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This study aimed to compare the accuracy of inferomedial orbital fracture restoration using customized orbital implant versus 3D preformed titanium mesh. Patients were divided into two groups. Group 1 underwent surgery with customized orbital implants and intraoperative navigation, while group 2 was treated using 3D preformed titanium meshes with preoperative virtual surgical planning (VSP) and intraoperative navigation. Reconstruction accuracy was assessed by: (1) comparing the postoperative reconstruction mesh position with the preoperative VSP; and (2) measuring the difference between the reconstructed and unaffected orbital volume. Pre- and postoperative diplopia and enophthalmos were also evaluated. Fifty-two patients were enrolled (25 in group 1 vs 27 in group 2). The mean difference between final plate position and ideal digital plan was 0.62 mm (SD = 0.235) in group 1 and 0.69 mm (SD = 0.246) in group 2, with no statistical difference between the groups (p = 0.282). The mean volume differences between the reconstructed and unaffected orbits were 0.95 ml and 1.02 ml in group 1 and group 2, respectively, with no significant difference between the groups (p = 0.860). Overall clinical improvements, as well as complications, were similar. 3D preformed titanium meshes can reconstruct inferomedial fractures with the same accuracy as customized implants. Therefore, in clinical practice, it is recommended to use 3D preformed meshes for this type of fracture due to their excellent results and the potential for reducing time and costs., Competing Interests: Declaration of competing interest None declared., (Copyright © 2024 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

To clinically and radiographically evaluate patient-specific titanium meshes via a trans-antral approach for correction of enophthalmos and orbital volume in patients with recent unilateral orbital floor fracture. Seven patients with unilateral orbital floor fractures received patient-specific titanium meshes that were designed based on a mirror-image of the contralateral intact orbit. The patient-specific implants (PSIs) were inserted via a trans-antral approach without endoscopic assistance. The patients were evaluated clinically for signs of diplopia and restricted gaze as well as radiographically for enophthalmos and orbital volume correction. Diplopia was totally resolved in two of the three patients who reported diplopia in the upward gaze. Whereas enophthalmos significantly improved in all but two patients, with a mean value of 0.2229 mm postoperatively compared to 0.9914 mm preoperatively. CT scans showed excellent adaptation of the PSIs to the orbital floor with a mean reduction of the orbital volume from 29.59 cc to 27.21 cc, a mean of 0.6% smaller than the intact orbit. It can be concluded that the proposed PSI can offer good reconstruction of the orbital floor through an isolated intraoral transantral approach with minimal complications. It could of special benefit in extensive orbital floor fractures., Competing Interests: Declaration of competing interest No conflict of interest declared., (Copyright © 2024 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

To compare the reconstruction of orbital fractures using patient-specific implants (PSI) and conventional pre-formed titanium mesh; to develop a method of three-dimensional (3D) superimposition and analysis of the reconstructed orbits; and to present the pitfalls in 3D planning of orbital PSI and how to avoid them. This was a retrospective study of patients with orbital fractures who were treated in our institution between the years 2022 and 2023 using PSI or conservative prefabricated titanium mesh. Three different methods for virtual reconstruction of orbital fractures were used and are detailed with advantages, disadvantages and indications. Data acquired included age, gender, method of reconstruction, functional outcomes and aesthetic outcomes. 3D analysis for accuracy of reconstruction was performed. A total of 23 patients were included; 12 were treated using PSI and 11 using prefabricated titanium meshes. There were 8 male and 4 female patients in the PSI group comparted to 5 and 6 in the prefabricated group. All three virtual methods for reconstruction were used successfully, each with the proper indications. When comparing PSI reconstruction to conventional mesh, a significant difference in accuracy was observed; PSI cases showed an inaccuracy of 0.58 mm compared to 1.54 mm with the conventional method. Complications are presented, and tips for avoiding them are detailed. Three different methods for virtual reconstruction were used successfully; automated computerized reconstruction is used for small defects, repositioning is the superior method for non-comminuted cases while mirroring is the method of choice in comminuted fractures. 3D analysis can be performed using a novel method detailed in this report. PSI reconstruction showed superior results, indicating it should be the method of choice when possible. Pitfalls are presented and approaches to prevent them are discussed. Orbital reconstruction is a very important entity in maxillofacial surgery with crucial functional and esthetical implications, and one should use virtual planning and PSI implants, as they significantly improve outcomes., Competing Interests: Declaration of competing interest None., (Copyright © 2024 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

