Volume 03 Issue 08-2023
78
International Journal of Medical Sciences And Clinical Research
(ISSN
–
2771-2265)
VOLUME
03
ISSUE
08
P
AGES
:
78-83
SJIF
I
MPACT
FACTOR
(2021:
5.
694
)
(2022:
5.
893
)
(2023:
6.
184
)
OCLC
–
1121105677
Publisher:
Oscar Publishing Services
Servi
ABSTRACT
This article devoted to the planning and surgical treatment of patients with post-traumatic defects of the lower wall
of orbit. Despite a significant amount of work, developments concerning the choice of planning methods and surgical
treatment are rather fragmentary and not systematized, which allows to orient the activity of the maxillofacial
surgeon and scientific research to develop and improve methods of diagnostics, planning and surgical treatment of
post-traumatic defects of the lower orbit wall.
KEYWORDS
Zygomatic-orbital, aesthetic, enophthalmos, binocular diplopia, limitation, maxillofacial surgery, nasal trauma.
INTRODUCTION
Fractures of the orbital floor are found among of all
injuries of the middle zone of the face in 20-35% of
cases, they take second place after nasal trauma [6,8].
Up to 91% of traumatic injuries of the zygomatic-orbital
complex mainly occur at the working age of 18
–
50
years [2,9]. All of the above dramatically reduces the
patient's quality of life, leading to his maladjustment in
society and possible mental disorders. Despite a
significant number of patients with this pathology,
there are a number of errors in diagnosing the volume
and nature of injuries, which does not allow choosing
the optimal treatment tactics in the shortest possible
time and leads to increase in potential complications.
Research Article
PLANNING AND SURGICAL TREATMENT OF A POST-TRAUMATIC DEFECT
OF THE ORBITAL FLOOR
Submission Date:
August 20, 2023,
Accepted Date:
August 25, 2023,
Published Date:
August 30, 2023
Crossref doi:
https://doi.org/10.37547/ijmscr/Volume03Issue08-11
Shokhrukh Sh. Yusupov
Tashkent Medical Academy, Uzbekistan
Journal
Website:
https://theusajournals.
com/index.php/ijmscr
Copyright:
Original
content from this work
may be used under the
terms of the creative
commons
attributes
4.0 licence.
Volume 03 Issue 08-2023
79
International Journal of Medical Sciences And Clinical Research
(ISSN
–
2771-2265)
VOLUME
03
ISSUE
08
P
AGES
:
78-83
SJIF
I
MPACT
FACTOR
(2021:
5.
694
)
(2022:
5.
893
)
(2023:
6.
184
)
OCLC
–
1121105677
Publisher:
Oscar Publishing Services
Servi
Damage to the lower wall of the orbit occupies a
special position, since the requirements for the
aesthetic and functional results of the treatment of this
pathology are high. A significant number of
unsatisfactory results of treatment associated with
inaccurate diagnosis of damage to the lower wall of the
orbit, the use of ineffective methods of treatment, lead
to the development of various complications:
enophthalmos, binocular diplopia, limitation of the
mobility of the eyeball, neuritis of the infraorbital
nerve, deformation of the lower wall of the orbit [5,11].
THE MAIN FINDINGS AND RESULTS
With the destruction of the bone walls of the orbit, its
volume increases due to changes in the size of the
maxillary sinus and cells of the ethmoid labyrinth. In
this case, the redistribution of fiber from the orbit to
the paranasal sinuses occurs, as a result of which the
eyeball changes its position, its mobility is disturbed,
and with the functional usefulness of the eye, the
patient complains of doubling - diplopia. There are
several options for changing the position of the
eyeball. Hypophthalmos - downward displacement of
the eyeball. It depends on the degree of bone
dislocation, is a consequence of rupture and violation
of the integrity of the suspension and fixation
ligamentous apparatus of the eye, is considered as a
manifestation of traumatic contusion syndrome in the
orbit. Enophthalmos, or retraction of the eyeball,
occurs as a result of an increase in the volume of the
deformed orbit, prolapse of its contents through the
area of a fracture or defect in the orbital tissue and
extraocular muscles. In addition, scarring of the orbital
tissue in the retrobulbar regions, pathological fixation
of the Tenon’s capsule or its derivatives with bone
fragments at the site of a defect in the lower wall of the
orbit, shortening of the extraocular muscles in the
posterior parts of the orbit due to the scarring process
leads to the retention of the eyeball in a deep position
[2,4,10].
