Options in orbital floor reconstruction in blowout fractures: a review of ten cases

Objective  The purpose of this case series was to assess the aesthetic and functional outcome of orbital floor reconstruction performed with calvarial bone graft, titanium mesh or prolene mesh. Methods  Ten cases of orbital blowout fractures treated at our centre from October 2006 to July 2008 were considered for this study. Clinical examination, patient satisfaction and radiographic investigations were used to assess repaired fractures. Results  Prolene mesh was used in four cases, titanium mesh was used in four cases and calvarial graft used in two cases. Nine patients had significant improvement in their esthetic appearance. Symmetry was restored in all cases. All ten cases had a noticeable improvement in the function. Of total ten cases six had diplopia, three recovered completely during the six months after the surgery. Three cases showed improvement later. All ten cases with enopthalmos recovered completely. Of the nine patients with infraorbital numbness, all recovered completely during the six months following surgery. One patient where the reconstruction was done with calvarial bone graft showed mild discrepancy in the ocular level. Conclusion  For small, linear defects measuring less than 2cm with enopthalmos and restricted ocular movements, prolene mesh (four cases) was used. For larger defects and impure blowout fractures involving the infraorbital rim, calvarial graft (two cases) or titanium mesh (four cases) was used. The outcome of surgery with all three materials was satisfactory. No postoperative complications were seen except for mild hypoglobus in a case reconstructed with calvarial graft. All three materials, calvarial graft, titanium mesh, prolene mesh, have the potential to be useful reconstructive materials in orbital floor blowout fractures.     

Reconstruction of skull bone defects using the hydroxyapatite cement with calvarial split transplants.

PURPOSE: We sought to present a new method for primary reconstruction of traumatic or tumor calvarial defects. PATIENTS AND METHODS: Forty-one patients underwent reconstruction of calvarial bone defects between October 1998 and December 2001. Among them were 19 patients who needed reconstruction of the calvaria due to traumatic bone loss. Five of these trauma cases had insufficient primary reconstruction of the calvaria. Tumor resection caused calvarial defects in 22 patients. For primary reconstruction of the skull bone defects, calvarial split grafts were used to cover the defect as accurately as possible. The monocortical layers of the calvaria were fixed with titanium miniplates. Irregular defects surrounding the transplanted regions were filled with hydroxyapatite cement. In one case of posttraumatic bone loss, hydroxyapatite cement alone was sufficient to reconstruct the defect. RESULTS: The follow-up of each patient was at least 6 months; the longest period was 38 months. Evaluated clinical and radiologic results are stable, showing no measurable side effects. CONCLUSION: Hydroxyapatite cement alone or in combination with calvarial split grafts gave clinically and aesthetically stable results in the reconstruction of skull bone defects. The cement can be used for many reconstruction possibilities in craniofacial surgery.     

Repair of traumatic inferior orbital wall defects with nasoseptal cartilage

PURPOSE: This study evaluated the effectiveness of nasoseptal cartilage for repairing traumatic orbital floor defects. PATIENTS AND METHODS: Autogenous septal cartilage was used in 20 patients. They were evaluated for the presence or absence of diplopia, enophthalmus, infraorbital nerve paresthesia, and ocular motility disorders. Surgical indications for orbital exploration included entrapment of orbital tissues, large orbital defect (greater than 50% of the orbital floor or more than 8 mm), or orbital floor defects with involvement of other zygomaticofrontal complex fractures. RESULTS: All patients were successfully treated by restoration of the orbital wall continuity. Follow-up at 1 week to 6 months showed 1 patient with postoperative enophthalmos and 1 patient with lower lid edema. There were no donor site and graft infections or graft extrusion. CONCLUSIONS: Nasal septal cartilage is a readily accessible autogenous tissue that should be considered when an autogenous graft is needed for orbital floor defect reconstruction.     

