下睑缘切口在眶下壁骨折内固定术中的应用

目的:评价下睑缘切口在眶下壁骨折内固定术中的应用价值.方法:在下睑缘睫毛下约2mm处平行于下睑缘作弧形切口,于眼轮匝肌深面与眶隔浅面之间向眶下缘分离,暴露眶下壁骨折部位,解除骨折线内嵌顿软组织,复位后用弧形钛板固定,细线缝合皮肤.结果:103例眶下壁骨折患者骨折愈合良好,无复视和眼球内陷等并发症.89例切口瘢痕平整、隐蔽、无缺陷;5例轻度下睑外翻,9例局部小皱褶.结论:下睑缘切口在眶下壁骨折内固定术中切口隐蔽,操作简便,创伤小,术野清晰,便于复位和固定.     

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.     

Implant malposition and revision surgery in primary orbital fracture reconstructions

The aim of the study was to assess factors leading to revision surgery and implant position of primary orbital fracture reconstructions.A retrospective cohort included patients who underwent orbital floor and/or medial wall fracture reconstruction for recent trauma. Demographics, fracture type, surgery and implant-related variables, and postoperative implant position were analyzed.The overall revision surgery rate was 6.5% (15 of 232 surgeries). The rate was highest in combined midfacial fractures with rim involvement (14.0%), lower in zygomatico-orbital fractures (8.7%), and lowest in isolated blowout fractures (3.8%). Fracture type, orbital rim fixation and implant malposition predicted revision. The best positioning was achieved with patient-specific milled titanium implants (mtPSI) and resorbable materials, whereas the poorest with preformed three-dimensional titanium plates.Combined midfacial fractures with rim involvement in particular have a high risk for orbital revision surgery. Within the limitations of the present study, mtPSIs should be preferred in the reconstruction of primary orbital fractures if possible.     

One-stage replacement surgery of orbital implants with noninfectious complications

Orbital implant-associated complications always affect patients, resulting in multiple operations. One-stage replacement of complicated implants has been attractive for reducing operation times and preventing long-time appearance without artificial eye. We retrospectively analyzed the outcomes of 1-stage replacement surgery of orbital implant. A total of 21 eyes in 21 cases with noninfectious complications, who failed conservative therapies and surgical repairs, were treated with 1-stage orbital implant replacement. After a detailed ophthalmic history was obtained and examinations performed, patients with apparent purulent secretion in conjunctival sac were excluded. The preexisting orbital implant was carefully removed, and a new hydroxyapatite sphere was implanted simultaneously. Wound healing status, prosthesis movement, and cosmetic features were evaluated and recorded after at least 6 months' follow-up. Orbital implant exposure(16 cases) was the main indication of the replacement surgery; other causes included superior orbital area depression (2 cases), conjunctival fistula (1 case), orbital implant malposition (1 case), and the metal material of implant obstructing magnetic resonance imaging scan in 1 case. Eye-socket hollow was redressed in all cases immediately, and 95.23% cases (20/21) could wear an artificial eye and had a good cosmetic appearance, whereas conjunctival sac fistula reoccurred in 1 patient, and the implant was removed ultimately. Conjunctival sac constrictions occurred in 4 cases after operation and were treated by secondary conjunctival sac reconstruction 6 months later. In conclusion, 1-stage replacement of orbital implants offers an effective and efficient strategy for dealing with severe postimplantation noninfectious complications in achieving a symmetrically cosmetic appearance without delay.     

Transconjunctival versus subciliary approach for orbital fracture repair—an anthropometric evaluation of 221 cases

Objectives

In the literature, there is an ongoing discussion about the influence of orbital fractures and the surgical approach on the rate of eyelid deformities of the lower eyelid.

Materials and methods

We present an evaluation of a series of 221 patients 9 months after zygomaticomaxillary complex fracture repair that underwent implant removal. Reference anthropometric data were measured on standardized pre- and postoperative photographs. Analysis included eye fissure width and height, lid sulcus and upper lid height, upper and lower iris coverage, position of cornea to palpebra inferior, canthal tilt, scleral show, ectropion, and entropion. Both operated and contralateral eyelids were evaluated as well as whether a transconjunctival or a subciliary approach was performed.