Prompt diagnosis and management of orbital entrapment fractures in the pediatric patient have been advocated. This retrospective study analyzed a cohort of orbital entrapment fractures in pediatric patients with regard to diagnostic pitfalls, treatment and outcomes in a Level I trauma center in Germany. Based on medical records and radiological imaging, patients under the age of 18 years who presented with orbital fractures during 2009-2021 were analyzed. Overall, 125 patients presented with orbital fractures, of whom 29 patients (23.2%) had orbital entrapment fractures. The majority of patients presented with monocle hematoma (n = 23), diplopia (n = 20), and/or restricted extraocular eye movement (n = 14). While all patients with orbital entrapment fractures underwent three-dimensional imaging, 10 radiological reports (34.5%) did not include findings on orbital entrapment fractures. All patients underwent surgical exploration in less than 24 h. In 12 patients, clinical symptoms such as diplopia and restricted ocular elevation were documented upon postoperative evaluation before discharge. Considering the significant proportion of orbital entrapment fractures that are not noted on radiological imaging, prompt clinical examination should be initiated in pediatric patients at risk for orbital fractures. Urgent surgical intervention should be recommended in entrapment fractures., Competing Interests: Declaration of competing interest The authors declare no conflict of interest., (Copyright © 2023 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

The purpose of this study was to verify whether the accuracy of automatic segmentation (AS) of computed tomography (CT) images of fractured orbits using deep learning (DL) is sufficient for clinical application. In the surgery of orbital fractures, many methods have been reported to create a 3D anatomical model for use as a reference. However, because the orbit bone is thin and complex, creating a segmentation model for 3D printing is complicated and time-consuming. Here, the training of DL was performed using U-Net as the DL model, and the AS output was validated with Dice coefficients and average symmetry surface distance (ASSD). In addition, the AS output was 3D printed and evaluated for accuracy by four surgeons, each with over 15 years of clinical experience. One hundred twenty-five CT images were prepared, and manual orbital segmentation was performed in all cases. Ten orbital fracture cases were randomly selected as validation data, and the remaining 115 were set as training data. AS was successful in all cases, with good accuracy: Dice, 0.860 ± 0.033 (mean ± SD); ASSD, 0.713 ± 0.212 mm. In evaluating AS accuracy, the expert surgeons generally considered that it could be used for surgical support without further modification. The orbital AS algorithm developed using DL in this study is extremely accurate and can create 3D models rapidly at low cost, potentially enabling safer and more accurate surgeries., Competing Interests: Conflict of interest None., (Copyright © 2023 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

