Volume 03 Issue 04-2023
80
International Journal of Medical Sciences And Clinical Research
(ISSN
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2771-2265)
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03
ISSUE
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1121105677
Publisher:
Oscar Publishing Services
Servi
ABSTRACT
Under our supervision there were 117 patients with fractures of the inferior wall of the orbit on the basis of the
department of plastic surgery and the department of neurosurgery of the multidisciplinary clinic of the Tashkent
Medical Academy in the period from 2019 to 2022. Surgical treatment of zygomatic-orbital complex injuries and
isolated injuries of the lower 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 using modern information technologies. A method for eliminating post-traumatic defects in the walls of
the orbit, including performing computer preoperative planning, manufacturing an implant, determines the
indications and contraindications for surgery, low-traumatic access to the damaged area, in addition, it also helps to
Research Article
OUR EXPERIENCE IN SURGICAL TREATMENT OF PATIENTS WITH
INJURIES OF THE ORBITAL FLOOR WITH COMBINED INJURIES OF THE
FACIAL SKELETON
Submission Date:
April 14, 2023,
Accepted Date:
April 19, 2023,
Published Date:
April 24, 2023
Crossref doi:
https://doi.org/10.37547/ijmscr/Volume03Issue04-12
Shokhrukh Yusupov
Researcher Tashkent Medical Academy, Uzbekistan
Shukhrat Boymuradov
Researcher Tashkent Medical Academy, Uzbekistan
Bakhtiyar Narmurotov
Researcher Tashkent Medical Academy, Uzbekistan
Komiljon Iminov
Researcher Tashkent Medical Academy, Uzbekistan
Yoqubjon Qurbonov
Researcher Tashkent Medical Academy, Uzbekistan
Maftuna Shukhratova
Researcher 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 04-2023
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International Journal of Medical Sciences And Clinical Research
(ISSN
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ISSUE
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(2021:
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6.
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OCLC
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1121105677
Publisher:
Oscar Publishing Services
Servi
reduce postoperative complications by 2.4 times, resulting in a reduction in the period of functional adaptation of
patients in 1.6 times.
KEYWORDS
Orbit, zygomatic-orbital complex, trauma, computed tomography, implant, porous titanium plate, 3D modeling, 3D
construction.
INTRODUCTION
Up to date, the problem of traumatic injuries of the
middle zone of the face remains extremely relevant.
According to the scientific literature, the number of
traumatic injuries is still increasing and in 2015 almost 5
million people were fatally injured [10, 11, 21]. One of
the directions for developing measures to improve
medical care for patients with urgent pathology was
the study of injury rates [12, 28]. It is noteworthy that
until the 1970s, purulent-inflammatory diseases of the
face and neck were the prevailing pathology, then
there was a gradual increase in the number of patients
with traumatic injuries. In the structure of traumatic
injuries, fractures of the lower jaw and fractures of the
upper jaw are leading throughout the years [5, 13, 27].
There has been a trend towards an increase in the
number of patients with injuries of the middle zone of
the facial skull, in particular, fractures of the wall of the
maxillary process of the orbit, which is associated with
a continuing increase in domestic, transport and
industrial injuries [25, 26]. Trauma of the orbit involving
the organ of vision and its auxiliary organs among all
injuries of the facial skeleton ranges from 36 to 64%.
According to a number of authors, the main cause of
blindness and low vision in people of childhood and
working age are injuries to the eye and orbital
structures, which approximately account for 20% of all
pathologies of the organ of vision [6, 9, 22].
Among all traumatic injuries of the maxillofacial zone,
40% are orbital fractures, of which in more than half of
the cases the lower wall from the medial part, the
infraorbital sulcus, is damaged. Combined damage to
several anatomical structures, trauma to the eyeball,
polymorphism of clinical manifestations, and the need
to develop optimal tactics for surgical treatment
require the use of a complex of radiation diagnostic
methods [15, 24].
Thus, the increase in the total number of injuries,
combined damage to the bone and soft tissue
anatomical structures of the midface, trauma to the
eyeball and its musculoskeletal system dictates the
need for timely diagnosis of such conditions for
preoperative planning and postoperative control.
With a wide range of modern options for the
reconstruction of the midface, plastic materials and
surgical approaches, today there is no unified protocol
for the management of patients with injuries of the
midface, questions on the choice of indications for
surgery, the timing of surgical intervention and the
technique of performing the operation remain
debatable [2 , 4, 13, 16, 29]. The criteria for successful
surgical treatment are the correct timing of the
operation, surgical access, and tactics of the operation
with the correct choice of various materials for
reconstruction [8, 18]. As implants and grafts of the
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Publisher:
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Servi
walls of the orbit, the following are used: autologous
bone from the anterior wall of the maxillary sinus, rib,
parietal bone, branches of the lower jaw, titanium
implants without coating and coated with high-density
polyethylene, polytetrafluoroethylene, silicone [17, 19,
20].
