Orbital floor reconstruction /certified fixed orthodontic courses by Indian dental academy

POST TRAUMATIC ORBITAL
FLOOR RECONSTRUCTION
GENERAL CONSIDERATIONS & TREATMENT OPTIONS

INDIAN DENTAL ACADEMY
Leader in continuing dental education
www.indiandentalacademy.com


‘ SO CLOSELY DO THE FEATURES
DEPEND FOR THEIR FORM UPON
THEIR BONY SUPPORT THAT LOSS
OF EVEN A SMALL PORTION OF ONE
OF THE FACIAL BONES WILL
GENERALLY ENTAIL A GREAT
DISFIGUREMENT”
- J.ASHURST-AMERICAN JOURNAL
OF MEDICAL SCIENCES(1864)

INTRODUCTION


BONY ORBIT HOUSES IMPORTANT
STRUCTURES OF THE FACIAL SKELETON



PRECISE KNOWLEDGE OF ANATOMY
REQUIRED FOR ORBITAL TRAUMA REPAIR


CLASSIFICATION – ORBITAL FLOOR #
-- PURE BLOW OUT #
Fujino et al
-- LINEAR #
 BLOW OUT # -- Smith & Regan
 BLOW IN # -- Dingman & Natvig(1964)


CLINICAL FEATURES
EYELID EDEMA
 CIRCUMORBITAL ECCHYMOSIS
 SUBCONJUNCTIVAL HEMORRHAGE
 ALTERATION OF VISUAL AXIS
 PARESTHESIA
 DIPLOPIA
 ENOPTHALMOS
 RESTRICTION OF OCULAR MOVEMENT



RADIOGRAPHIC SIGNS





FOR BLOW OUT #s (ZIZMOR et al)
Orbital floor fragmentation
Displacement of fragments
“Hanging drop sign”


When to intervene and reconstruct
 Persistent

diplopia & enophthalmos
 Muscle entrapments
 Depression / elevation- inferior orbital rim
 Cosmetic deformities
 Orbital floor defects> 50%
 Prolapse of orbital contents

Timing of repair
 Deferred

for 5-7 days
 Immediate intervention
-- traumatic optic neuropathy
-- increased I.O pressure
-- direct muscle injuries

GUIDELINES FOR SURGICAL
EXPLORATION
 Infraorbital

.f to midpoint of IOF—24mm
 ALC--AEF– 24mm
 ALC– medial aspect of OC—42mm
 FZ suture to SOF– 40mm
 Supraorbital notch – SOF—40mm
 Supraorbital notch– superior aspect of OC—45mm

TREATMENT GOALS

AIMS
Preservation of binocular vision
Restoration and reconstruction
of bony orbit

TREATMENT MODALITIES
Antral

packing/ floor grafting with
antral support
Reconstruction with autogenous /
allogenous bone/ alloplasts


ANTRAL PACKING
Indications
 Communition

with fragments retaining periosteal

attachments
 “Trap door type” #s

Approach: standard Caldwell Luc

GRAFTING AND ANTRAL SUPPORT
Indication
Severe loss of bone from posterior limit of orbital
floor
complication
Increased risk of graft infections


ORBITAL FLOOR GRAFTING
Functions of Ideal graft:• Seal orbit from antrum
• Restore orbital contour & dimensions
• Inert smooth surface
• Indirect globe support

Autografts
 For

defects 1 – 1.5cm dia
 Ideal graft material
 Inserted with cortical surface towards globe
 About 1/3rd (25%) resorbs
 Iliac crest grafts not indicated in children
 Always over correct floor defects

Auto grafts (Contd.)
Antral Wall
 Nasal septal cartilage
 Cancellous bone ( Mastoid)
 Iliac crest (inner table)
 Ramus
 Coronoid, Symphysis
 Rib
 Tibia
 Auricular Cartilage
 Zygomatic Buttress
 Calvarial Bone



Allografts
Allogenic bone & Cartilage not used now
 Lyophilised dura ( Luhr – 1969)


•
•


Disadv of dura:Not for large defects
Cannot correct enophthalmos
“ Creutzfeld – Jakob disease”

• For defects up to 2 cm dia

Alloplasts
 Inserted

subperiosteally
 Encapsulated by fibrous tissue
 Medpore for primary orbital floor #’s
& Secondary enophthalmos reconstruction


Alloplastic materials
Silicone polymers
 Teflon ( Freeman – 1962)
 Poly vinyl sponge (Henderson – 1963)
 Dacron reinforced silastic (Lerman & Cramer – 1964)
 Dacron urethane (Leake etal – 1980)
 Al: oxide ceramic ( Niederdellman etal –1976)
 Tantalum gauze ( Prowler – 1965)
 Marlex mesh, Gelfilm
 Porous Polyethylene (Medpore) – Rubin (1961)



Graft Fixation
With

28g wire / resorbable suture
Engaging lip of alloplastic
material into # site


Complications
Persistent enophthalmos
 Depression of globe
 Persistent diplopia in vertical gaze
 Extrusion of implant
 Infection & C/c fistula formation
 Ectropion
 Intra Orbital hemmorhage
 Edema of lower eyelid
 Tissue reaction to implant
 Dacryocystitis
 Blindness


Orbital floor reconstruction /certified fixed orthodontic courses by Indian dental academy

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