Effectiveness of a nasoseptal cartilaginous graft for repairing traumatic fractures of the inferior orbital wall

The goals of reconstruction after an orbital fracture are to restore the continuity of the floor, provide support for the orbital contents, and prevent fibrosis of the soft tissues. Nasoseptal cartilage is an easily accessible, abundant, and autogenous source that supports the orbital floor and gives minimal donor site morbidity. We evaluated the effectiveness of nasoseptal cartilage for repairing traumatic defects of the orbital floor. Autogenous nasoseptal cartilage was used in 20 patients. Presence or absence of diplopia, enophthalmos, paraesthesia of the infraorbital nerve, dystopia, range of covering of the defect by nasoseptal cartilage, complications at the recipient and donor sites, resorption of the graft, and ocular mobility disorders were recorded. Entrapment of orbital tissues, a large orbital defect (more than 50% of orbital floor or more than 8mm), or defects of the orbital floor with involvement of other fractures of the zygomaticofrontal complex are indications for exploration of the orbit. In one case after 24 months, the surgical field was explored for direct evaluation of the efficacy of the graft. All patients were treated successfully by restoration of the continuity of the orbital floor. Six months to 2 years follow up showed only one patient with postoperative enophthalmos. There was no donor site morbidity, and no grafts became infected or extruded. The nasoseptal graft was completely covered with underlying tissue. Nasoseptal cartilage is readily accessible autogenous tissue that should be considered when an autogenous graft is needed for reconstruction of a defect of the orbital floor.     

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.     

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.     

What are the limitations of the non-patient-specific implant in titanium reconstruction of the orbit?

There is ongoing discussion about patient-specific implants (PSI) to reconstruct orbital defects. Although PSI offer excellent clinical outcome, they are expensive. Subsequently, their routine application is not indicated. The purpose of this study was to estimate the frequency of implant malposition and revision procedures after primary orbital repair with preformed plates and to identify cases where primary use of PSI would help to prevent revision surgery. All patients included in the study were operated on for orbital fractures at the Royal London Hospital between August 2017 and July 2018. Selection criteria included adult patients treated for orbital fractures with a titanium plate. Revision was planned in symptomatic patients presenting with clear implant malposition. Seventy-nine patients with 81 implants were included, 33 of whom had multiple orbital wall fractures (medial wall and floor or all four walls) and were summarised as group 2. Group 1 consisted of single orbital floor/medial wall fractures. The five patients for whom revision surgery was planned or undertaken because of radiological poorly positioned implants and substantial clinical symptoms all had multiple wall fractures. This finding was significant (p = 0.006). The major reason for revision was a defect that was too large for the prescribed plate. Patients with large orbital defects needing surgical treatment are at risk of implant malposition. The orbital reconstruction with preformed plate evidences good outcome in single wall fractures. However, the risk of malposition increases massively with fracture size. We therefore postulate that in large, two-wall fractures, primary treatment with a PSI has to be considered.     

A novel cranioplasty technique incorporating cancellous femoral bone and recombinant bone morphogenic protein 2

Large calvarial defects in the setting of chronic infection and limited autologous donor sites present challenging problems for the reconstructive surgeon. We report on a novel osteogenic implant as a potential calvarial reconstruction solution. Two patients with an extensive history of severe traumatic brain injury and multiple cranial operations desired delayed calvarial reconstruction subsequent to removal of infected acrylic and titanium implants. These patients underwent harvesting of cancellous femoral bone and bone marrow, which was placed between 2 layers of recombinant bone morphogenic protein 2 impregnated in acellular collagen sponges and an outer layer of sturdily pliable Vicryl mesh to create a moldable osteogenic implant construct. The construct was molded into the shape of the defect and secured with sutures to the skull surrounding the defect. The osteogenic implant showed evidence of bone formation and maintained coverage over the original calvarial defect at 26 months postoperatively as well as subjective satisfaction by both patients and the senior surgeon. This technically straightforward technique with acceptable functional and aesthetic outcomes may be useful to reconstructing selected calvarial defects.     

Use of membrane and bone grafts in the reconstruction of orbital fractures

OBJECTIVE: To present and analyze the clinical results derived from the use of different grafts for the reconstruction of orbital defects during a 10-year period.Study Design: Fifty-five fracture cases with orbital bony defect, requiring a graft, are presented. The surgical treatment includes the reconstruction of the fracture (osteosynthesis) and the repair of the remaining bone defect by graft, with the type of graft dependent on the size of the defect. For minor defects membranes were used (lyophilized dura or alloplastic dura mater), whereas major defects were repaired with bone grafts (autografts, heterografts, or bone substitute material). All patients have been regularly evaluated for at least one year postoperatively. RESULTS: All grafts were well tolerated by the patients. Diplopia subsided in all but 5 cases, motility disturbance was fully repaired in all but 3 cases. Esthetics were improved in cases with severe bone defect. CONCLUSION: The wide variety of grafts available allows successful reconstruction of all types of orbital bony defects. The clinician should be able to use different types of grafts depending on the type and size of the defect.     