In accordance with many years of research by foreign
scientists, alloys based on titanium nickelide are among
the most prominent representatives of the class of
alloys that produce the shape memory effect. It has
been established that superplastic medical materials
based on titanium nickelide outperform all existing
metallic materials in terms of biochemical and
biomechanical compatibility criteria [3, 7].
One of the perfect methods for diagnosing and
planning surgical treatment is 3D technology, virtual
computer simulation. 3D planning allows you to plan
and determine the scope of the operation, the
selection of the implant, determining the size and type
of the implant, as well as its fixation [1, 5, 14, 23]. That
is why the possibility of effective surgical treatment
using 3D reconstruction is relevant. In this regard, the
aim of our study was to improve the planning and
surgical treatment of patients with fractures of the
orbital walls in concomitant trauma.
MATERIAL AND METHODS
The study is based on examination data of 117 patients
with injuries of the zygomatic-orbital complex who
were treated in the department of plastic surgery and
neurosurgery of the multidisciplinary clinic of the
Tashkent Medical Academy in the period from 2019 to
2022. The prevailing majority of patients were aged 21
to 40 years. Data analysis shows that the clinical study
was dominated by young (88 patients, 75.2%) and
middle (29 patients, 24.8%) individuals, which indicates
the social significance of the study. Among all patients
(n=117; 100%), there was a predominance of males
(n=100; 85.5%) over females (n=17; 14.5%). Most
patients were injured as a result of traffic accidents
(n=71; 60.7%).
All patients admitted for examination were distributed
depending on the time of injury, according to the 3
main stages of the process of formation of post-
traumatic deformities. In the acute period (up to 4
weeks), 102 patients (87.2%) were admitted, during the
period of emerging post-traumatic deformities - up to
3 months after the injury - 7 patients (6.0%) were
hospitalized, in the stage of formed post-traumatic
deformities, 8 patients applied for examination
patients (6.8%).
All patients (n=117; 100%) admitted for examination
underwent a collection of complaints and anamnesis, a
clinical examination by a maxillofacial surgeon, a
neuropathologist and an ophthalmologist - the criteria
for ophthalmological assessment consisted of:
assessment of facial configuration, orbits and skin
condition ; assessment of the movement of the
eyeballs; assessment of visual function. Examination
using methods of radiation diagnostics - MSCT with 3D
reconstruction was performed on a GE Light Speed 64
device. Tomography of the facial skeleton was
performed with the following parameters: slice
thickness - 0.6 mm, slice collimation - 64 * 0.6, mA / slice
- 200, voltage - 120 kV, increment - 0.6, pitch - 0.5,
reconstruction resolution - high, radiation exposure -
0.4 - 0.8 mSv. The patient's head was previously freed
from all removable metal elements and laid flat on the
headrest. The patient's gaze was asked to be fixed
centrally. Laser marks were used to accurately
determine the scanning area. To mark the study area, a
topogram was performed. Tomography was started
from the top of the skull to the lower border of the
div of the lower jaw (or from the frontal region to the
Volume 03 Issue 04-2023
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International Journal of Medical Sciences And Clinical Research
(ISSN
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VOLUME
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(2021:
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(2023:
6.
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OCLC
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1121105677
Publisher:
Oscar Publishing Services
Servi
alveolar process of the upper jaw). MSCT data in the
axial, sagittal, and coronal planes were supplemented
with a multispiral reconstruction in the coronal and
sagittal planes with the construction of a 3D
reconstruction.
An anthropometric analysis of a post-traumatic defect
in the wall of the orbit and maxillary sinus was also
performed. For the study, multislice computed
tomograms were used in axial, sagittal and coronal
sections. Anatomical structures were measured using
the RadiAnt licensed software package for viewing CT
scans in DICOM format. Orbital wall defects were
measured in axial, sagittal, and coronal sections. The
maxillary sinus was measured in height - the largest
vertical dimension on the sagittal section and width -
the largest width on the sagittal section.
And in addition to the direct examination of the
patient, studies were used on the obtained digital
photographs taken on a Canon EOS 90 D camera
equipped with a Canon 18-105 mm f73.5-5.6G lens.
Photographs of the full-face projection and the state
raised back were studied. All patients underwent
photometric analysis before and after surgery. The first
series of photographs for the patient after the
operation was taken on the 2nd day, then the second
series of photographs was taken 10 days later. Long-
term results of photographing were carried out after 3-
6 months. Photos before and after surgical treatment
served as a control over the result.
RESULTS AND DISCUSSION
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.
