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O.038 Experiences with the Salzburg Sinus Endothesis
10
Journal of Cranio-Maxillofacial Surgery 34(2006) Suppl. S1
were surveyed using pre- and post-operative CT and photographic documentation of the clinical aspect. A transoral approach was chosen; the zygoma and the infraorbital margin were exposed. The anterior wall of the maxillary sinus was opened just to allow preparation of the orbital floor under endoscopic control. Pre- and post-operative complaints, complications and time of hospitalization were compared. Results: Along with our personal learning curve we had two minor postoperative bleedings and two cases of post-operative sinusitis. Conclusion: The minimal invasive transmaxillary endoscopic treatment of the fracture of the orbital floor allows well-controlled reposition without additional bulbus trauma and aesthetic impairment. O.035 Downsizing of osteosynthesis of orbitozygomatic fractures – 5 years clinical experience P.J. Voss, N. Weyer, B. Hohlweg-Majert, M.C. Metzger, R. Sch¨on. Department of Oral and Maxillofacial Surgery, University Hospital Freiburg, Hugstetter St. 55, 79106 Freiburg, Germany Introduction and Objectives: Rigid fixation of orbitozygomatic fractures is usually performed with 1.5 miniplate osteosynthesis. This study presents the clinical and radiological results of orbitozygoma fractures treated with 1.3 microplates. Material and Methods: Eighty five patients, each with an isolated, unilateral dislocated orbitozygomatic fracture, were exclusively fixed with microplates (Compact 1.3, Synthes, Umkirch, Germany) between January 2001 and June 2005 in our department. Intraoral, transconjunctival and blepharoplasty approaches were used. Retrospectively length and amount of the 1.3 microplates were analysed by radiographics (Waters and panoramic view). Additionally, clinical complications were documented. Results: The mean age of the 60 male and 25 female patients was 44 years (10–93). In total 221 1.3 microplates (161 straight adaptation plates, 30 curved orbital rim plates, 30 L-plates) and 931 screws (9×3 mm length, 446×4 mm, 191×5 mm, 281× 6 mm, 4× 8 mm) were used. Ninety five of 161 adaptation plates had 4–6 holes, 36 plates had 2–3 holes and 40 plates had 7–10 holes. Out of 30 orbital rim plates 17 plates had 4–6 holes and 13 plates had 7–9 holes. Twenty six L-plates with 6 holes and 4 plates with 7 holes were used. Neither loosening of the osteosynthesis, nor of plate fractures, nor of pseudoarthrosis were found postoperatively. In all cases undisturbed fracture healing was noted. Conclusions: The treatment of orbitozygomatic fractures with 1.3 microplates shows sufficient stability and excellent handling. Downsizing of osteosynthesis results in a better functional and aesthetic outcome due to an easier alignment. However, microplates are more expensive than miniplates. O.036 Transconjunctival approach for orbit reconstruction surgery K.K. Warnecke, P. Sieg. Sektion Kiefer- und Gesichtschirurgie, Universit¨atsklinikum Schleswig-Holstein, Ratzeburger Allee 160, 23538 L¨ubeck, Germany Since 1991 the transconjunctival approach for the treatment of mid-face fractures has been performed at the Department of Maxillo-Facial Surgery at the University Hospital in L¨ubeck, Germany. Among all of the traumatologic patients 568 patients with a total number of 892 transconjunctival approaches were found. In a retrospective analysis the number of complications
Abstracts, EACFMS XVIII Congress due to the surgical approach were documented as well as their surgical corrections. Moreover, the possible relations between the experience of the surgeon, technical details in surgery and the patients data were examined. Complications caused by the surgical approach as such were documented in 4.26% of the cases. We identified intraoperative injuries like lacrimal system injury (n = 3), laceration of the lid margin (n = 10), postoperative complications like retraction of the lower lid (n = 2), entropium (n = 7), ectropium (n = 2) and conjunctival granuloma (n = 5). Surgical correction was successful in all these cases. Temporary dysfunctions like chemosis, conjunctivitis and hyposphagma that are sometimes observed in the course of regular woundhealing were documented but not taken into account. The transconjunctival approach is an elegant surgical way to provide excellent exposure of the margo infraorbitale, the orbital floor and the caudal parts of the medial and lateral orbita wall. At the same time no visible scars are left. With 4.26% the rate of complications is low compared to the subciliar approach, although it is