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Orbital Defect Repair and Secondary Reconstruction of Enophthalmos With Mirror-Technique Fabricated Titanium Mesh
Symposia
SYMPOSIUM ON TRAUMA Saturday, September 20, 2008, 7:30 am–9:30 am
Complex Cranio-Orbital Trauma Bernard J. Costello, DMD, MD, Pittsburgh, PA Treatment of complex cranio-orbital trauma requires that the surgeon have a clear understanding of these complex injuries, their relationship to the central nervous system, and the challenges of reconstruction. Primary and secondary reconstruction techniques are discussed for a variety of injury patterns in children and adults. The diagnosis and management of cranial vault fractures, naso-orbital ethmoid fractures, and complex cranio-orbital injury are reviewed. Numerous approaches to the craniomaxillofacial skeleton may be utilized to accomplish the reconstructive goals. A variety of approaches to the craniofacial skeleton are reviewed including their benefits and drawbacks. The key literature is reviewed and case examples will illustrate finer points to help the clinician decide the best operative plan for each of their patients with these types of traumatic injuries. A variety of materials can be utilized for cranial and orbital reconstruction in the child and adult. Autogenous, allogeneic, and synthetic materials are discussed for various indications. Specific attention is directed at the complications of cranio-orbital trauma, secondary revision of traumatic deformities, and state of the art reconstructive methods. Technology and innovation have expanded the possibilities for reconstructive planning and execution of the operative plan. References Garibaldi DC, Iliff NT, Grant MP, Merbs SL. Use of porous polyethylene with embedded titanium in orbital reconstruction: a review of 106 patients. Ophthal Plast Reconstr Surg. 2007 Nov-Dec;23(6):439-44 Edgin WA, Morgan-Marshall A, Fitzsimmons TD. Transcaruncular approach to medial orbital wall fractures. J Oral Maxillofac Surg. 2007 Nov;65(11):2345-9 Pham AM, Rafii AA, Metzger MC, Jamali A, Strong EB. Computer modeling and intraoperative navigation in maxillofacial surgery. Otolaryngol Head Neck Surg. 2007 Oct;137(4):624-31
Orbital Defect Repair and Secondary Reconstruction of Enophthalmos With Mirror-Technique Fabricated Titanium Mesh Yi Zhang, DDS, MD, Beijing, China Purpose: Post-traumatic enophthalmos was recognized as the result of volume discrepancy between orbital cavity and orbital contents. Anatomical reduction of AAOMS • 2008
orbital rim, accurate reconstruction of orbital walls and augmentation of orbital soft tissue contents together compose a sequencing surgical principle for late correction of enophthalmos resulted from impure orbital fractures. The purpose of this study is to evaluate the outcomes of mirroring-reconstructing orbital walls by using computer-assisted fabricated Ti-mesh technique and assess the need of orbital soft tissue content augment. Patients and Methods: With full informed consent, 20 patients with unilateral impure orbital fracture and subsequent enophthalmos fell into this prospective study from Sept. 2004 to Oct. 2007. 0.625 mm slice spacing CT scan was taken for each and orbital CT data was transferred to Mimics8.11 image software in which 3-D orbit image was rebuild. The unaffected orbit was mirrored to replace the affected orbit. Based on, a resin model was produced and used to customfabricated a shape-adapted Ti-mesh. This Ti-mesh was intraoperatively placed within orbit to cover the fractured areas, simultaneously the herniated orbital soft tissue was repositioned. The same CT was taken two weeks postoperatively. By means of image software (Geomagic Studio 4.0 and Mimics8.11), the degree of enophthalmos and the expanded orbital volume were measured for the affected side before and after operation. As standard for comparison, the eyeball proptosis and orbital volume of the unaffected side were measured also. The data was processed with SPSS 1.30 statistical software and the correlations between them were analyzed. Results: For the included, with volumetric expansion of 7.33⫾4.35 ml at the affected sides the eyeballs sank 4.01⫾2.21 mm on average. Between the degree of enophthalmos and the increment of orbital volume, there was a higher correlation with a coefficient of 0.461, which meant 1 mm of late enophthalmos resulted from 0.461 ml orbital volume increment. Orbital cavity reconstruction made the affected orbits reduced by 4.44⫾2.94 ml in volume, and incidentally late enophthalmos improved 1.79⫾1.72 mm. But, statistical analysis demonstrated no correlation between the reduction of orbital volume and the change of eyeball proptosis postoperatively. After operation, there still was 2.89⫾2.85 ml orbital volumetric difference between the affected and unaffected side, and corresponding, enophthalmos of 2.22⫾1.51mm remained for rectification. Conclusions: In the formation of late enophthalmos caused by impure orbital fractures, there is a ratio of 1 mm enophthalmos to 0.461 orbital volumetric increment. Use of the computer-assisted shape-adapted fab19
Symposia ricated Ti-mesh to mirroring-reconstruct orbital walls can only recuperate 60% of pathologically expanded orbital volume and brought in 45% correction of late enophthalmos. The orbital soft tissue content augment should be followed for a better outcomes.
Philip L. Maloney Lecture Frontobasilar Trauma Management James B. Holton, DDS, MSD, Tyler, TX No abstract provided.
