reconstruction of the orbital floor fracture with no donor site morbidity.

     

Medial canthopexy of old unrepaired naso-orbito-ethmoidal (noe) traumatic telecanthus

IntroductionTraumatic telecanthus resulting from injuries to the naso-orbito-ethmoidal (NOE) complex is a difficult deformity to treat and involves both esthetic and functional aspects. Delayed or inadequate primary treatment often results in scarring and secondary deformities that are severe and make them extremely problematic to correct. The intricate anatomy of this area makes NOE injuries one of the most challenging areas of facial reconstruction. Several techniques were described to reconstruct the medial canthal tendon (MCT) and repair the telecanthus deformity. Transnasal wiring remains the gold standard. However, the procedure is technically difficult. It necessitates wide exposure sufficient to allow transverse passage of wires through bony fenestrations deep within the orbit, and involves dissection of the contralateral orbit.AimThis study proposes a minor modification to simplify transnasal-wiring technique in the difficult cases presenting with telecanthus following unrepaired NOE fractures.Patients & methodsThe study included 13 patients (11 males and 2 females) presenting with telecanthus, at least six months after sustaining NOE fractures. Transnasal canthopexy was the fundamental step in reconstruction. Two wires held independently the anterior and posterior limbs of the MCT to ensure an adequate grip. They were delivered in a single pass through a single hole instead of two to avoid weakening of the thin lacrimal bones. The wires were then secured to a titanium mesh fixed to the contralateral medial orbital rim to guarantee a stable fixation.ResultsThe technique restored the normal canthal position along the lacrimal crest. Good functional and esthetic results are reported based on the measurement of pre- and postoperative intercanthal & canthal–midline distances over a period of 2-years, with an average follow-up period of 12 months.ConclusionThe results reveal the simplicity and reliability of this technique in restoring palpebral shape and intercanthal distance without any recoded functional complications throughout the follow-up.     

Post-traumatic orbital sub periosteal hematoma in children: Clinical spectrum and management outcomes

Orbital subperiosteal hematoma (OSPH) is a rare entity following blunt trauma that can significantly affect the vision of a growing child. The purpose of this study was to describe the spectrum of the clinical presentations along with the imaging findings and treatment outcome of traumatic OSPH.This is a retrospective case series of six patients below 16 years of age, diagnosed with OSPH following trauma. Electronic medical records were reviewed for details of clinical features, imaging findings, management details and outcomes.The median duration of the presentation was 7 days (range 6–50 days). Proptosis and dystopia remained the most common presenting features. Significant vision loss was noted in four patients at presentation. A computed tomography (CT) scan revealed the superior quadrant of the orbit to be involved most frequently. Five patients were treated surgically and one conservatively. Significant vision loss was noted in one patient despite of initial surgical management.Although rare, OSPH should be considered a differential diagnosis in children presenting with proptosis and dystopia following blunt trauma. Younger children are particularly at higher risk for developing permanent visual loss and should be treated promptly by draining the OSPH.