The application of navigation and endoscope is an area of intense interest in the surgical repair of orbital fractures. This study explored the advantages of a combined endoscopy navigation technique (ENT) for repairing large orbital floor and medial wall fractures (OFMWFs) with destruction of the inferomedial strut (IMS). Fifty-two consecutive patients with large OFMWFs with the destruction of the IMS underwent ENT-assisted surgical repair from January 2013 to February 2016. Patient demographics, causes of injury, clinical features, imaging data, and follow-up information (diplopia, ocular dysmotility, enophthalmos, infraorbital hypoesthesia, and other conditions) were collected and analyzed. Orbital volumes and implant positions were also evaluated. The median follow-up duration was 21 (range, 16-29) months. At the end of the follow-up visits, orbital reconstruction was demonstrated by orbital computed tomography. Of the 30 patients with diplopia within the 30-degree visual field of gaze, 27 (90%) reached diplopia remission. Of 40 patients, 34 (85%) achieved complete elimination of ocular dysmotility. Of 47 patients with enophthalmos of >2 mm, 43 (91%) acquired good symmetry with a mean improvement of 3.00 ± 1.00 mm. Of 33 patients, 27 (82%) recovered from infraorbital hypoesthesia. The postoperative orbital volumes of the two sides showed no significant differences (p = 0.087, paired t-test). Early surgical repair showed better outcomes of diplopia, ocular motility, and enophthalmos than late repair (p = 0.001, p = 0.007, and p = 0.000, generalized estimated equations). No patient developed surgery-related complications of visual acuity compromise, strabismus, ectropion, entropion, or lacrimal canaliculus injuries. ENT-assisted surgery appears to be safe, precise, and effective for the repair of large OFMWFs with destruction of the IMS., Competing Interests: Declaration of Competing interests None declared., (Copyright © 2022 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Objective: The aim was to preliminarily evaluate the effect of individualized preformed titanium mesh in the treatment of orbital wall fractures with superior orbital fissure syndrome (SOFS)., Study Design: This study consisted of 10 patients of orbital wall fracture and SOFS who were treated at the Affiliated Stomatology Hospital of Southwest Medical University. On the basis of preoperative computed tomography data, individualized titanium mesh was produced by mirror engineering and rapid prototyping, and it was implanted into defects in the orbital walls to restore the normal anatomy. Early orbital wall reconstruction was performed to improve the SOFS. Postoperatively, the ocular and facial appearance and eye function were evaluated., Results: The orbital structure, volume, and size of the SOF were restored in the 10 patients using the individualized titanium mesh. The symptoms of SOFS completely disappeared in all patients with no severe postoperative complications. Significant recovery of ocular and facial appearance and eye function was reported., Conclusions: This pilot study demonstrated that individualized preformed titanium mesh can accurately restore the orbital walls and the structure and size of the SOF, and it is useful in the treatment of SOFS without intraorbital bone fragment displacement., (Copyright © 2022 Elsevier Inc. All rights reserved.)

The aim of this study was to evaluate the clinical outcomes of linear and orbital volume measurements in severe orbital trauma. Patients with severe orbital trauma that involved more than two walls and entailed a marked degree of comminution were included in this retrospective analysis. However, patients with incomplete clinical records and a simple blowout or zygmatico-orbital fractures were excluded. All the cases underwent surgical correction guided by virtual surgical planning and 3D-printed templates. The measurement protocol depended on assessing orbital dimensions, orbital volumetry, and the zygomatic bone's position in the three-dimensional planes. All patients' preoperative 3D CT scans were obtained, and DICOM files were imported into a three-dimensional image processing software. Data were then converted for 3D reconstruction in the axial, coronal, and sagittal views. A total of 18 patients with a mean age was 39.28 ± 6.28 were included in this study. The results revealed a significant difference between the pre and postoperative differences in distances in relation to the FHP (Frankfurt Horizontal Plane) (P = 0.0014) and sagittal planes (P < 0.0001). The orbital width and height of the traumatized orbit were significantly decreased from 45.26 ± 6.72 mm and 45.30 ± 2.89 mm to 39.74 ± 3.91 mm (P = 0.0022), and 40.34 ± 0.86 mm (P < 0.0001), respectively. Clinically, there was a satisfactory degree of symmetry regarding the zygomatic bones' position and orbital dimensions postoperatively. Moreover, the mean orbital volume on the traumatized side decreased significantly from 23.16 ± 1.91 cm 3 preoperatively to 20.7 ± 1.96 cm 3 postoperatively (P < 0.0001). These findings were associated with a low incidence of complications. Within the limitations of the study it seems that the described methodology is a relevant addition to clinical treatment options. It incorporates all the latest technology to plan virtual reconstruction surgery in the treatment of complex orbital trauma and should be adapted accordingly in cases of severe displacement and comminution., Competing Interests: Declaration of competing interest The authors declare no conflicts of interest., (Copyright © 2023 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

