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Reconstruction of the Orbital floor using Titanium mesh : a study of three

cases

Article in International Journal of Medical and Dental Case Reports · September 2014
DOI: 10.15713/ins.ijmdcr.13

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 International Journal of Medical and Dental Case Reports (2014), Article ID 201114, 3 Pages

CASE REPORT

Reconstruction of the orbital floor using titanium mesh:

A study of three cases
Madhumati Singh, N. S. Mamatha, N. S. Kedarnath, R. Sathesh Kumar, S. Vijayanand, Naqoosh Haidry
Department of Oral & Maxillofacial Surgery, Rajarajeswari Dental College & Hospital, Bengaluru, Karnataka, India

Correspondence Abstract
Dr. R. Sathesh Kumar, Department of Oral & Orbital fractures account for 40% of craniofacial injuries; of the four walls of the orbit,
Maxillofacial Surgery, Rajarajeswari Dental
the floor, which is extremely thin, is the most frequently injured. According to the
College & Hospital, Mysore Road, Bengaluru,
pertinent literature, such fractures represent 67-84% of cases of orbital fractures. Orbital
Karnataka, India. Email: [email protected]
floor fractures can be broadly classified as pure or impure blowout fractures; the first
Received 11 September 2014; are isolated orbital floor fractures, and the second are also associated with an orbital
Accepted 18 November 2014 rim fracture, involving other skeletal elements: zygomatic, frontal, nasoethmoidal, or
maxillary bone. The main aim for the reconstruction of the orbital defect was restoration
doi: 10.15713/ins.ijmdcr.13 of function, esthetics anatomy, and volume. Each biomaterial has its own merits and
demerits, but the most important criteria of a material, is to allow the surgical objectives
How to cite the article: to be fulfilled. Orbital reconstruction should separate the orbital contents from the
Singh M, Mamatha NS, Kedarnath NS, Kumar paranasal sinuses and nasal cavity and should prevent enophthalmos and diplopia.
RS, Vijayanand S, Haidry N. Reconstruction of
orbital floor using titanium mesh: A study of Keywords: Fractures, orbital floor, titanium mesh
three cases. Int J Med Dent Case Rep 2014:1-3.

Introduction Titanium mesh was very appropriate reconstructive material

that provides exact anatomic reconstruction.[2,3] The objective
The orbit’s close proximity to the nose, paranasal sinuses, nervous of our study was to find the efficacy and advantages of titanium
system along with its important role in support and function of the mesh reconstruction in large orbital floor defects.
eye as well as facial esthetics makes it a vital anatomical structure. Patients were reported to our department with a history of
A variety of injuries ranging from subtle orbital floor blowout to road traffic accident (RTA).
gross comminution may result in disruption of this anatomically Investigation: Orthopantomogram and posterior-anterior of
complex region of the middle third of the face. With inadequate skull radiographs, computed tomography and blood investigations
treatment, permanent orbital deformity, incapacitating visual
dysfunction and unsatisfactory esthetics may handicap an
individual functionally, esthetically and socially. Case Reports
Orbital floor fracture results in a disruption of bony Case 1
continuity permitting bone fragments, orbital contents, and torn
periosteum to herniate beyond the original bony orbit leading to A 27-year-old female reported to our department with facial
enophthalmos, dystopia infraorbital paresthesia and hypoglobus. swelling followed by RTA. Also with the chief complaint of
Soft tissue incarceration or entrapment may also occur, causing inability to open her mouth, double vision and numbness over
restricted ocular movements. left upper lip. On examination there was left circumorbital
According to Haug et al. reported that the average weight of ecchymosis, subconjuctival hemorrhage, diplopia, step
orbital contents is 42.97 (±4.05) g, and almost all biomaterials deformity in infra orbital rim, zygomatic buttress and depression
should provide adequate support to the orbital floor.[1] of the zygomatic arch. Infraorbital paresthesia has been noted.
Development of late posttraumatic enophthalmos and After routine investigation, it was finally diagnosed as left
diplopia depend on increased orbital volume and loss of zygomatic complex fracture involving floor of the orbit, infra and
intraorbital contents, and inappropriate anatomic reconstruction supraorbital rim [Figure 1a-c].
and the amount of fibrosis resultant.[1]
Case 2
Successful treatment depends on appropriate planning,
conscientious surgical dissection and unique selection of size, A 30-year-old male reported to our department with the chief
shape, and kind of the reconstruction material. complaint of inability to open his mouth followed by RTA.

