Aplicación clínica de la planificación virtual y la navegación en el tratamiento de las fracturas del suelo de la órbita / Clinical application of virtual planning and navigation for the treatment of the orbital floor fractures

El objetivo del tratamiento de las fracturas de órbita es reconstruir la forma tridimensional de las paredes orbitarias para restablecer el volumen orbitario y la función ocular. El enoftalmos y la diplopía producidos por la reconstrucción inapropiada de la anatomía orbitaria tras un traumatismo continúan siendo todavía una secuela de estas fracturas. El objetivo de este trabajo es describir la técnica de la planificación virtual y la navegación intraoperatoria en el tratamiento de fracturas de suelo y pared medial de la órbita como herramienta útil en el tratamiento de estas fracturas. La técnica de planificación virtual y navegación intraorbitaria se aplica para el tratamiento de pacientes con fracturas de suelo o pared medial de órbita. La corrección virtual de la órbita fracturada se realiza utilizando la imagen en espejo del lado sano superpuesta sobre el lado fracturado. La planificación preoperatoria permite, además, importar y seleccionar preoperatoriamnete una malla premoldeada y determinar la adecuación de esta, en forma y tamaño, para tratar la fractura. La navegación intraoperatoria permite la disección segura y adecuada del contenido orbitario («primera» navegación) y la confirmación de la adecuada reconstrucción de las paredes orbitarias («segunda» navegación). La planificación en ordenador, la cirugía virtual y la navegación intraoperatoria aportan una guía útil, precisa y segura para la reconstrucción orbitaria (AU)

The goal of the treatment of orbital fractures is to reconstruct the three-dimensional shape of the orbital walls to restore the orbital volume and eye function. Enophthalmos and diplopía caused by inappropriate orbital wall anatomy reconstruction after trauma, remain still a sequel to these fractures. The objectives of this paper are to describe the technique of virtual planning and intraoperative navigation in the treatment of floor and medial wall fractures of the orbit as a useful tool in the treatment of these fractures. We have applied the technique of virtual planning and navigation for the treatment of patients with fractures of floor and/or medial orbital wall. The virtual correction of the fractured orbit is performed using the mirror image of the healthy side superimposed on the fractured side. Preoperative computer planning also allows importing the object ‘premolded mesh' to the plan to determine its appropriateness, in shape and size, to treat the fracture. Intraoperative navigation allows a safe and proper dissection ('first' navigation) of the orbital contents and confirmed the proper reconstruction of the orbital walls ('second' navigation). Navigation allows a safe dissection of the orbital contents and a verification of the accuracy of the position of the mesh. Computer planning, virtual surgery and intraoperative navigation provide precise guidance and safety for orbital reconstruction (AU)

[Capabilities of physiotherapy for orbital trauma].

The article describes the results of conservative treatment of 78 patients with injuries of ocular adnexa (isolated fractures of orbital walls as well as cicatrical deformities of orbits and eyelids). Ophthalmological assessment was made both in the early and the late periods following blunt trauma. All patients underwent a standard assessment of functional ability of the eye and, additionally, an orbital computed tomography scan to characterize the fractures. In all cases physiotherapy (endonasal electrophoresis with proteolytic enzymes) was carried out to resolve the orbital hemorrhage. Binocular vision evaluation was done to control the effectiveness of the treatment. For that, the extent of diplopia in the central field and the total area of peripheral double vision were measured and the vertical edges of the diplopia zone were defined.

[Surgical rehabilitation in patients with zygomatic orbital fractures and orbital floor fractures].

The study presents the results of surgical management of 65 patients with zygomatico-orbital complex and orbital floor fractures according to a self-designed technique using polymer implants Reperen. Being a method of choice the technique reduces treatment time, promotes good esthetic results, reduces complication rate, and contributes to a patient's quality life improvement.

Orbital implants for fracture repair.