The aim of the study was to compare automated and manually conducted (slice-by-slice) virtual orbital wall reconstruction in terms of PSI design, manufacture, and clinical application for orbital fracture management. Patients with orbital wall fractures were evaluated for the potential for treatment with PSI, based on automated virtual wall reconstruction; these formed the main group. The surgical outcomes of these main-group patients' treatments were compared with those of the control group, which comprised patients randomly selected for this study, each of whom had the same orbital trauma patterns and were also managed with PSI. However, the control group patients were treated using 'slice-by-slice' virtual orbital reconstruction. Mean volume differences between the intact and reconstructed orbit were 0.65 ± 0.26 cm 3 in the main group (n = 23) and 0.57 ± 0.23 cm 3 in the control (n = 27; p = 0.837). In both groups, no cases of implant malposition or enophthalmos were detected after surgery. Orbital shape difference was similar for the main group and the control, at -3.3 ± 3.5% and 3.25 ± 2.5%, respectively (p = 0.929). Diplopia was diagnosed at the 3-month follow-up in 13.0% of the main group and in 11.1% of the control (p = 0.651). The average times spent on computer-aided design (CAD) procedures, including segmentation, virtual orbital reconstruction, and PSI design, were 36.7 ± 6.9 min in the main group and 72.9 ± 7.7 min in the control group (p < 0.001). Within the limitations of the study it seems that PSI based on automated virtual reconstruction is a relevant alternative treatment option for orbital fractures because of its clinical efficacy that is similar to PSI based on a 'slice-by-slice' CAD protocol., Competing Interests: Declaration of competing interest The authors declare that they have no conflicts of interest., (Copyright © 2022 The Authors. Published by Elsevier Ltd.. All rights reserved.)

The management of blow-out orbital fractures (BOFs) continues to be controversial and regularly questioned. In recent years, treatment decision-making has shifted from a clinically dominated emphasis to a more objective data-based approach. This has come about through the refinement of imaging technologies that can more precisely define the fracture itself. Decision-making is now mainly driven by computed tomography (CT) parameters among which the fracture's size is by far the most often used. The variability in a patient's clinical presentation and outcomes for similar types of BOFs raises serious doubts about the pertinence of applying standardized guidelines based on quantitative data for the treatment of individual patients. An approach that fails to include patient variability and relies too heavily on average objective results with an emphasis on the application of quantitative rather than qualitative methods can lead to poor patient outcomes. A review of the knowledge accumulated over the many years of treatment of BOFs has demonstrated that despite the exceptional imaging-based technologies available, clinical acumen remains the most sophisticated decision-assistive tool. Thus, the treatment of BOFs must be regarded as a patient rather than merely a geometrical imaging issue. Imaging then becomes a valuable diagnostic rather than a final decision-making tool. This more conservative approach leads to a substantial decrease in indications for surgical repair., Competing Interests: Declaration of competing interest None, (Copyright © 2022 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

The aim of this study was to assess the correlation between volumetric risk factors, orbital volume (OV), orbital volume ratio (OVR), herniated volume (HV), and the newly described herniated volume ratio (HVR), with the occurrence of late enophthalmos. Patients presenting a unilateral unoperated blow-out fracture were retrospectively included. OV and HV were measured using planimetry on the initial CT scan images. OVR and HVR were then calculated. Enophthalmos was measured on the 2-month follow-up CT scan images. The population was divided into two groups according to their enophthalmos status. Correlations and multiple linear regression model were used. 17 patients out of 45 presented a late enophthalmos of 1 mm or more. There were significantly higher OVR (107 (3.76); p < 0.0001), HV (0.8 (0.47); p < 0.0001) and HVR (3.3 (1.82); p < 0.0001) in the enophthalmos group. A very strong linear correlation between enophthalmos and OVR (r s  = 0.806), HV (r s  = 0.948) and HVR (r s  = 0.951) was found. Enophthalmos prediction using these volumetric parameters can help the surgeon's decision-making in orbital blow-out fractures in order to prevent late enophthalmos. Measurement is simple and reproducible. However, larger prospective studies are needed to confirm these results., (Copyright © 2022 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