Improving diagnostic methods in maxillofacial surgery
requires the introduction of more informative and
ergonomic methods into practice, which has become
possible thanks to computer technology.
Computed tomography (CT) occupies a dominant
place in the diagnosis of orbital damage. With the help
of CT, simultaneous visualization of the soft tissue and
bone structures of the orbit is possible. It is possible to
conduct a biometric study in the plane of interest, for
example, strictly along the muscle diameter [7].
One of the perfect methods for diagnosing and
planning treatment is 3D reconstruction, which
accurately determines the nature and location of the
injury [1,12]. The construction of three-dimensional
graphical models was based on obtaining x-ray
computed tomograms at minimum time intervals,
which make it possible to create texture segmentation
and three-dimensional reconstruction of organs.
Volume 03 Issue 08-2023
80
International Journal of Medical Sciences And Clinical Research
(ISSN
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2771-2265)
VOLUME
03
ISSUE
08
P
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:
78-83
SJIF
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(2021:
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5.
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(2023:
6.
184
)
OCLC
–
1121105677
Publisher:
Oscar Publishing Services
Servi
Surgical treatment of fractures and elimination of
defects in the lower wall of the orbit is still an urgent
problem of reconstructive surgery, occupying the
minds of physicians of various specialties for a number
of years.
Despite numerous studies, the surgical treatment of
isolated fractures of the lower wall of the orbit,
especially its defects and deformities, remains one of
the significant problems of maxillofacial surgery, and
its study continues.
The aim of our study was to improve the planning and
surgical treatment of post-traumatic defects in the
lower wall of the orbit.
Materials and research methods. In the department of
plastic surgery of the multidisciplinary clinic of the
Tashkent Medical Academy, 38 patients with post-
traumatic defects in the lower wall of the orbit were
operated on in the period from 2022 to 2023. Of these,
men accounted for 82% and women 18%. The age of the
patients varied from 20 to 45 years. In 28 cases, the
causes of trauma to the middle zone of the face were
road accidents, and in 10 cases, domestic trauma. All
patients
underwent
a
classic
comprehensive
examination upon admission, including diagnostics by
related specialists (neurosurgeon, ophthalmologist,
otorhinolaryngologist) and multislice computed
tomography with 3D reconstruction in three
projections. Scanning was carried out in automatic
mode according to a special program embedded in the
computer software of the tomograph. To determine
the state of the lower wall of the orbit, sections were
obtained in the frontal (coronal) plane. For a detailed
assessment of the state of the infraorbital canal and
extraocular muscles, images were obtained in the axial
plane, layer collimation 0.6 mm, reconstruction
interval 0.6 mm with multispiral reconstruction of the
obtained images in sagittal and coronary projections.
The planning of surgical elimination of a post-traumatic
defect of the bones of the lower wall of the orbit is a
virtual computer simulation with a special computer
program that can accurately determine the nature and
localization of the defect.
RESEARCH RESULTS
Posttraumatic deformity of the zygomatic-orbital
complex with a defect in the inferior wall of the orbit
was diagnosed most frequently in 22 (58%) cases.
