Abstract The goal of orbital reconstruction is to repair trauma defects, to correct the position of the eye anatomically, avoiding enophthalmos, and to restore ocular function. For the reconstruction ...of (trauma) defects, many surgeons recommend materials that can be bent into an anatomical shape and that possess the properties of radiopacity and long-term stability. However, apart from these desired properties, the ideal material for orbital reconstruction remains controversial. Autologous bone is often mentioned as the ‘gold standard,’ likely because of its mechanical properties, revascularization potential, and its adaptation to the orbital tissue with minimal acute and chronic immune reactivity. However, autologous bone can show unpredictable resorption rates and suboptimal volume correction. In recent years, an increasing interest in the use of alloplasts for orbital reconstruction has become apparent in the literature. Modern technological advantages, such as preoperative planning, navigation, and perioperative imaging, can be beneficial in the decision to choose a certain implant. The aim of this review is to give a comprehensive overview of the advantages and disadvantages of materials used to reconstruct traumatic orbital defects and to provide a practical, evidence-based, complexity-driven set of guidelines.
Abstract The timing of orbital reconstruction is a determinative factor with respect to the incidence of potential postoperative orbital complications. In orbital trauma surgery, a general ...distinction is made between immediate (within hours), early (within 2 weeks), and late surgical intervention. There is a strong consensus on the indications for immediate repair, but clinicians face challenges in identifying patients with minimal defects who may actually benefit from delayed surgical treatment. Moreover, controversies exist regarding the risk of late surgery-related orbital fibrosis, since traumatic ocular motility disorders sometimes recover spontaneously and therefore do not necessarily require surgery. In this study, all currently available evidence on timing as an independent variable in orbital fracture reduction outcomes for paediatric and adult patients was systematically reviewed. Current evidence supports guidelines for immediate repair but is insufficient to support guidelines on the best timing for non-immediate orbital reconstruction.
Abstract In the 1980s, computed tomography was introduced as an imaging modality for diagnosing orbital fractures. Since then, new light has been shed on the field of orbital fracture management. ...Currently, most surgeons are likely to repair orbital fractures based on clinical findings and particularly on data obtained from computed tomography scans. However, an important but unresolved issue is the fracture size, which dictates the extent and type of reconstruction. In other fields of trauma surgery, an increasing body of evidence is stressing the importance of complexity-based treatment models. The aim of this study was to systematically review all articles on orbital reconstruction, with a focus on the indication for surgery and the defect size and location, in order to identify the reconstruction methods that show the best results for the different types of orbital fractures.
A hallmark of atopic eczema (AE) is skin barrier dysfunction. Lipids in the stratum corneum (SC), primarily ceramides, fatty acids, and cholesterol, are crucial for the barrier function, but their ...role in relation to AE is indistinct. Filaggrin is an epithelial barrier protein with a central role in the pathogenesis of AE. Nevertheless, the precise causes of AE-associated barrier dysfunction are largely unknown. In this study, a comprehensive analysis of ceramide composition and lipid organization in nonlesional SC of AE patients and control subjects was performed by means of mass spectrometry, infrared spectroscopy, and X-ray diffraction. In addition, the skin barrier and clinical state of the disease were examined. The level of ceramides with an extreme short chain length is drastically increased in SC of AE patients, which leads to an aberrant lipid organization and a decreased skin barrier function. Changes in SC lipid properties correlate with disease severity but are independent of filaggrin mutations. We demonstrate for the first time that changes in ceramide chain length and lipid organization are directly correlated with the skin barrier defects in nonlesional skin of AE patients. We envisage that these insights will provide a new therapeutic entry in therapy and prevention of AE.
In orbital reconstruction, a patient-specific implant (PSI) may provide accurate reconstruction in complex cases, since the design can be tailored to the anatomy. Several design options may be ...embedded, for ease of positioning and precision of reconstruction. This study describes a cohort of 22 patients treated for secondary orbital reconstruction with a PSI; one patient received two PSI. The preoperative clinical characteristics and implant design options used are presented. When compared to preoperative characteristics, the postoperative clinical outcomes showed significant improvements in terms of enophthalmos (P < 0.001), diplopia (P < 0.001), and hypoglobus (P = 0.002). The implant position in all previous reconstructions was considered inadequate. Quantitative analysis after PSI reconstruction showed accurate positioning of the implant, with small median and 90th percentile deviations (roll: median 1.3°, 90th percentile 4.6°; pitch: median 1.4°, 90th percentile 3.9°; yaw: median 1.0°, 90th percentile 4.4°; translation: median 1.4 mm, 90th percentile 2.7 mm). Rim support proved to be a significant predictor of roll and rim extension for yaw. No significant relationship between design options or PSI position and clinical outcomes could be established. The results of this study show the benefits of PSI for the clinical outcomes in a large cohort of secondary post-traumatic orbital reconstructions.