Introduction: The treatment of midfacial fractures is always difficult. The purpose of this study was to verify whether optimized three-dimensional (3D) digital surgical guide plates combined with preformed titanium plates improved the treatment effect in complex midfacial fractures., Patients and Methods: Twenty-six patients with complex midfacial fractures were recruited and randomized into three groups: ten for Group A, eight for Group B, and eight for Group C. Group A was treated with a combination of preformed titanium plates and optimized 3D digital surgical guide plates. Group B was treated with preformed titanium plates only. Group C was treated conventionally. Clinical effects, patient-reported outcome measures (PROMs), midfacial contour, facial symmetry, surgical accuracy, △orbital volume (the absolute value of the bilateral orbital volume difference), and maximum deviation were evaluated in each of the three groups., Results: Group A had the best postoperative clinical effects and patient-reported outcomes. Significant improvements in midfacial contour (L1[0.72±0.29 mm, P = 0.001], L2[1.04±0.46 mm, P < 0.001]), facial symmetry (S1[0.71±0.30 mm, P < 0.001], S2[0.96±0.58 mm, P < 0.001], S3[0.86±0.40 mm, P < 0.001], S5[0.81±0.16 mm, P = 0.003], S8[0.95±0.30 mm, P < 0.001], S9[1.03±0.38 mm, P < 0.001], S11[0.64±0.46 mm, P < 0.001]) and surgical accuracy (M1[R, 0.82±0.31 mm, P < 0.001], M2[R, 0.87±0.44 mm, P < 0.001], M3[L, 0.88±0.22 mm, P = 0.004], M3[R, 1.06±0.31 mm, P = 0.003], M4[L, 0.96±0.45 mm, P = 0.008], M4[R, 1.11±0.57 mm, P = 0.003], M5[R, 0.76±0.26 mm, P < 0.001], M6[L, 1.00±0.46 mm, P = 0.003], M6[R, 1.00±0.58 mm, P = 0.001], M7[0.87±0.53 mm, P = 0.001], M8[R, 0.91±0.53 mm, P < 0.001], M9[R, 0.81±0.32 mm, P = 0.010], M10[R, 1.19±0.42 mm, P = 0.009], M11[L, 0.85±0.51 mm, P = 0.021], M11[R, 0.96±0.49 mm, P = 0.003]) were found in Group A compared with the other two groups. The results of △orbital volume and maximum deviation analysis showed an ideal surgical treatment effect in Group A., Conclusion: Optimized 3D digital guide plates can accurately locate preformed titanium plates and effectively improve the treatment effect in complex midfacial fractures., Competing Interests: Declaration of Competing Interest The authors declare that they have no conflicts of interest., (Copyright © 2022. Published by Elsevier Ltd.)

Background: To assess the accuracy with which CAD/CAM-fabricated patient-specific titanium implants (PSI) are positioned for inferior and/or medial orbital wall reconstruction without the use of intraoperative navigation., Methods: Patients who underwent a primary reconstruction of the orbital walls with PSI due to fractures were enrolled in this retrospective cohort analysis. The primary outcome variables were the mean surface distances (MSD) between virtually planned and postoperative PSI position and single linear deviations in the x-, y- and z-axis at corresponding reference points. Secondary outcome variables included demographic data, classification of orbital wall defects and clinical outcomes., Results: A total of 33 PSI (orbital floor n = 22; medial wall, n = 11) were examined in 27 patients. MSD was on a comparable level for the orbital floor and medial wall (median 0.39 mm, range 0.22-1.53 mm vs. median 0.42 mm, range 0.21-0.98 mm; p = 0.56). Single linear deviations were lower for reconstructions of the orbital floor compared to the medial wall (median 0.45 vs. 0.79 mm; p < 0.05). There was no association between the occurrence of diplopia and the accuracy level (p = 0.418)., Conclusions: Free-hand positioning of PSI reaches a clinically appropriate level of accuracy, limiting the necessity of navigational systems to selected cases., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

The aim of the study was to assess factors leading to revision surgery and implant position of primary orbital fracture reconstructions. A retrospective cohort included patients who underwent orbital floor and/or medial wall fracture reconstruction for recent trauma. Demographics, fracture type, surgery and implant-related variables, and postoperative implant position were analyzed. The overall revision surgery rate was 6.5% (15 of 232 surgeries). The rate was highest in combined midfacial fractures with rim involvement (14.0%), lower in zygomatico-orbital fractures (8.7%), and lowest in isolated blowout fractures (3.8%). Fracture type, orbital rim fixation and implant malposition predicted revision. The best positioning was achieved with patient-specific milled titanium implants (mtPSI) and resorbable materials, whereas the poorest with preformed three-dimensional titanium plates. Combined midfacial fractures with rim involvement in particular have a high risk for orbital revision surgery. Within the limitations of the present study, mtPSIs should be preferred in the reconstruction of primary orbital fractures if possible., Competing Interests: Declaration of competing interest The authors declare that there is no conflict of interest., (Copyright © 2021 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