Results

Time, surgery, and surgical approach presented significant effects on eye fissure index and lower iris coverage. Scleral show was significantly influenced by the surgical procedure itself as well as by the type of incision. The rate of ectropion increased significantly pre- to postoperative.

Conclusions

The subciliary approach included the highest risk of lower lid retraction. The low pre- to postoperative increase of scleral show and ectropion compared to recent studies gives us an idea about the influence of the underlying trauma on the rate of lower lid retraction. The standardized measurements described are accurately and objective to evaluate postoperative results.

Clinical relevance

The transconjunctival approach is preferable in orbital fracture repair.     

Experience of orbital floor fractures in a UK level one trauma centre: a focus on the surgical approach and lid-related complications

The two surgical approaches to access orbital fractures are transconjunctival and transcutaneous. The aim of this study was to assess the outcomes of orbital repairs with a focus on lid-related complications and their management. A retrospective analysis was carried out over a five-year period (January 2015 to January 2020) to assess all consecutive orbital repairs in our unit. Data were collected for variables including demographics, fracture pattern, surgical approach, and details of postoperative complications. A total of 111 patients were included in the study, 94 were male (85%), the majority being between 16 and 45 years of age. A total of 46 (41%) had isolated orbital floor fractures, 31 (28%) zygomaticomaxillary complex, and 18 (16%) Le Fort pattern fractures. Eighty per cent (n = 91) received a transconjunctival approach as first choice. In the transconjunctival group, six (6.6%) had entropion and increased scleral show, four (4.4%) had ectropion, and none had canthal malposition. In the transcutaneous group (n = 20) there was a higher rate of ectropion (25%, n = 5), a lower rate of entropion (n = 1, 5%) and higher rate of increased scleral show (n = 2, 10%). Factors associated with a higher rate of complications included complex fractures, use of conjunctival sutures, and increased length of time to surgery. Seventy-two per cent of patients who suffered entropion required further surgical treatment. The most common complication of the transconjunctival approach was entropion, and clinicians should have a low threshold for early surgical management. We feel that this should be part of the consenting process, especially in high-risk cases.     

Tarsal strip technique for correction of malposition of the lower eyelid after treatment of orbital trauma

Purpose

The transconjunctival, subciliary, subtarsal, and subpalpebral approaches for accessing the infraorbital rim and orbital floor have both advantages and disadvantages. The most common complications include rounding of the lateral canthal angle, lower eyelid retraction with inferior scleral show, and frank ectropion.

Materials and patients

From 2000 to 2007, we treated 29 patients with lower eyelid malposition after surgery to manage the floor and infraorbital trauma (22 subciliary approaches, five transconjunctival approaches and lateral canthotomies, and two transconjunctival approaches). To correct lower eyelid malposition, we applied the tarsal strip technique in all patients.

Results

Twenty-five patients had scleral show and four patients had ectropion: three were previous treated using transconjunctival access and one using subciliary access. Twenty-six patients obtained satisfactory correction of eyelid malposition in a single-step surgical procedure, while three patients required a second surgical step to correct the remaining scleral show. Good aesthetic and functional results were achieved in all cases.

Conclusions

All approaches to the infraorbital rim or orbital floor have the potential for postoperative sequelae. The tarsal strip technique is a relatively simple technique that oral and maxillofacial surgeons can use to manage lower lid malposition, such as scleral show and ectropion.     

钛网在上前牙唇侧重度骨缺损种植中的临床研究

目的:探讨在上前牙种植时使用钛网联合胶原膜和富血小板纤维蛋白(platelet rich fibrin,PRF)在修复唇侧骨板重度缺损的骨再生效果.方法:选择20例上前牙种植唇侧骨板重度缺损的患者,随机分为两组.一组使用骨粉+胶原膜+PRF进行骨增量,一组使用钛网+骨粉+胶原膜+PRF进行骨增量.埋入式愈合6个月二期手...     