An evaluation of calvarial and iliac donor sites in alveolar cleft grafting

A clinical study evaluating the use of calvarial (two different techniques of harvest) versus iliac donor bone in secondary unilateral alveolar cleft reconstruction based on clinical and radiographic assessment was conducted. Both iliac bone and the Hudson brace harvested calvarial bone resulted in high rates of radiographic evidence of osseous continuity between the maxillary segments and clinical resolution of the alveolar cleft defect. Calvarial bone obtained with the craniotome had a lower rate of success that was statistically different from the other two groups. The utilization of calvarial bone and the implications of harvest technique on graft transfer biology are discussed.     

Extensive augmentation of the alveolar ridge using autogenous calvarial split bone grafts for dental rehabilitation

Free autogenous iliac bone is the most commonly used graft material for an extensive alveolar ridge reconstruction. The application of iliac bone, however, is associated with problems, such as transplant loss resulting from postoperative infection and late bone resorption. A bone-graft material more suitable than iliac bone is therefore still needed. This paper describes a concept for alveolar-ridge reconstruction using calvarial split bone, and the related surgical techniques. Clinical and radiological follow-up examinations were undertaken to evaluate the potential benefit of calvarial split bone in alveolar-ridge reconstruction. Between 1999 and 2002, 13 patients with a mean age of 54 years (range 31-70 years) underwent surgery, seven patients in the maxilla and six in the mandible. In four cases, wound dehiscence occurred postoperatively. In one of these cases, the dehiscence was associated with a local infection. However, no bone transplants were lost. After a mean follow-up time of 19.6 months, bone resorption, measured radiologically, was minimal. Endosseous dental implants were successfully installed and maintained. Satisfactory prosthetic rehabilitation was achieved in all patients. Our preliminary experience suggests that calvarial split bone may be regarded as a promising alternative to autogenous iliac bone in connection with extensive augmentation of the alveolar ridge.     

钛网支架修复眶底缺损

目的：探讨经头皮冠状切口或睑结膜切口入路,应用钛网支架重建眶底缺损的临床疗效。方法根据CT扫描和三维成像诊断,对18例眶底缺损患者进行微型钛网内固定术重建眶底缺损,其中10例为眶底伴邻近颅面骨折,采用头皮发际内冠状切口;8例为陈旧性眶底骨折,采用睑结膜切口。结果18例患者的眼球内陷和部分合并颧骨骨折的状况得到纠正,切口均愈合良好,切口位置较隐秘或未遗留瘢痕,颜面畸形得到明显改善。术后随访3～24个月,钛网支架无1例松动或移位或者其他并发症,疗效满意。结论头皮冠状切口入路以及睑结膜入路都能为术者提供足够视野与操作空间,应用微型钛网内固定术可重建眶底缺损,防止复视,术后美观效果佳。     

Combination of vascularized outer-table calvarial bone graft based on the superficial temporal vessels and allomatrix for the repair of an orbito-frontal blow-out fracture in a child.

CASE PRESENTATION: A vascularized outer-table calvarial bone graft was used for repairing a Posnick type 2 traumatic orbito-frontal bone defect supported by the use of a calcium-based putty (Allomatrix) in a 7-year-old girl. Gaps between the donor and recipient sites were filled with Allomatrix containing demineralized bone matrix particles. Four years later there was a good cosmetic result using an artificial left eye. DISCUSSION: Orbito-frontal defects have been repaired using iso-, allo- or xenografts as well as synthetic materials. Anatomical studies have pointed to the importance of the superficial temporal vessels for the vascular supply of a graft to the calvaria. CONCLUSION: The vascularized outer-table calvarial bone graft based on the superficial temporal vessels is a reliable option for repairing bony defects in the craniofacial skeleton especially in irradiated or scarred areas where there is a paucity of well-vascularized tissues. It also has the potential for bony growth in children.     