slighly higher than in the classic infraorbital approach. We will give you a detailed picture of our results. O.037 Accuracy of orbital floor reconstruction using resorbable and titanium materials N. Weyer, R. Sch¨on, P. Voss, M.C. Metzger. Department of Oral and Maxillofacial Surgery, University Clinic Freiburg, Freiburg i. Br., Germany Introduction and Objectives: Fractures of the orbital floor are a common injury secondary to blunt trauma of the ocular globe. If the orbital floor is not reconstructed properly, enophtalmos or double vision might occur. Orbital reconstruction is often performed using resorbable or non-resorbable materials. The purpose of this study is the evaluation of accuracy of reconstruction of orbital floor fractures in comparison to the unaffected site. Material and Methods: Thirty six patients (12 women and 24 men) who were treated with orbital floor fractures between April 2003 and December 2004 were examined clinically and with CT scans 1 year after trauma. The fractures were reconstructed either with resorbable (PDS, n = 18) or non-resorbable (titanium mesh, n = 18) materials. Using 3D-CT scans, the reconstructed orbital floor was compared to the unaffected site. Clinically, double vision or enophtalmos was measured using Hertel index and hotographs. Results: If treated with titanium mesh, reconstruction of the orbital floor was very precise compared to the unaffected site. Clinically, two patients had double vision (11.1%) and one patient had enophtalmos (5.5%). After reconstruction with PDS, in 12 patients (66.7%) the orbital floor was lower in the vertical dimension compared to the unaffected site. Two patients had double vision (11.1%) and 5 patients had enophtalmos (27.8%). Conclusions: Compared to the unaffected orbit, reconstruction of orbital floor fractures with resorbable materials seems to lead to increased appearance of enophtalmos or double vision, especially in bigger floor defects. If the fracture is treated with titanium mesh, reconstruction is more precise and clinically fewer complications occur. O.038 Experiences with the Salzburg Sinus Endothesis J. Hachleitner, Ch. Konstantiniuk, Ch. Krenkel. Department of Maxillo-Facial Surgery, St. Johanns-Spital, PMU, Salzburg, Austria Introduction and Objectives: Severely dislocated fractures of the orbital floor require optimal primary reduction and stabi-
Oral Presentations lization. Bridging of defects by titanium meshes or resorbable foils needs wide surgical access and offers no possibility of post-operative correction. With spherical or tetrahedron-shaped balloons reduction may be inadequate and pressure necrosis may cause infections of the mucosal lining of the sinus. Material and Methods: To prevent these disadvantages an anatomically shaped sinus implant (endothesis) was developed at the Department of Maxillo-Facial Surgery Salzburg (Holzner, Krenkel, Lixl, 1986). Impression casts were taken from 24 cadaveric maxillary sinuses. On the basis of the typical average shape three thin walled hollow implants of medical silicone were fabricated for each side. Severe fractures of the orbital floor are explored from infraorbital first. To support the orbital floor from caudal the sinus endothesis is then inserted through a window in the facial sinus wall and filled with contrast agent through the nasal drain. In the postoperative period filling pressures can be corrected as required. After 4 weeks the endothesis is evacuated and removed through the nasal window in local anesthesia. Results: At our department more than 400 patients with orbital floor fractures have been treated with this technique between 1986 and 2005. A follow-up of 99 patients shows 2.5% diplopia in the central field of vision and enophthalmos (of more than 3 mm) in 5% in the late check-up. Conclusions: The Salzburg Sinus Endothesis allows exact anatomical reconstruction of the orbital floor after trauma including the possibility of post-operative correction. O.039 Reconstruction of orbital floor fractures. A current surgical management M. Marasco, F.S. De Ponte. Department of Oral and Maxillofacial surgery, University of Messina, Italy The ideal management of orbital floor fractures continues to be debated. The goal of surgery is 2-fold: To reposition of herniated orbital fat and tissue within the orbit, and restore the anatomy and volume of the orbit. Many materials, both autogenous and alloplastic, have been used to span the defect. Objective: We compare the use of autogenous bone with alloplastic implants (Medpor, Titanium mesh) for the repair of orbital floor defects after trauma. Material and Methods: Three hundred and twenty