Retrospective analysis of orbital floor fractures—complications,outcome, and review of literature

This retrospective study aimed at investigating indications, surgical approaches, and the materials used for orbital floor reconstructions, as well as the clinical follow-up, particularly with regard to postoperative complications. This study comprised 189 patients who underwent surgery for fractures of the orbital floor between 2003 and 2007. Diagnosis and treatment were based on both physical examination and computed tomography scan of the orbit. Patients were retrospectively analyzed for data, such as mechanism of injury, classification of fracture, and complications. The most common cause of injury was physical assault followed by traffic accidents. Surgery was conducted with a mean delay of 2.9 days after the incident. Mid lower eyelid incision was the most common surgical approach to the orbital floor. For orbital floor reconstruction, polydioxanone sheets (70.5%) were mainly used, followed by Ethisorb Dura (23.3%) and titanium mesh (6.2%). There were 19.0% of patients who showed postoperative complications: 5.8% suffered from persisting motility impairment, 3.7% from enophthalmos, 3.2% from consistent diplopia, 2.6% from ectropion, and 0.5% from orbital infection. Intraorbital hematoma (3.2%) represented the most severe complications, one patient suffered lasting impairment of sight and another one, complete blindness of the affected eye. If postoperative impairment of vision becomes evident, immediate surgical intervention is mandatory. Retrobulbar hematoma is more likely to occur in heavily traumatized patients with comminuted fractures and also in patients taking anticoagulative medication. The subciliary approach to the orbit and repeated operations by the same approach are associated with a higher risk of developing ectropion.     

Mandibular Fracture in Conjunction with Bicortical Penetration,Using Wide‐Diameter Endosseous Dental Implants

Prosthodontic rehabilitation of a patient with an atrophic edentulous mandible presents a significant challenge in restoring esthetics and function. The purpose of this clinical report is to describe fracture of an atrophic edentulous mandible opposing maxillary natural dentition in association with endosseous dental implants. The patient received two wide‐diameter implants in the anterior mandible for an implant‐assisted mandibular overdenture, in which the implants penetrated the inferior border of the mandible for bicortical stabilization. Three months following implant placement surgery, the patient experienced pain, swelling, and intraoral purulent drainage around the right implant. Panoramic radiograph revealed a fracture of the mandible through the right implant site and signs of infection around the left implant. The implants were removed surgically, and open reduction and fixation of the fracture site were undertaken using a titanium bone fixation plate. This clinical report demonstrates that placement of wide‐diameter implants in conjunction with bicortical penetration in a severely atrophic edentulous mandible can risk fracture of the mandible.     

Composite Z plasty for cicatricial ectropion of Tessier III cleft

Tessier III clefts represent one of the most difficult and challenging malformations of the face to repair. Ectropion caused by a Tessier III cleft may be secondary to a vertical loss of both the anterior and posterior lamellae of the lower eyelids.A composite Z plasty to treat recurrence of cicatricial ectropion of the lower eyelids in Tessier III cleft is described. This is not only a technically easy and effective surgical method but also has a short operation time. To the best of the authors' knowledge, this is the first report of the application of a composite Z plasty in the successful treatment of ectropion.     

小切口配合提骨钩用于颧骨复合体骨折治疗的临床总结

目的:探讨提骨钩、小切口在颧骨复合体骨折三维复位中的临床效果。方法:32例颧骨复合体骨折患者,经术前X线片或三维CT成像等影像学检查确诊后,手术取眉弓外、下睑结膜内及同侧上颌磨牙区前庭沟切口,配合提骨钩行三维复位后,分别用小型钛板进行颧额缝、眶下缘、颧上颌缝3点的坚强内固定。结果:所有患者切口均一期愈合,颧面部外形满意,张口度正常,无复视、眼睑外翻、面部麻木等并发症。结论:小切口配合提骨钩可减少手术损伤,并能达到骨折三维复位的目的,具有一定的临床推广价值。     

Intraoperative imaging in orbital reconstruction: how does it affect the position of the implant?

Intraoperative imaging enables the surgeon to control the position of the implant during orbital reconstruction. Although it might improve surgical outcome and avoid the need for revision surgery, it may also increase the duration of the operation and the exposure to radiation. The goal of this study was to find out whether intraoperative imaging improves the position of the implant in reconstructions of the orbital floor and medial wall. Two surgeons reconstructed complex orbital fractures in 10 cadavers. After the reconstruction a computed tomographic scan was made to confirm the position of the implant and, if required, to make any adjustments. Scans were repeated until the surgeon was satisfied. The ideal position was ascertained by scans that were obtained before and after creation of the fractures. The position of the implant achieved was compared with that of the ideal position of the implant, and improved significantly for yaw (p = 0.04) and roll (p = 0.03). A mean of 1.6 scans was required for each reconstruction (maximum n = 3). The main reason for alteration was the rotation roll. Intraoperative imaging significantly improves the position of the implant in fractures of the orbital floor and medial wall. The surgeon has quality control of its position during the reconstruction to restore the anatomical boundaries.     