Isolated post-traumatic defects of the inferior wall of
the orbit were diagnosed in 16 (42%) cases. The
duration of the fracture ranged from 14 days to 6
months. All patients in the preoperative period had all
the symptoms of post-traumatic deformity of the
zygomatic-orbital complex, including orbital deformity
and
varying
degrees
of
enophthalmos
and
hypophthalmos, as well as diplopia of a different
nature. We observed limitation of eyeball mobility in
the preoperative period in 75% of patients. When
performing a standard radiography, there were no
Volume 03 Issue 08-2023
81
International Journal of Medical Sciences And Clinical Research
(ISSN
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2771-2265)
VOLUME
03
ISSUE
08
P
AGES
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78-83
SJIF
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FACTOR
(2021:
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(2022:
5.
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(2023:
6.
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OCLC
–
1121105677
Publisher:
Oscar Publishing Services
Servi
signs of a violation of the integrity of the infraorbital
margin of the maxillary bone and the adjacent part of
the zygomatic bone. CT scan in the frontal plane
revealed an isolated linear fracture of the lower wall of
the orbit in the middle third with a displacement of
more than 2 mm and infringement of the lower rectus
muscle in the fracture zone - in 30% with prolapse of
retrobulbar tissue into the maxillary sinus - 48%, blood
in the maxillary sinus - 59% . However, it was not
possible to assess the state of the inferior rectus
muscle, which was restrained in the fracture zone. The
clinical and radiological (multispiral computed
tomography with 3D reconstruction) examination
made it possible to: clarify the location and nature of
the damage, assess the state of the oculomotor
muscles, the position of the eyeball, detect prolapse of
the orbital tissue and clarify the size of the defect in the
orbital walls, which is especially important for choosing
an orbital implant and surgery planning. All patients in
the preoperative period were made a computer 3D
model of the orbit with a stereolithographic
intraoperative template printed on a 3D printer. All
patients underwent surgery under general anesthesia
and included the steps to eliminate the deformity of
the lower edge of the orbit using miniplates (75%),
endoprosthesis of the orbital walls (80%), and the use
of balloon endothesis (20%). The terms of surgical
treatment of patients were as follows: on the 5th
–
14th
day - 28 (73%) patients and after 1
–
2 months. after injury
- 10 (27%). Surgical treatment of injuries of the
zygomatic-orbital complex, isolated injuries of the
inferior wall of the orbit was performed according to
the technique developed by us, observing a number of
features depending on the severity and localization of
injuries, as well as the timing of the surgical
intervention. The most important stage of the
operation was the careful revision of orbital fractures,
the release of the restrained oculomotor muscles, the
elimination of prolapse of the orbital fat, and the most
important is the plasty of the bone defect of the lower
wall of the orbit, based on a stereolithographic
intraoperative template, with which we determine the
exact size, give the shape of the implant and the place
of its fixation, and the implant itself is a porous
titanium membrane. In the postoperative period, all
patients were prescribed standard anti-inflammatory
therapy, and rehabilitation was carried out together
with an ophthalmologist to restore eye function. 14
days after the operation, diplopia persisted in 4 (16.6%)
patients. Restoration of binocular vision in these
patients lasted up to 2
–
3 months, which was
associated with the nature of the eyeball injury and the
late terms of surgical treatment.
CONCLUSIONS
Thus, the planning of reconstructive surgery using
virtual computer simulation allows the use of
stereolithographic intraoperative templates on a 3D
printer. This technique helps to reduce the time of
surgical intervention and increases the accuracy of
Volume 03 Issue 08-2023
82
International Journal of Medical Sciences And Clinical Research
(ISSN
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2771-2265)
VOLUME
03
ISSUE
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(2021:
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)
(2023:
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)
OCLC
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1121105677
Publisher:
Oscar Publishing Services
Servi
planning and implementation of surgical treatment.
Virtual computer simulation allowed us to accurately
determine the scope of the operation, the selection
and manufacture of an individual implant, as well as its
fixation. Thanks to the stereolithographic model of the
orbit, it is possible to determine the indications and
contraindications for surgery, the technique of surgical
intervention, low-traumatic access to the damaged
area, in addition, it also helps to avoid postoperative
complications.
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Publisher:
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