five patients with orbital floor fracture were analysed from 2000 to 2005 at Department of Oral and Maxillo-Facial of the University of Messina (Italy). The reconstruction was made by autogenous bone graft, titanium mesh, Medpor. Results: During a mean follow-up of 25 months, patients had no post-operative complicationss. The were no instances of infection at the surgical site and donor site. No evidence of extrusion of implants. No clinical evidence of enophtalmous or diplopia. Extraocular movements were intact in all patients. Conclusion: There are so many implants to reconstruct orbital floor fractures after trauma. In this study we analyse the pro and vs of all these implants. Today alloplastic materials merit consideration in many circumstances when bone autogenous graft is contraidicated or when the surgeon does not want to use it. O.040 Post traumatic enopthalmos: Principles of correction and reconstruction L. Clauser, R. Tieghi. Dept. of Cranio-Maxillofacial Surgery, Ferrara, Italy Introduction and Objectives: Post-traumatic enophthalmos is a poorly understood condition that challenge the surgical talent of the most experienced surgeons. Recent research has improved a
Facial trauma: orbit
11
better understanding this condition and has provided a basis for improved surgical correction. Enophthalmos is defined as a backward and downward displacement of the globe into the bony orbit. This condition is due to: enlargement of the orbital cavity; escape of orbital fat into the maxillary sinus. Several additional mechanisms have been proposed to explain the condition. These includes fat atrophy, loss of ligament support, scar contracture. Korneef recently suggested that entrapment of the eyeball ligament system could hold the globe in a displaced position. Of the postulated etiologies, orbital enlargement, fat displacement and fat atrophy have received the most attention, but only recently, with the advent of volumetric studies and threedimensional computerized tomographic imaging capabilities, have the mechanisms of post-traumatic enophthalmos been more accurately evacuated. There are three basic structures that determine globe position: the bony orbit, the ligament system, orbital fat. Materials and Methods: Given that the volumes of orbital soft tissue are not changed in the usual post-traumetic orbit, eye position may be restored by releasing the adherence of soft tissue to the displaced bony walls of the orbit and squeezing this soft tissue mass forward and upward by restructuring the bony orbit to its preinjury dimensions. Such a bone reconstruction will then determine proper globe position O.041 Delayed correction of orbital-maxillo-zygomatic complex fractures with stereolithographic models A. D’Agostino, R. Scala, P. Procacci, L. Trevisiol. Maxillo-Facial Surgery Department, University of Verona, Italy Introduction: The etiology of post-traumatic orbital deformities is most frequently due to impossibility of an immediate surgical treatment because of any systemic pathology that may represent a life risk. It may be possible to achieve a suitable surgical result pursuing the following aims: restoration of the threedimensional structure of the orbit, soft tissue correction and eventually restoration of lost tissues with autologous or similar ones. In the correction of post-traumatic orbital sequelae, many surgical options exist: osteotomies, reconstructive and camouflage techniques using alloplastic material or bone grafts and soft tissues restoration. The aim of this study is to evaluate if the use of stereolithographic models in the pre-operative planning allows an accurate evaluation of the orbital defect or alteration and makes the surgical planning and intraoperative steps easier and more predictable. Material and Methods: Five patients affected by post-traumatic orbital sequelae, both aesthetic and functional, were surgically treated. In order to achieve an accurate pre-operative diagnosis, conventional X-rays, TC multi-slice with three-dimensional reconstructions and then the fabrication of custom stereolithographic models were performed. Results and Conclusions: The use of stereolithographic models in the preoperative planning allows an accurate evaluation of the volumetric orbital defect or alteration; it makes the surgical planning easier because many choices, usually made during surgery, can be done during the aforementioned planning. We refer to timing and modality of the osteotomies, reallignament of bony segments after osteotomy, pre or intraoperative moulding of the osteo-synthesis plates and pre-fabrication, using a template, of autologous or alloplastic grafts.