Lateral rectus muscle injury, orbital fracture, mouth locking, and facial palsy resulting from reduction malarplasty

I report here on a patient with serious complications (lateral rectus muscle injury, orbital fracture, mouth locking, and facial palsy) that were caused by reduction malarplasty. A 32-year-old woman was referred to our department with complaints of inability to move her right eyeball laterally and inability to open her mouth. She has undergone reduction malarplasty 30 days previously at a local clinic. On examination, her maximal mouth opening was less than 3 mm. Her upper lip deviated to the left side when whistling. The orbit was displaced laterally and inferiorly. The upward and lateral gaze were limited. Computed tomography revealed fracture of the right orbital floor and lateral orbital wall extending to the orbital roof. The right lateral rectus muscle showed disconnection. The osteotomized segments were displaced inferiorly, and they pressed on the masseter muscle and coronoid process on the left side. On the 43rd postoperative day, a revision operation for the zygoma and orbit was carried out. Four days after the revision operation, surgery was performed for the myorrhaphy of the lateral rectus muscle and transposition of the medial rectus muscle. This case suggests the possibility of orbital fracture that can occur as a result of sawing in the wrong direction when using the intraoral approach. Although orbital fracture is extremely rare, it is hoped that this case will heighten the awareness of surgeons for this potential orbital fracture.     

钛板携带种植体修复下颌骨缺损的临床应用

目的:探讨钛板携带种植体与植骨联合修复大型下颌骨缺损的可行性。方法:对9例下颌骨体部和颏部同时缺损者用带有HA涂层种植体的钛板进行修复,并在钛板上方和种植体周围植骨,术后给抗生素防感染,6个月后安装基台和义齿、拍X线片、观察钛板和种植体与植骨的结合情况,并对咀嚼功能、面部形态及并发症进行评价。结果:钛板携带种植体植入下颌骨后切口一期愈合,6个月至5年随访,8例面部形态恢复良好,安装基台行义齿修复后可咀嚼软食,未见伤口裂开和钛板外露,X线拍片见种植体周围的植骨生存良好,植骨与种植体之间无低密度影;1例在放射治疗18个月后植骨吸收,部分钛板和种植体暴露,但仍可佩戴义齿,无明显假体周围炎。结论:钛板携带种植体与植骨联合修复大型下颌骨缺损可恢复患者的面形和咀嚼功能,对大型下颌骨缺损的修复是可行的方法。     

口腔颌面部术后钛板出现异常情况的原因及对策

目的:总结和分析口腔颌面部不同手术中使用钛板出现异常情况的原因并提出相应的预防和处理措施。方法:对28例钛板裸露、螺钉松动或脱落及钛板断裂患者的手术类型、手术时的情况,钛板出现异常情况的时间等进行了回顾性分析与研究。结果:局部软组织张力过大,清创不彻底,钛板所固定的骨段不健康以及操作过程中不规范是钛板出现裸露和螺钉松动的主要原因。手术中反复弯制钛板,钻孔时裂钻紧贴钛板边缘,容易导致术后钛板断裂。结论:钛板放置位置和操作过程应遵循坚固内固定的基本原则,术区软组织避免过度牵拉和损伤,术中尽量减少钛板弯制的次数,在严重污染和继发感染的骨创面应慎用坚固内固定技术。     

Efficacy of pre-expanded forehead flap based on the superficial temporal artery in correction of cicatricial ectropion of the lower eyelid

Lower eyelid retraction or ectropion bring suffering to the patients both physically and mentally. Efforts to explore pertinent surgical treatments are still needed. Here we have described our preferred surgical technique for lower eyelid ectropion repair with pre-expanded island forehead flaps or pedicled forehead flaps. Between July 2007 and March 2017, a retrospective review of 12 patients who suffered from cicatricial lower eyelid ectropion as a result of trauma, surgery, or infection was conducted. Forehead skin flap based on the superficial temporal artery was expanded depending on the area of defect of the lower eyelid. Tissue expansion, flap transfer, pedicle delaying and division were involved in this process. There were no major complications, such as expander exposure, infection, haematoma or large skin flap necrosis in all the 12 patients. Venous congestion was reported in two patients. No recurrent ectropion was noted in any patient. During the three-month to two-year follow-up all patients were satisfied with the results in terms of the skin texture, colour, and flexibility after the treatment with an expanded forehead skin flap. This study suggests that expanded forehead skin flaps are effective for correction of cicatricial lower eyelid ectropion.     