–
first of all, after the MSCT examination,
files in the DICOM format are transferred to a special
program Implant-Assistant (version 4.2.1) based on the
tomographic examination data, a virtual three-
dimensional model of the bones of the face and the
area of the post-traumatic defect of the orbital wall is
created with a reconstruction interval of 0.6 mm s
multispiral reconstruction of the obtained images in
sagittal and coronal projections. The received data is
converted into stl format. and are transferred to the 3D
laboratory to the specialists of process engineers for
virtual modeling, for the manufacture of a surgical
template of the implant. Based on the data obtained, a
specialist process engineer sequentially synthesizes,
first, the volumetric parameters of the preserved
orbital wall, and then the volumetric parameters of the
orbital wall with an anatomical defect. Next,
symmetrical (mirror) computer transformations are
performed, and by combining (overlapping) these
parameters, the differential estimate determines the
volumetric mathematical parameters of the implant,
the contact surfaces of which are adapted to specific
anatomical objects of the skull of a particular
individual.
A complete set of information about the volumetric
mathematical parameters of an individualized implant
is exported in an automatic prototyping device - a
Formlabs form 2 3D printer, and a surgical implant
template is made. Then, using a surgical template, we
make an individual implant from a porous titanium
plate, and then send it for sterilization.
The computer planning of the surgical intervention
made it possible to: clarify the location and nature of
the damage, assess the condition of the oculomotor
muscles, the position of the eyeball, detect prolapse of
the orbital tissue and clarify the size of the defect in the
walls of the orbit, which is especially important for
choosing an orbital implant and planning surgical
intervention.
Volume 03 Issue 04-2023
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(2023:
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Publisher:
Oscar Publishing Services
Servi
All patients underwent surgery under general
intubation anesthesia and included the stage of
osteosynthesis of the lower edge of the orbit and
endoprosthesis of the orbital walls.
The terms of surgical treatment of patients were as
follows: on days 5-14 - 102 (87.2%) patients and after 1-2
months. after injury - 15 (12.8%).
Surgical treatment of injuries of the zygomatic-orbital
complex and 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, which determines the exact size, shape of
the implant and its location. fixation, and the implant
itself is a porous titanium plate. 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.
On the 8th day after the operation, the following was
carried out: removal of postoperative sutures, clinical
examination of the periorbital region, photographing
of the patient was carried out in a double project. Then
a second clinical examination with photographs was
carried out one month after the operation. 3 months
after the operation, the patient undergoes a second
examination: clinical examination, photography, MSCT
examination, general blood test, consultation with an
ophthalmologist and, if necessary, a neuropathologist.
After 6 months and a year later (repeated examination
is carried out: clinical examination, photography, MSCT
examination, general blood test, ophthalmologist's
consultation). The duration of surgery was 49.8±2.6
minutes. The duration of stay in hospital treatment in
patients was 3.6 ± 0.2 days. The patient spent 10.2 ± 0.2
days on outpatient treatment. The total period of
disability in these patients was 13.8±0.2 days. 14 days
after the operation, diplopia was reduced in 8 (6%)
patients.
On the 8th day after the operation, the following was
performed: removal of postoperative sutures, clinical
examination of the periorbital region, the patient was
photographed in two projections.
Then a second clinical examination with photography
was carried out one month after the operation.
3 months after the operation, the patient undergoes a
second
examination:
clinical
examination,
photography, MSCT examination, complete blood
count, consultation with an ophthalmologist and, if
necessary, a neuropathologist.
After 6 months and a year later (re-examination is
underway: clinical examination, photographing, MSCT
examination, complete blood count, consultation with
an ophthalmologist).
The duration of the surgical intervention was 49.8±2.6
minutes. The length of stay in hospital for patients was
3.6±0.2 days. Patients were on outpatient treatment
for 10.2±0.2 days. The total period of disability in these
patients was 13.8±0.2 days. 14 days after the operation,
diplopia persisted in 8 (6%) patients.
CONCLUSION
Thus, the planning of reconstructive surgery using
computer
modeling
allows
the
use
of
stereolithographic intraoperative templates on a 3D
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Publisher:
Oscar Publishing Services
Servi
printer. This technique helps to reduce the time of
surgical intervention and increases the accuracy of
planning and implementation of surgical treatment. 3D
planning allows you to plan and determine the scope
of the operation, the selection of the implant,
determining the size and type of the implant, as well as
its fixation.
The proposed method for eliminating post-traumatic
defects in the walls of the orbit, including performing
computed tomography of the facial part of the skull,
measuring parameters, synthesizing volumetric
parameters
based
on
the
data
obtained,
manufacturing an implant, determines the indications
and contraindications for surgery, low-traumatic
access to the damaged area, and also helps to reduce
postoperative complications in 2.4 times, such as
impaired sensitivity in the region of innervation of the
infraorbital nerve (by 12.9%), facial asymmetry (by 11%),
diplopia (by 16.7%), enophthalmos (by 13.3%), etc.
When evaluating the effectiveness of the proposed
method of surgical treatment of fractures of the walls
of the orbit and the zygomatic-orbital complex, good
results with stable positive dynamics were established
in 90.6% of cases.
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03
ISSUE
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P
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:
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SJIF
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FACTOR
(2021:
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)
(2022:
5.
893
)
(2023:
6.
184
)
OCLC
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1121105677
Publisher:
Oscar Publishing Services
Servi
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