Journal of Cranio-Maxillofacial Surgery 34(2006) Suppl. S1
were surveyed using pre- and post-operative CT and photographic documentation of the clinical aspect. A transoral approach was chosen; the zygoma and the infraorbital margin were exposed. The anterior wall of the maxillary sinus was opened just to allow preparation of the orbital floor under endoscopic control. Pre- and post-operative complaints, complications and time of hospitalization were compared. Results: Along with our personal learning curve we had two minor postoperative bleedings and two cases of post-operative sinusitis. Conclusion: The minimal invasive transmaxillary endoscopic treatment of the fracture of the orbital floor allows well-controlled reposition without additional bulbus trauma and aesthetic impairment. O.035 Downsizing of osteosynthesis of orbitozygomatic fractures – 5 years clinical experience P.J. Voss, N. Weyer, B. Hohlweg-Majert, M.C. Metzger, R. Sch¨on. Department of Oral and Maxillofacial Surgery, University Hospital Freiburg, Hugstetter St. 55, 79106 Freiburg, Germany Introduction and Objectives: Rigid fixation of orbitozygomatic fractures is usually performed with 1.5 miniplate osteosynthesis. This study presents the clinical and radiological results of orbitozygoma fractures treated with 1.3 microplates. Material and Methods: Eighty five patients, each with an isolated, unilateral dislocated orbitozygomatic fracture, were exclusively fixed with microplates (Compact 1.3, Synthes, Umkirch, Germany) between January 2001 and June 2005 in our department. Intraoral, transconjunctival and blepharoplasty approaches were used. Retrospectively length and amount of the 1.3 microplates were analysed by radiographics (Waters and panoramic view). Additionally, clinical complications were documented. Results: The mean age of the 60 male and 25 female patients was 44 years (10–93). In total 221 1.3 microplates (161 straight adaptation plates, 30 curved orbital rim plates, 30 L-plates) and 931 screws (9×3 mm length, 446×4 mm, 191×5 mm, 281× 6 mm, 4× 8 mm) were used. Ninety five of 161 adaptation plates had 4–6 holes, 36 plates had 2–3 holes and 40 plates had 7–10 holes. Out of 30 orbital rim plates 17 plates had 4–6 holes and 13 plates had 7–9 holes. Twenty six L-plates with 6 holes and 4 plates with 7 holes were used. Neither loosening of the osteosynthesis, nor of plate fractures, nor of pseudoarthrosis were found postoperatively. In all cases undisturbed fracture healing was noted. Conclusions: The treatment of orbitozygomatic fractures with 1.3 microplates shows sufficient stability and excellent handling. Downsizing of osteosynthesis results in a better functional and aesthetic outcome due to an easier alignment. However, microplates are more expensive than miniplates. O.036 Transconjunctival approach for orbit reconstruction surgery K.K. Warnecke, P. Sieg. Sektion Kiefer- und Gesichtschirurgie, Universit¨atsklinikum Schleswig-Holstein, Ratzeburger Allee 160, 23538 L¨ubeck, Germany Since 1991 the transconjunctival approach for the treatment of mid-face fractures has been performed at the Department of Maxillo-Facial Surgery at the University Hospital in L¨ubeck, Germany. Among all of the traumatologic patients 568 patients with a total number of 892 transconjunctival approaches were found. In a retrospective analysis the number of complications
Abstracts, EACFMS XVIII Congress due to the surgical approach were documented as well as their surgical corrections. Moreover, the possible relations between the experience of the surgeon, technical details in surgery and the patients data were examined. Complications caused by the surgical approach as such were documented in 4.26% of the cases. We identified intraoperative injuries like lacrimal system injury (n = 3), laceration of the lid margin (n = 10), postoperative complications like retraction of the lower lid (n = 2), entropium (n = 7), ectropium (n = 2) and conjunctival granuloma (n = 5). Surgical correction was successful in all these cases. Temporary dysfunctions like chemosis, conjunctivitis and hyposphagma that are sometimes observed in the course of regular woundhealing were documented but not taken into account. The transconjunctival approach is an elegant surgical way to provide excellent exposure of the margo infraorbitale, the orbital floor and the caudal parts of the medial and lateral orbita wall. At the same time no visible scars are left. With 4.26% the rate of complications is low compared to the subciliar approach, although it is slighly higher than in the classic infraorbital approach. We will give you