PURPOSE OF REVIEW: To review the latest advancements in implant materials for orbital fracture repair, including analysis of the last year in research. RECENT FINDINGS: Advances in the manufacture of highly biocompatible alloplastic materials offer an alternative to traditional autologous implants for orbital fracture repair. The emergence of the composite implant offers the stability and strength of traditional titanium mesh, while the porous polyethylene shell allows for greater fibrovascular integration and a potential for decreased risk of postoperative complications. Development of copolymers and biomechanical constructs for the delivery of bone stimulating proteins and stem cells serve to restore orbital volume after fracture repair through stimulation of the patient's own tissue. These recent developments are promising; however, their safety and efficacy have not been verified in humans. SUMMARY: The appropriate choice of orbital implant for fracture repair ensures appropriate orbital reconstruction in an effort to alleviate diplopia, enophthalmos, orbital dystopia, and extraocular muscle restriction.

Comparison of cutaneous incisions to approach the infraorbital rim and orbital floor

Aim: The aim of this article was to retrospectively analyze and compare the esthetic outcomes achieved after the use of 20 subciliary incisions, 22 subtarsal incisions and 16 infraorbital incisions to approach the infraorbital rim and orbital floor in orbital fractures. Methods: The sample consisted of 58 patients (37 males and 21 females) with orbital trauma (floor and infraorbital rim) treated with open reduction and internal rigid fixation in the Department of Oral and Maxillofacial Surgery at “Hospital de Base do Distrito Federal”, Brazil, between September 1996 and August 2003. The following aspects were evaluated: (1) the average distance of the scars measured from the ciliary margin caudally, (2) the esthetic appearance of the scars, (3) chronic lid edema, (4) scleral show, (5) ectropion. Results: Subciliary incision demonstrated better surgical results when compared to the non-subciliary incisions. No statistically significant difference in chronic lid edema rates was found between the three groups of incisions (Fisher, p>0.217 in all cases). There was no statistically significant difference in ectropion, scleral show and chronic edema rates between the three groups of incisions. Conclusions: The subciliary and subtarsal incisions offer better esthetic results than the infraorbital incision.

Use of porous polyethylene with embedded titanium in orbital reconstruction: a review of 106 patients.

PURPOSE: To evaluate our initial experience with a porous polyethylene implant with embedded titanium in orbital reconstruction. METHODS: A retrospective review of the charts was performed for patients receiving at least 1 orbital porous polyethylene implant with embedded titanium from October 2004 through April 2006. Patient demographics, implant type and size, method of fixation, postoperative complications, and length of follow-up were recorded. RESULTS: One-hundred six patients received at least one embedded titanium implant (80 men, 26 women). Age ranged from 3 years to 85 years (mean, 31 years). Indications included orbital fracture repair (102 patients), correction of enophthalmos (3 patients), and reconstruction after tumor resection (1 patient). The average floor implant used was 22.3 mm wide by 27.9 mm long. The average medial wall implant was 13.6 mm tall by 22 mm long. Implants were fixated with 1 or 2 microscrews in 75 patients (70.8%) and placed without fixation in 31 patients (29.2%). Four postoperative complications were noted: a retrobulbar hemorrhage on postoperative day 3 that resolved without sequelae, a vertical overcorrection requiring removal of the implant, a transient oculomotor disturbance, and a screw placed in proximity to the infraorbital nerve canal resulting in hypesthesia and chronic pain that required removal of the screw. In the 3 complications potentially related to the implant, the embedded titanium allowed postoperative implant visualization and guided subsequent management. No implant extrusions or postoperative infections were noted. CONCLUSIONS: Porous polyethylene implants with embedded titanium provide a new alternative to alloplastic implant materials for orbital reconstruction with a profile that combines several advantages of porous polyethylene and titanium implants.