1
Singh, et al. Orbital floor reconstruction with titanium mesh

On examination there was right circumorbital ecchymosis, arch and enophthalmos. After routine investigation, it was finally
subconjuctival hemorrhage, step deformity in infraorbital diagnosed as right zygomatic complex fracture involving floor of
rim. After routine investigation, it was finally diagnosed as the orbit, infra and supraorbital rim [Figure 3a-c].
right zygomatic complex fracture involving floor of the orbit, Under general anesthesia, open reduction and internal
infraorbital rim [Figure 2a-c]. fixation using titanium plates and screws. Orbital floor was
explored and reconstructed using titanium mesh and screws.
Case 3 Infraorbital nerve paresthesia has been resolved gradually over
A 27-year-old male reported to the department with the chief the period of 6 months after the reduction of fracture segments.
complaint of difficulty to open his mouth and numbness over the We observed there was late enolpthalmos due to the atrophy
right cheek region. On examination there was right circumorbital of orbital fat in two of our cases (one female and one male).
ecchymosis, subconjunctival hemorrhage step deformity in There was persistent mild diplopia in upper extreme gaze noted
infraorbital rim, zygomatic buttress depression of zygomatic in that female patient which was corrected using prism glasses.

Discussion
In the reconstruction of the orbital floor, timing is vital to
restore lost globe support and to normalize orbital volume
to prevent a functional and cosmetic defect. Delayed surgery
permits cicatricial contracture of herniated or incarcerated
intraorbital contents. If diplopia is caused by the inferior rectus
a
or the inferior oblique muscles being caught in the fracture,
b
surgery is required to free them within 3 weeks or these delicate
muscles will atrophy since timely reduction of orbital soft tissue
limits the degree of ischemia caused by entrapment. Burnstine
recommends surgical repair within 2 weeks if greater than half of
the floor is depressed.[4]
All patients were operated upon for reconstruction of the
orbital floor within 2 weeks from the day of the trauma.
The indications for surgical exploration of the fractured
c
orbital floor include:
Figure 1: (a) Pre-operative showing left circumorbital ecchymosis. 1. Hypoglobus or enophthalmos >2 mm
(b) Intraoperative showing titanium mesh in position. (c) Post- 2. Limitation of extraocular muscle function,
operative after 3 months showing mild enopthalmous

a b
a b

c c
Figure 2: (a) Pre-operative showing right circumorbital ecchymosis. Figure 3: (a) Pre-operative showing right circumorbital ecchymosis.
(b) Intraoperative titanium mesh in place. (c) Post-operative aft (b) Intraoperative showing titanium mesh in position. (c) Post-
1 month operative after 3 months

2
 Orbital floor reconstruction with titanium mesh Singh, et al.

3. A large orbital floor defect with herniation of soft tissue reconstruction with titanium mesh has been encouraging, and
into the maxillary sinus on computed tomography (CT) or the results obtained were satisfactory.
fractures that involve >50% of the floor
4. Step deformity along the infraorbital margin with paraesthesia
Conclusion
of the infraorbital nerve causing numbness
Jason K. Potter reviewed the biomaterials that were available Titanium mesh is apt material for of orbital floor reconstruction,
for orbital floor reconstruction to provide insight into their and complications were mostly due to problems in reforming
selection and application. Because of the diversity of problems anatomical shape and volume.
that may present in orbital reconstruction and limitations of each Surgical procedure decreases the frequency of post-operative
material, currently no single material is ideal. Rigid materials are diplopia and enophthalmos in blowout fractures which needs
best suited for reconstruction of large defects to prevent sagging correction with less complications.[6]
and displacement into the maxillary antrum. There is no unanimity exists on the choice of implants for
Titanium mesh has good biocompatibility and is easily orbital floor reconstruction and several materials are available.
adjustable. It is easy to trim and mold exactly to the orbital The ideal material for the reconstruction of the orbital skeleton
contour. Because of the structure, connective tissue can grow is influenced by many factors including specific characteristics
into the implant meshwork, thus preventing its migration. It of the injury, cost, patient choice and experience and opinion
can be reliably fixed with screws in areas such as the infraorbital of the surgeon. For small defects, <2 cm with enophthalmos
border. Titanium mesh has good physical strength in thin and limitation in ocular movements due to entrapment of the
sections, and it produces less artifacts on CT scans than other extraocular muscles, prolene mesh can be used. For larger
metals. It can be sterilized in conventional autoclaves. However, defects, involving the infraorbital rim, with gross comminution
the mesh structure makes removal difficult. Ingrowth of fibrous of the orbital floor and herniation of the orbital contents into the
connective tissue through mesh pores has been documented in maxillary antrum, calvarial graft or titanium mesh can be used.[7]
at least one recent study.
Literature is plenty with several studies where titanium has
References
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