SYMPOSIUM ON KEYS AND TREATMENT FUNDAMENTALS FOR ESTHETIC AND FUNCTIONAL IMPLANT MANAGEMENT Saturday, September 20, 2008, 10:00 am–12:00 noon
Factors Effecting Crestal Bone Preservation Around Implants
Teeth and Implants: When to Extract and When to Save
Lyndon F. Cooper, DDS, MS, PhD, Chapel Hill, NC
Gary A. Morris, DDS, Buffalo Grove, IL
No abstract provided.
No abstract provided.
Diagnosis and Treatment Planning as an Essential Key to Proper Surgical Treatment Sergio Rubinstein, DDS, Skokie, IL No abstract provided.
SYMPOSIUM ON SURGICAL MANAGEMENT OF THE ASYMMETRIC PATIENT Saturday, September 20, 2008, 10:00 am–12:00 noon
Diagnosis and Management of Facial Asymmetries Jeffrey C. Posnick, DMD, MD, Chevy Chase, MD Mirror image asymmetry, like facial disproportion, may affect head and neck function and negatively impact on facial aesthetics. While minor degrees of asymmetry may provide character to the individual when a tipping point is reached the facial appearance may become distracting to the observer when viewed at conversational distance. The causes of facial asymmetry are varied and can result from a spectrum of disease entities (congenital, developmental, tumor, trauma, infection, metabolic), can effect any tissue layer (skeleton, soft tissues, viscera) or region of the head and neck. Facial asymmetries may affect a range of functions including vision, breathing, chewing, hearing, and speech. This presentation attempts to give perspective in how asymmetries of the face may affect head and neck function and facial esthetics. Generally accepted strategies 20
for timing and techniques of reconstruction are discussed through patient examples. References Farkas LG. Asymmetry of the Head and Face. In Farkas LG (ed). Anthropometry of the Head and Face, ed.2. New York, Raven Press, 1994, pages 301-311 Livio, M. The Golden Ratio. New York: Broadway Books, 2002 M. Michael Cohen, Jr. Perspectives on the Face. Oxford University Press, 2006
Surgical Treatment of Arch Asymmetries Myron R. Tucker, DDS, Charlotte, NC The components of facial asymmetry include several skeletal abnormalities such as cranial deformity, abnormal growth of the maxilla, zygomas, nasal bones and mandible as well as a wide variety of soft tissue abnormalities. In addition to the skeletal abnormalities, dental arch asymmetry is often a major component of the deformity. Dental arch asymmetries may be a result of abnormal dental development and/or dental compensation related to the skeletal abnormality. AAOMS • 2008
SYMPOSIUM ON TRAUMA Saturday, September 20, 2008, 7:30 am–9:30 am
Complex Cranio-Orbital Trauma Bernard J. Costello, DMD, MD, Pittsburgh, PA Treatment of complex cranio-orbital trauma requires that the surgeon have a clear understanding of these complex injuries, their relationship to the central nervous system, and the challenges of reconstruction. Primary and secondary reconstruction techniques are discussed for a variety of injury patterns in children and adults. The diagnosis and management of cranial vault fractures, naso-orbital ethmoid fractures, and complex cranio-orbital injury are reviewed. Numerous approaches to the craniomaxillofacial skeleton may be utilized to accomplish the reconstructive goals. A variety of approaches to the craniofacial skeleton are reviewed including their benefits and drawbacks. The key literature is reviewed and case examples will illustrate finer points to help the clinician decide the best operative plan for each of their patients with these types of traumatic injuries. A variety of materials can be utilized for cranial and orbital reconstruction in the child and adult. Autogenous, allogeneic, and synthetic materials are discussed for various indications. Specific attention is directed at the complications of cranio-orbital trauma, secondary revision of traumatic deformities, and state of the art reconstructive methods. Technology and innovation have expanded the possibilities for reconstructive planning and execution of the operative plan. References Garibaldi DC, Iliff NT, Grant MP, Merbs SL. Use of porous polyethylene with embedded titanium in orbital reconstruction: a review of 106 patients. Ophthal Plast Reconstr Surg. 2007 Nov-Dec;23(6):439-44 Edgin WA, Morgan-Marshall A, Fitzsimmons TD. Transcaruncular approach to medial orbital wall fractures. J Oral Maxillofac Surg. 2007 Nov;65(11):2345-9 Pham AM, Rafii AA, Metzger MC, Jamali A, Strong EB. Computer modeling and intraoperative navigation in maxillofacial surgery. Otolaryngol Head Neck Surg. 2007 Oct;137(4):624-31
Orbital Defect Repair and Secondary Reconstruction of Enophthalmos With Mirror-Technique Fabricated Titanium Mesh Yi Zhang, DDS, MD, Beijing, China Purpose: Post-traumatic enophthalmos was recognized as the result of volume discrepancy between orbital cavity and orbital contents. Anatomical reduction of AAOMS • 2008