a detailed picture of our results. O.037 Accuracy of orbital floor reconstruction using resorbable and titanium materials N. Weyer, R. Sch¨on, P. Voss, M.C. Metzger. Department of Oral and Maxillofacial Surgery, University Clinic Freiburg, Freiburg i. Br., Germany Introduction and Objectives: Fractures of the orbital floor are a common injury secondary to blunt trauma of the ocular globe. If the orbital floor is not reconstructed properly, enophtalmos or double vision might occur. Orbital reconstruction is often performed using resorbable or non-resorbable materials. The purpose of this study is the evaluation of accuracy of reconstruction of orbital floor fractures in comparison to the unaffected site. Material and Methods: Thirty six patients (12 women and 24 men) who were treated with orbital floor fractures between April 2003 and December 2004 were examined clinically and with CT scans 1 year after trauma. The fractures were reconstructed either with resorbable (PDS, n = 18) or non-resorbable (titanium mesh, n = 18) materials. Using 3D-CT scans, the reconstructed orbital floor was compared to the unaffected site. Clinically, double vision or enophtalmos was measured using Hertel index and hotographs. Results: If treated with titanium mesh, reconstruction of the orbital floor was very precise compared to the unaffected site. Clinically, two patients had double vision (11.1%) and one patient had enophtalmos (5.5%). After reconstruction with PDS, in 12 patients (66.7%) the orbital floor was lower in the vertical dimension compared to the unaffected site. Two patients had double vision (11.1%) and 5 patients had enophtalmos (27.8%). Conclusions: Compared to the unaffected orbit, reconstruction of orbital floor fractures with resorbable materials seems to lead to increased appearance of enophtalmos or double vision, especially in bigger floor defects. If the fracture is treated with titanium mesh, reconstruction is more precise and clinically fewer complications occur. O.038 Experiences with the Salzburg Sinus Endothesis J. Hachleitner, Ch. Konstantiniuk, Ch. Krenkel. Department of Maxillo-Facial Surgery, St. Johanns-Spital, PMU, Salzburg, Austria Introduction and Objectives: Severely dislocated fractures of the orbital floor require optimal primary reduction and stabi-
Oral Presentations lization. Bridging of defects by titanium meshes or resorbable foils needs wide surgical access and offers no possibility of post-operative correction. With spherical or tetrahedron-shaped balloons reduction may be inadequate and pressure necrosis may cause infections of the mucosal lining of the sinus. Material and Methods: To prevent these disadvantages an anatomically shaped sinus implant (endothesis) was developed at the Department of Maxillo-Facial Surgery Salzburg (Holzner, Krenkel, Lixl, 1986). Impression casts were taken from 24 cadaveric maxillary sinuses. On the basis of the typical average shape three thin walled hollow implants of medical silicone were fabricated for each side. Severe fractures of the orbital floor are explored from infraorbital first. To support the orbital floor from caudal the sinus endothesis is then inserted through a window in the facial sinus wall and filled with contrast agent through the nasal drain. In the postoperative period filling pressures can be corrected as required. After 4 weeks the endothesis is evacuated and removed through the nasal window in local anesthesia. Results: At our department more than 400 patients with orbital floor fractures have been treated with this technique between 1986 and 2005. A follow-up of 99 patients shows 2.5% diplopia in the central field of vision and enophthalmos (of more than 3 mm) in 5% in the late check-up. Conclusions: The Salzburg Sinus Endothesis allows exact anatomical reconstruction of the orbital floor after trauma including the possibility of post-operative correction. O.039 Reconstruction of orbital floor fractures. A current surgical management M. Marasco, F.S. De Ponte. Department of Oral and Maxillofacial surgery, University of Messina, Italy The ideal management of orbital floor fractures continues to be debated. The goal of surgery is 2-fold: To reposition of herniated orbital fat and tissue within the orbit, and restore the anatomy and volume of the orbit. Many materials, both autogenous and alloplastic, have been used to span the defect. Objective: We compare the use of autogenous bone with alloplastic implants (Medpor, Titanium mesh) for the repair of orbital floor defects after trauma. Material and Methods: Three hundred and twenty five patients with orbital floor