Utilización del BOP en el tratamiento de fracturas de órbita y fronto-orbitales / The use of bio-compatible osteo-conductor polymer (BOP) for treatment of orbital and fronto-orbital fractures

Desde hace muchos años, se han usado diferentes materiales en el tratamiento de las fracturas orbitarias y fronto-orbitarias. Estos materiales generalmente han sido silastic, proplast, hidroxiapatita, e injertos óseos autólogos u homólogos. Sin embargo, desde hace 13 años se desarrolló en la entonces Unión Soviética un compuesto de N-vinyl 2 pirrolidona, líquido de color amarillo soluble en metanol, acetona, metilmetacrilato, gluconato de calcio y fibras de poliamida a alta tensión; este material fue denominado polímero osteoconductor biocompatible (BOP). Se reportan los resultados preliminares de 20 casos de estas fracturas tratadas con BOP; no hubo complicaciones y se corroboró que el BOP es un material inerte, biocompatible y útil para corregir asimetrías faciales. De acuerdo con los resultados obtenidos hasta el presente, se propone seguir los casos por un periodo más largo, con el objeto de demostrar la osteointegración, ya que la razón del éxito en las 20 fracturas ha sido el hecho de que se ha utilizado el BOP en esta serie como un implante, más que como un injerto, en una zona de efectos biomecánicos mínimos

La utilización del polímero osteoconductor biocompatible POB en fracturas de órbita y fronto orbitarias / The use of biocompatible osteoconductor polymer BOP in fractures of the orbit or fronto-orbital regions

Desde hace muchos años, diferentes materiales han sido usados en el tratamiento de las fracturas orbitarias y fronto orbitarias. Estos materiales generalmente han sido silastic, proplast, hidroxihapatita e injertos óseos autólogos u homólogos. Sin embargo, desde hace 13 años se desarrolló en la Unión Soviética un compuesto de N-vinyl 2 pirrolidona, líquido de color amarillo soluble en metanol, acetona, metilmetacrilato, gluconato de calcio y fibras de poliamida a alta tensión, este material fue denominado Polímero Osteoconductor Biocompartible (POB). Se reportan los resultados preliminares de 20 casos de fracturas tratadas con este polímero, en los que se observó que no hubo complicaciones y se corroboró que el POB es un material inerte, no tóxico y biocompatible útil para corregir asimetrías faciales. No obstante los resultados positivos a la fecha, se sugiere vigilar los casos por un periodo largo, con objeto de asegurar la osteointegración del polímero. La razón del éxito en las 20 fracturas se debe a la utilización del POB como un implante más que como injerto, en una zona de efectos biomecánico mínimos

Internal fixation vs. conventional therapy in midface fractures.

The purpose of this review is to evaluate internal fixation by means of AO miniplates compared to conventional therapy for the treatment of complicated midface fractures. A more precise division of midface fractures into functional units than that afforded by the Le Fort classification was employed to categorize the complexity of injury. The criteria of evaluation were ease of functional rehabilitation, incidence of complications, and results of surgery. The classification system was helpful in surgical planning and in subsequent analysis of results. Forty-nine of the 92 midface fractures treated by open repair between July 1980 and January 1986 were malar fractures, and 41 of these had associated orbital fractures. The remaining 43 had Le Fort II or more complicated midface fractures, only 15 of which could be adequately categorized by the Le Fort classification. Twenty-two of the 43 patients with complicated midface fractures were surgically treated with internal fixation utilizing 67 AO miniplates. The remaining 21 patients were treated with conventional therapy utilizing a combination of intermaxillary fixation (IMF), and/or interosseous wiring, and/or primary bone grafting. Among the problems encountered were a nonunion of the midface in a delayed repair of a severely comminuted midface fracture, which required secondary split rib grafting. Three plates were removed because of intraoral extrusion. There were no plate-related infections. One of the advantages of internal fixation is that the need for primary bone grafting and external fixation is eliminated. Another is that intermaxillary fixation is needed less frequently, allowing immediate access to the oral cavity for control of airway, care of intraoral wounds, and rapid return to normal alimentation with full mandibular function. Most patients with no associated GI problems tolerated a soft diet within 6 days. Tracheostomy tubes were removed within 3 days if no pulmonary failure was present. We can conclude that internal fixation provides excellent stabilization and repair of complicated midface injuries with minimal complications and rapid return to function for most patients.