orbital rim, accurate reconstruction of orbital walls and augmentation of orbital soft tissue contents together compose a sequencing surgical principle for late correction of enophthalmos resulted from impure orbital fractures. The purpose of this study is to evaluate the outcomes of mirroring-reconstructing orbital walls by using computer-assisted fabricated Ti-mesh technique and assess the need of orbital soft tissue content augment. Patients and Methods: With full informed consent, 20 patients with unilateral impure orbital fracture and subsequent enophthalmos fell into this prospective study from Sept. 2004 to Oct. 2007. 0.625 mm slice spacing CT scan was taken for each and orbital CT data was transferred to Mimics8.11 image software in which 3-D orbit image was rebuild. The unaffected orbit was mirrored to replace the affected orbit. Based on, a resin model was produced and used to customfabricated a shape-adapted Ti-mesh. This Ti-mesh was intraoperatively placed within orbit to cover the fractured areas, simultaneously the herniated orbital soft tissue was repositioned. The same CT was taken two weeks postoperatively. By means of image software (Geomagic Studio 4.0 and Mimics8.11), the degree of enophthalmos and the expanded orbital volume were measured for the affected side before and after operation. As standard for comparison, the eyeball proptosis and orbital volume of the unaffected side were measured also. The data was processed with SPSS 1.30 statistical software and the correlations between them were analyzed. Results: For the included, with volumetric expansion of 7.33⫾4.35 ml at the affected sides the eyeballs sank 4.01⫾2.21 mm on average. Between the degree of enophthalmos and the increment of orbital volume, there was a higher correlation with a coefficient of 0.461, which meant 1 mm of late enophthalmos resulted from 0.461 ml orbital volume increment. Orbital cavity reconstruction made the affected orbits reduced by 4.44⫾2.94 ml in volume, and incidentally late enophthalmos improved 1.79⫾1.72 mm. But, statistical analysis demonstrated no correlation between the reduction of orbital volume and the change of eyeball proptosis postoperatively. After operation, there still was 2.89⫾2.85 ml orbital volumetric difference between the affected and unaffected side, and corresponding, enophthalmos of 2.22⫾1.51mm remained for rectification. Conclusions: In the formation of late enophthalmos caused by impure orbital fractures, there is a ratio of 1 mm enophthalmos to 0.461 orbital volumetric increment. Use of the computer-assisted shape-adapted fab19
Symposia ricated Ti-mesh to mirroring-reconstruct orbital walls can only recuperate 60% of pathologically expanded orbital volume and brought in 45% correction of late enophthalmos. The orbital soft tissue content augment should be followed for a better outcomes.
Philip L. Maloney Lecture Frontobasilar Trauma Management James B. Holton, DDS, MSD, Tyler, TX No abstract provided.
SYMPOSIUM ON KEYS AND TREATMENT FUNDAMENTALS FOR ESTHETIC AND FUNCTIONAL IMPLANT MANAGEMENT Saturday, September 20, 2008, 10:00 am–12:00 noon
Factors Effecting Crestal Bone Preservation Around Implants
Teeth and Implants: When to Extract and When to Save
Lyndon F. Cooper, DDS, MS, PhD, Chapel Hill, NC
Gary A. Morris, DDS, Buffalo Grove, IL
No abstract provided.
No abstract provided.
Diagnosis and Treatment Planning as an Essential Key to Proper Surgical Treatment Sergio Rubinstein, DDS, Skokie, IL No abstract provided.
SYMPOSIUM ON SURGICAL MANAGEMENT OF THE ASYMMETRIC PATIENT Saturday, September 20, 2008, 10:00 am–12:00 noon
Diagnosis and Management of Facial Asymmetries Jeffrey C. Posnick, DMD, MD, Chevy Chase, MD Mirror image asymmetry, like facial disproportion, may affect head and neck function and negatively impact on facial aesthetics. While minor degrees of asymmetry may provide character to the individual when a tipping point is reached the facial appearance may become distracting to the observer when viewed at conversational distance. The causes of facial asymmetry are varied and can result from a spectrum of disease entities (congenital, developmental, tumor, trauma, infection, metabolic), can effect any tissue layer (skeleton, soft tissues, viscera) or region of the head and neck. Facial asymmetries may affect a range of functions including vision, breathing, chewing, hearing, and speech. This presentation attempts to give perspective in how asymmetries of the face may affect head and neck function and facial esthetics. Generally accepted strategies 20
for timing and techniques of reconstruction are discussed through patient examples. References Farkas LG. Asymmetry of the Head and Face. In Farkas LG (ed). Anthropometry of the Head and Face, ed.2. New York, Raven Press, 1994, pages 301-311 Livio, M. The Golden Ratio. New York: Broadway Books, 2002 M. Michael Cohen, Jr. Perspectives on the Face. Oxford University Press, 2006
Surgical Treatment of Arch Asymmetries Myron R. Tucker, DDS, Charlotte, NC The components of facial asymmetry include several skeletal abnormalities such as cranial deformity, abnormal growth of the maxilla, zygomas, nasal bones and mandible as well as a wide variety of soft tissue abnormalities. In addition to the skeletal abnormalities, dental arch asymmetry is often a major component of the deformity. Dental arch asymmetries may be a result of abnormal dental development and/or dental compensation related to the skeletal abnormality. AAOMS • 2008