This OpenAccess - textbook sheds new light on pathology in and around the orbit, which is typically an area where many medical disciplines overlap. Each physician brings a specific expertise, but the ...goal should be that the end result of all this input is much more than the sum of the parts. Collaboration, insight and overall knowledge of all parties involved are essential to achieve an optimal patient outcome. Oral and Maxillofacial surgeons have traditionally focused on the bony parts of the orbit, but usually have limited knowledge of the intricacies of binocular single vision, and for the Ophthalmologist it may be the other way around. In the past, scientific articles were often written from a single point of view, resulting in tunnel vision for the physician. The multidisciplinary approach to the orbit leads to an improvement in treatment that should not be underestimated and from which the patient benefits immensely. But especially for the physician and the trainees, a multidisciplinary consultation is a real goldmine in which a lot can be gained. Not every medical problem needs to be tackled in a multidisciplinary framework, but problems around the eye socket often do. At Amphia Hospital in Breda, the Netherlands, more than fifteen years ago, a collaboration between Oral and Maxillofacial Surgeons, Endocrinologists, Radiologists and Ophthalmologists was initiated, which has proven to be very fruitful. The main focus was on Graves' Orbitopathy and orbital fractures, but problems associated with these conditions were also frequently encountered. For those who want to follow this example, or for those who are interested in both orbital surgery, anatomy or ophthalmological orbital issues, this book could prove to be complementary.
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.
Abstract The aim of this study was to evaluate the outcomes of coronectomy as an alternative surgical procedure to complete removal of the impacted mandibular third molar in patients with a suspected ...close relationship between the tooth root(s) and the mandibular canal. A total of 151 patients underwent coronectomy and were followed up with clinical examinations and panoramic radiographs for a minimum of 6 months after surgery. None of the patients exhibited inferior alveolar nerve injury. Eruption of the retained root(s) was more frequent in younger patients (18–35 years). Thirty-six patients (23.8%) exhibited insufficient growth of new bone in the alveolar defect, and 11.3% required a second surgical procedure to remove the root remnant(s). Our results indicate that coronectomy can be a reliable alternative to complete removal of the impacted mandibular third molar in patients exhibiting an increased risk of damage to the inferior alveolar nerve on panoramic radiographs.
This OpenAccess - textbook sheds new light on pathology in and around the orbit, which is typically an area where many medical disciplines overlap. Each physician brings a specific expertise, but the ...goal should be that the end result of all this input is much more than the sum of the parts. Collaboration, insight and overall knowledge of all parties involved are essential to achieve an optimal patient outcome. Oral and Maxillofacial surgeons have traditionally focused on the bony parts of the orbit, but usually have limited knowledge of the intricacies of binocular single vision, and for the Ophthalmologist it may be the other way around. In the past, scientific articles were often written from a single point of view, resulting in tunnel vision for the physician. The multidisciplinary approach to the orbit leads to an improvement in treatment that should not be underestimated and from which the patient benefits immensely. But especially forthe physician and the trainees, a multidisciplinary consultation is a real goldmine in which a lot can be gained. Not every medical problem needs to be tackled in a multidisciplinary framework, but problems around the eye socket often do. At Amphia Hospital in Breda, the Netherlands, more than fifteen years ago, a collaboration between Oral and Maxillofacial Surgeons, Endocrinologists, Radiologists and Ophthalmologists was initiated, which has proven to be very fruitful. The main focus was on Graves' Orbitopathy and orbital fractures, but problems associated with these conditions were also frequently encountered. For those who want to follow this example, or for those who are interested in both orbital surgery, anatomy or ophthalmological orbital issues, this book could prove to be complementary.
This study presents the results of an updated clinical protocol for orbital blow-out fractures, with a special emphasis on nonsurgical treatment and orthoptic evaluation of functional improvement.
A ...two-centre multidisciplinary prospective cohort study was designed to monitor the results of a clinical protocol by assessing ductions, diplopia, globe position, and fracture size. Patients underwent clinical assessment and orthoptic evaluation at first presentation and then at 2 weeks and 3/6/12 months after nonsurgical or surgical treatment. Outcome parameters were field of binocular single vision (BSV), ductions, degree of enophthalmos, a diplopia quality-of-life (QoL) questionnaire, and other sequelae or surgical complications.
46 of the 58 patients who completed the 3, 6 and/or 12-month follow-up received nonsurgical treatment. There was full recovery without diplopia or enophthalmos (>2 mm) in 45 of the 58 patients. The other 13 patients had limited diplopia, mainly in extreme upward gaze (average BSV 90). Five of those 13 patients did not experience impairment of diplopia in daily life. The average QoL score at the end of follow-up was 97. No patients developed late enophthalmos.
This study showed that a high percentage of patients with orbital floor and/or medial wall fracture recovered spontaneously without lasting diplopia or cosmetically disfiguring enophthalmos. The conservative treatment protocol assessed here underlines the importance of orthoptic evaluation of functional parameters.
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