To investigate the trend of restoration of postoperative eye movements after orbital blowout fractures by analyzing the percentage of Hess area ratio (HAR%). This was a retrospective study of patients who underwent orbital blow out reconstruction surgery within 28-days post injury. Eye movements were measured preoperatively and 3, 6, and 12 months post operatively by Hess chart. Orbital fractures were classified into three shapes: trap-door fracture with muscle entrapment, trap-door fracture with incarcerated tissue, and depressed fracture. Correlations between fracture shapes, regions, reconstruction implant, age and HAR% were analyzed. This study involved 125 eyes (64 right eyes and 61 left eyes) of 125 isolated orbital fracture cases (95 males, 30 females, mean age: 27.2, range 4-85 years old). Of the total 125 cases, 96 patients had orbital floor fractures, 18 had orbital medial wall fractures, and 11 had combined orbital medial wall and floor fractures. Three had trap-door fractures with muscle entrapment, 42 had trap-door fractures with incarcerated tissue, and 80 had orbital depressed fractures. The overall mean HAR% improved significantly from 76.0 pre-operatively to 95.5 post-12 months (P < 0.01). The mean HAR% in orbital floor fracture improved significantly from 76.7 pre-operatively to 92.9 and 94.7 at 3, 6 months respectively. There was a non-significant improvement in the HAR% in medial wall fractures from 83.2 pre-operatively to 89.5 at 3 months and a significant improvement to 93.2 at 6 months (p < 0.05). Orbital fractures were reconstructed with either Unsintered hydroxyapatite particles/poly l-lactide composite sheet (u-HA/PLLA composite sheet) (91 patients), a silicone silastic sheet (20 patients) a combination of sheets (7 patients) or without an implant (7 patients). There was no significant difference in the HAR% improvement between the different implants. The HAR% improvement was significantly greater in patients <18 years old than in those aged 18 or over. The HAR% is an effective method of the objective assessment of recovery after orbital fracture. Patients and surgeons should be aware that the recovery after medial wall fractures is slower than after floor fractures and continues after three months post-surgery and that a longer period of observation without further intervention may be required for medial wall fractures, whilst floor fractures are likely to have achieved their maximal recovery by three months., (Copyright © 2021 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

Objective: This retrospective study evaluates the occurrence and frequency of different fracture patterns in a series of computed tomography (CT) scans in terms of the AOCMF Trauma Classification (TC) orbit module and correlates the assigned defects with measurements of the fracture area in order to get an approximate guideline for fracture size predictions on the basis of the classification., Material and Methods: CT scans of patients with orbital floor fractures were evaluated using the AOCMFTC to determine the topographical subregions. The coding consisted of: W = orbital wall, 1 = anterior orbit, 2 = midorbit, i = inferior, m = medial. The 3-dimensional surface area size of the fractures was quantified by the "defect body" method (Brainlab, Munich, Germany). The fracture area size and its confidence and prediction interval within each topographical subregion was estimated by regression analysis., Results: A total of 137 CT scans exhibited 145 orbital floor fractures, which were combined with 34 medial orbital wall fractures in 31 patients. The floor fractures - W1(i)2(i) (n = 86) and W1(i) (n = 19) were the most frequent patterns. Combined floor and medial wall fractures most frequently corresponded to the pattern W1 (im)2 (im) (n = 15) ahead of W1 (im) 2(i) (n = 10). The surface area size ranged from 0.11 cm 2 to 6.09 cm 2 for orbital floor and from 0.29 cm 2 to 5.43 cm 2 for medial wall fractures. The prediction values of the mean fracture area size within the subregions were computed as follows: W1(i) = 2.25 cm 2 , W2(i) = 1.64 cm 2 , W1(i)2(i) = 3.10 cm 2 , W1(m) = 1.36 cm 2 , W2(m) = 1.65 cm 2 , W1(m)2(m) = 2.98 cm 2 , W1 (im) = 3.35 cm 2 , W1 (im) 2(i) = 4.63 cm 2 , W1 (im)2(m) = 4.06 cm 2 and W1 (im)2 (im) = 7.16 cm 2 ., Conclusion: The AOCMFTC orbital module offers a suitable framework for topographical allocation of fracture patterns inside the infero-medial orbital cavity. The involvement of the subregions is of predictive value providing estimations of the mean 3-D fracture area size., (Copyright © 2020 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