Reconstruction of Orbital Floor Fractures with Autogenous Bone Graft Application from Anterior Wall of Maxillary Sinus: A Retrospective Study

Introduction

Orbital wall fracture implies a situation where disruptions of the walls or floor have occurred. It is a blowout type fracture where bone fragments with torn periosteum are pushed outside of the original bony orbit. There is no intact bone even near the defect area except the thin bone rim surrounding the blowout fracture. The purpose of this defect repair is to support orbital contents, free entrapped tissue, and, especially, restore the original orbital volume.

Material and methods

Ten patients (seven males and three females) who underwent repair of orbital floor factures with maxillary sinus bone grafts were included in this study. Surgical procedure for harvesting graft and its fixation was almost same in all operated cases.

Conclusion

The collection in the maxillary sinus due to fracture of floor of orbit, blood and bony fragments collected in the maxillary sinus can be easily drained and removed after removal of anterior wall of maxillary sinus and through the same approach you can reduce the floor of orbit manually to the proper position which helps to decease the orbital floor defect.     

Autogenous mandibular symphysis graft for orbital floor reconstruction: a preliminary study

Objective  The present study aimed to evaluate and analyze postoperative results of Autogenous Mandibular Symphysis graft material for orbital floor reconstruction. Material and methods  A retrospective study was conducted on 11 patients, having an isolated blow out fracture (n=4) or orbital floor defects associated with other fractures (n=7). These fractures were reconstructed with Mandibular symphysis bone grafts. The Grafts were used where the defects were more than 1.5 centimeter [1]in diameter. Follow up as long as 1.5 year was kept. Patients were evaluated at recall visits by checking various extraoccular movements. Evidence of any complications like diplopia or enopthalmos, or rejection of graft or any symptoms of infection, or of paresthesia was recorded. Results  During a 1.5 year period of follow up, most of the patients had no postoperative complaints. There was good restoration of the orbital floor, with no clinical evidence of enopthalmos or diplopia. Extraoccular movements were intact in all patients. Only one patient presented with the symptoms of infection at a follow up period of 9 months. The infection subsided after removal of titanium plates, used for the stabilization of graft. Conclusion  Autogenous Mandibular Symphysis graft is a good alternative with minimal morbidity for orbital floor reconstruction. The contour as well as the size of the graft available from symphysis region best suits for orbital floor reconstruction.     

Ortho- and heterotopic bone grafts in bifocal transport osteogenesis for craniofacial reconstruction--an experimental study in sheep

Bifocal transport osteogenesis (BTO) is a promising technique for the reconstruction of extended osseous craniofacial defects. Aim of this study was to determine the potential of this technique related to various donor sites of the transport segment. In 10 adult sheep critical size defects of the calvaria were treated by gradual movement of a transport segment consisting either of autogenous regional free calvarial bone grafts (n=5) or autogenous illiac free bone grafts (n=5). Latency period was 5 days; the rate of distraction was 1mm per day and extended approximately 40 days. The consolidation period was 28 days. After harvesting, specimens were investigated by conventional radiography, CT-scans, histologically and by fluorescence. In both groups transport osteogenesis resulted in a complete closure of the critical size defect. Membranous bone formation and remodeling occurred during the entire period of distraction and consolidation. The volumes and thickness of newly formed bone at the defect site were increased significantly when calvarial bone grafts were used (P<0.05). Iliac bone grafts became progrediently smaller during distraction, while the volume of calvarial grafts remained relatively constant (P<0.05). In conclusion, transport segments consisting of calvarial and iliac bone resulted in a reliable closure of craniofacial critical size defects in adult organisms; the application of calvarial bone grafts resulted in an increased extend of bone formation.     

Reconstruction of the frontal calvarian continuity in a child using a freeze-preserved autogenous bone graft.

Today, extended craniofacial defects in childhood can be treated by using modern techniques of bone banking and osteosynthesis, of particular importance when the restoration needs to consider calvarial growth. This is a report of an 8-year-old boy whose right frontal bone was removed during primary multidisciplinary trauma care. The bone was stored at a tissue bank using sterilization and freeze-dried preservation. Nine months later the graft was replaced and fixed with resorbable miniplates. Postoperatively no complications were observed and the (auto)graft has taken well. There was symmetrical craniofacial growth as well as a good aesthetic result three years after reconstruction.     