fracture were analysed from 2000 to 2005 at Department of Oral and Maxillo-Facial of the University of Messina (Italy). The reconstruction was made by autogenous bone graft, titanium mesh, Medpor. Results: During a mean follow-up of 25 months, patients had no post-operative complicationss. The were no instances of infection at the surgical site and donor site. No evidence of extrusion of implants. No clinical evidence of enophtalmous or diplopia. Extraocular movements were intact in all patients. Conclusion: There are so many implants to reconstruct orbital floor fractures after trauma. In this study we analyse the pro and vs of all these implants. Today alloplastic materials merit consideration in many circumstances when bone autogenous graft is contraidicated or when the surgeon does not want to use it. O.040 Post traumatic enopthalmos: Principles of correction and reconstruction L. Clauser, R. Tieghi. Dept. of Cranio-Maxillofacial Surgery, Ferrara, Italy Introduction and Objectives: Post-traumatic enophthalmos is a poorly understood condition that challenge the surgical talent of the most experienced surgeons. Recent research has improved a
Facial trauma: orbit
11
better understanding this condition and has provided a basis for improved surgical correction. Enophthalmos is defined as a backward and downward displacement of the globe into the bony orbit. This condition is due to: enlargement of the orbital cavity; escape of orbital fat into the maxillary sinus. Several additional mechanisms have been proposed to explain the condition. These includes fat atrophy, loss of ligament support, scar contracture. Korneef recently suggested that entrapment of the eyeball ligament system could hold the globe in a displaced position. Of the postulated etiologies, orbital enlargement, fat displacement and fat atrophy have received the most attention, but only recently, with the advent of volumetric studies and threedimensional computerized tomographic imaging capabilities, have the mechanisms of post-traumatic enophthalmos been more accurately evacuated. There are three basic structures that determine globe position: the bony orbit, the ligament system, orbital fat. Materials and Methods: Given that the volumes of orbital soft tissue are not changed in the usual post-traumetic orbit, eye position may be restored by releasing the adherence of soft tissue to the displaced bony walls of the orbit and squeezing this soft tissue mass forward and upward by restructuring the bony orbit to its preinjury dimensions. Such a bone reconstruction will then determine proper globe position O.041 Delayed correction of orbital-maxillo-zygomatic complex fractures with stereolithographic models A. D’Agostino, R. Scala, P. Procacci, L. Trevisiol. Maxillo-Facial Surgery Department, University of Verona, Italy Introduction: The etiology of post-traumatic orbital deformities is most frequently due to impossibility of an immediate surgical treatment because of any systemic pathology that may represent a life risk. It may be possible to achieve a suitable surgical result pursuing the following aims: restoration of the threedimensional structure of the orbit, soft tissue correction and eventually restoration of lost tissues with autologous or similar ones. In the correction of post-traumatic orbital sequelae, many surgical options exist: osteotomies, reconstructive and camouflage techniques using alloplastic material or bone grafts and soft tissues restoration. The aim of this study is to evaluate if the use of stereolithographic models in the pre-operative planning allows an accurate evaluation of the orbital defect or alteration and makes the surgical planning and intraoperative steps easier and more predictable. Material and Methods: Five patients affected by post-traumatic orbital sequelae, both aesthetic and functional, were surgically treated. In order to achieve an accurate pre-operative diagnosis, conventional X-rays, TC multi-slice with three-dimensional reconstructions and then the fabrication of custom stereolithographic models were performed. Results and Conclusions: The use of stereolithographic models in the preoperative planning allows an accurate evaluation of the volumetric orbital defect or alteration; it makes the surgical planning easier because many choices, usually made during surgery, can be done during the aforementioned planning. We refer to timing and modality of the osteotomies, reallignament of bony segments after osteotomy, pre or intraoperative moulding of the osteo-synthesis plates and pre-fabrication, using a template, of autologous or alloplastic grafts.