Reconstruction of traumatic orbital floor fractures with resorbable mesh plate

Various materials such as autogenous bone, cartilage and alloplastic implants have been used to reconstruct orbital floor fractures. A new material is needed because of disadvantages of nonresorbable alloplastic materials and difficulties in harvesting autogenous tissues. In this study safety and value of the use of resorbable mesh plate in the treatment of orbital floor fractures are discussed. Between 2002 and 2004 a total of 17 maxillofacial trauma patients complicated with orbital floor fractures were treated with resorbable mesh plate through subciliary or transconjunctival incisions. Pure blow-out fractures were determined in 6 patients and 11 patients had accompanying maxillofacial fractures. Resorbable plate was easily shaped to fit to the orbital floor by cutting with scissors. Patients were evaluated clinically and with computed tomography scans preoperatively and at 3-, 6- and 12-month intervals postoperatively. Twelve patients had preoperative enophthalmos. Two patients had diplopia that was corrected postoperatively. In all 17 cases there was no evidence of infection, diplopia and gaze restriction postoperatively. Scleral show appeared in three patients by the second postoperative week but resolved totally within 3 to 6 weeks except one patient. In this patient anterior displacement of mesh was evident which caused ectropion and enophthalmos and required re-operation. No any other mesh related problems were seen at 15 months mean follow-up time. The advantage of the resorbable mesh system in orbital floor fracture is the maintenance of orbital contents against herniation forces during the initial phase of healing and then complete resorption through natural processes after its support is no longer needed. Our experience represents that resorbable mesh is a safe and effective material for reconstruction of the selected, non-extensive orbital floor fractures.     

Facial reconstruction with latissimus dorsi myocutaneous island flap following total maxillectomy

Following total maxillectomy for maxillary cancer, facial reconstruction was performed using a latissimus dorsi myocutaneous island flap. Postreconstructive deformity was studied in 10 patients. In 5 patients, after simple total maxillectomy the inner raw surface of the facial skin and orbito was covered by the flap, and the other extended total maxillectomy patients where the orbital contents and facial skin were involved, reconstruction was by means of the folded flap. In the patients with simple total maxillectomy, cicatricial contracture of the facial skin and cicatricial ectropion of the lower eyelid were quite small, and in the patients with extended total maxillectomy, reconstructed facial skin did not give rise to cicatricial contracture.     

Triangulating the ledge: radiographic study of the floor of orbit and derivation of a novel template

In orbital floor reconstruction, the need for the orbital implant to reach the exact position of the posteromedial ledge is essential, but owing to the complex anatomy of the region, visualisation of the ledge may be difficult. Several morphometric studies, both radiographic and cadaveric, have calculated a mean length from the orbital rim to the ledge. However, those linear measurements are unreliable and possess a higher margin of error for intraoperative guidance. This study attempts to triangulate the position of the posterior ledge from three easily accessible and reproducible points on the orbit and tries to provide a better guideline. A total of 50 patients (25 male and 25 female) with no history of orbital trauma or orbital surgery were selected randomly for this study. Computed tomography (CT) of both orbits, was done from three anatomically consistent and reproducible points: the infraorbital rim just above the infraorbital foramen (point A), hamulus lacrimalis (point B), and the most anterior point of the inferior orbital fissure (point C). The distance from these landmarks to the posterior ledge was measured using DICOM imaging software. A polygonal template was fabricated using the data obtained, which was used for intraoperative guidance. The mean (SD) distance to the posterior ledge from point A was 32.99 (1.35) mm, from point B was 31.36 (1.31) mm, and from point C was 20.19 (1.40) mm. There were no significant differences between left and right orbit or between male and female subjects. The template guides the shape, size, and direction of the orbital implant, reducing the risk of undersized or misplaced implants.