带蒂颞肌颅骨瓣修复上颌骨上份的缺损

目的探讨带蒂颞肌颅骨瓣修复上颌骨上份缺损的优缺点。方法对6例上颌骨缺损的患者,用带蒂颞肌颅骨瓣修复上颌骨上份（眶底）缺损,同时封闭口鼻瘘。结果术后患者的伤口均一期愈合,皮瓣成活,术后随访12个月,其面部外形满意,能够正常进食,进食时无食物从鼻腔返流,语音清晰。结论应用带蒂颞肌颅骨瓣重建上颌骨上份（眶下区）缺损,术后患者上颌骨外形和语音恢复正常,值得推广应用。     

Effect of hyperbaric oxygen on grafted and nongrafted calvarial critical-sized defects

OBJECTIVES: This study was undertaken to evaluate the effect of hyperbaric oxygen (HBO) on the repair of critical-sized defects in the presence and absence of a nonvascularized autogenous bone graft. STUDY DESIGN: Ten New Zealand White rabbits were randomly divided into 2 groups of 5 animals each. Bilateral 15-mm calvarial defects were created in the parietal bones of each animal, resulting in 20 critical-sized defects. Autogenous bone grafts (ABG) were allocated to the left or right defect of each animal. Group 1 received HBO treatment at 2.4 ATA 100% oxygen for 90 minutes per day 5 days a week for 4 weeks. Group 2 served as a normobaric (NBO) control, breathing only room air. The animals in each group were humanely killed at 6 weeks. Calvaria were analyzed by micro-CT and histomorphometry. RESULTS: Micro-CT analysis indicated that as expected there was a higher bone mineral density (BMD) and bone mineral content (BMC) in ABG than unfilled defects (P < .05). However, there was a significant decline in the bone mineral content (BMC) of HBO-treated grafted defects compared to NBO-treated grafted defects (P < .05). Histologically complete bridging of the defect was observed in both NBO and HBO ABG grafted defects. Histomorphometic analysis showed that HBO treatment increased new bone and marrow, and reduced fibrous tissue in the defects (P < .01 for all). Examination of residual graft showed a near significant reduction in residual graft volume (11.2 +/- 4.7 versus 19.1 +/- 7.7, HBO versus NBO P = .085) in the HBO group. The use of a graft increased new bone and marrow in the NBO group (P < .001 for both); however, in the HBO-treated animals the differences between grafted and ungrafted were not significant. CONCLUSION: HBO enhances bony healing in ungrafted rabbit calvarial critical-sized defects and may increase the rate of residual graft resorption in autogenous bone-grafted defects.     

Assessment of internal orbital reconstructions for pure blowout fractures: cranial bone grafts versus titanium mesh.

PURPOSE: To assess the adequacy of internal orbital reconstruction in pure blowout fractures using either cranial bone grafts or titanium mesh implants. PATIENTS AND METHODS: The preoperative and postoperative true coronal computed tomography (CT) scans of 58 patients with unilateral pure orbital blowout fractures were included in the study. Demographic data and measurements of the pretreatment size of the defects were tabulated. The accuracy of reconstruction was assessed subjectively by 1 surgeon by scoring the position of the implant/graft, repositioning of orbital soft tissues, and assessment of orbital volume using the uninjured side for comparison. The cross-sectional area of the anterior, middle, and posterior regions of the reconstructed defect was statistically compared with the same locations on the uninjured orbits by scanning the CT scans and calculating the number of pixels within the selected CT slices. A comparison of the accuracy of reconstructions for those reconstructed with cranial bone graft and those with titanium mesh was statistically performed using parametric (for subjective analyses) and nonparametric tests (for cross-sectional area data). RESULTS: Thirty-eight cases were classified as fractures of the orbital floor, 4 as isolated medial wall fractures, and 16 as combined floor/medial wall fractures. There was a statistically significant difference in the surgeon's subjective ratings of adequacy of reconstructions between titanium mesh and bone-grafted groups. Orbits reconstructed with titanium mesh were more accurate than those reconstructed with bone (P <.001). Overall, there was no significant difference in cross-sectional areas between the reconstructed and uninjured orbits in the middle and posterior regions of the defects, but the anterior region showed significantly smaller cross-sectional areas in the reconstructed orbits (P <.001). CONCLUSIONS: Although there was great individual variability and both materials could be successfully used, the orbits reconstructed with titanium mesh showed better overall reconstructions than those reconstructed with bone grafts.