The aim of this study was to determine whether patients benefit from a secondary reconstruction since it carries the risks of no improvement or worsening of their current situation. Patients treated with individual computer-aided-design/computer-aided-manufacturing (CAD/CAM) ceramic implants were reviewed. To ascertain changes throughout the secondary reconstruction, the study investigators reviewed ophthalmological examinations, took volumetric measurements of the orbits and asked the patients for evaluation of their situation before and after the reconstruction. Points addressed were double vision, visual acuity, field of vision, limitations in daily life and aesthetic considerations. A total of 14 patients were reviewed and 11 answered the questionnaire. Ophthalmological examinations showed that the physical integrity of the eye was maintained. Volumetric measurements preopeatively (33.94 ± 3.24 cm 3 ) and postoperatively (30.67 ± 2.07 cm 3 ) showed that a statistically significant overcorrection of orbital volume leads to good functional and aesthetic outcomes. Patients' subjective opinions were that they greatly benefitted, especially concerning limitations in daily life, which improved by 4.4 ± 2.8 points out of 10 possible points, and aesthetics, with an improvement of 5.9 ± 1.78 points. Based on these findings, we conclude that secondary reconstructions contribute to improvement of the patients' quality of life and therefore should be considered as an option to improve patients' condition., Competing Interests: Declaration of Competing Interest The authors have declared no conflicts of interest., (Copyright © 2021 European Association for Cranio-Maxillo-Facial Surgery. All rights reserved.)

Background: Secondary post-traumatic orbital reconstructions are challenging. Portable computed tomography (CT) provides the option to acquire real-time, intraoperative images that help to detect the insufficient reconstruction of the orbit immediately. We retrospectively analyzed patients who received intraoperative CT imaging and analyzed the effect of intraoperative CT scans on revision rates and orbital volume changes before, during, and after surgery., Methods: From August 2014 to September 2016, eleven patients received intraoperative cone-beam CT scans to evaluate the results of secondary orbit reconstruction using Medpor + titanium implants. Patient demographics, surgical details, CT scanning protocol, and follow-up results were analyzed. 3D CT volumetry was used to analyze the orbital volume based on OsiriX MD software., Results: Based on intraoperative CT findings, seven cases required intraoperative revision to further augment the orbital cavity or adjust implants. The mean preoperative measured enophthalmos was 3.41±1.4 mm (range: 2-6 mm), which decreased to 0.73±0.4 mm (range: 0-1 mm) at postop assessment (p<0.0001). On the fracture side, there was a significant difference between preoperative vs. intraoperative and preoperative vs. postoperative volume measurements (p<0.01 for both subsets), but no significant difference between intraoperative vs. postoperative measurements., Conclusion: Intraoperative CT is a valuable tool in secondary orbital reconstruction cases based on clinical enophthalmos evaluation and 3D CT volumetry. For these patients, the avoidance of another revision surgery may outweigh the disadvantage of increased operation time and additional radiation exposure., Competing Interests: Declaration of Competing Interest No conflicts of interest to declare. No funding sources to declare. None of the authors have a financial interest in any of the products, devices, or drugs mentioned in this article., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Purpose: This study aimed to examine the usefulness of treating orbital blowout fracture using a customized rigid carrier., Material and Methods: Patients who underwent surgery for orbital blowout fractures in our department from April 2016 to March 2019 were recruited in the study. We molded a rigid thermoplastic material into the same shape as the reconstruction material according to the 3D model and transplanted it into the orbital space along with the reconstruction material. We assessed Hertel exophthalmometry, awareness of diplopia, and the Hess area ratio (HAR%)., Results: We performed this procedure in 15 patients with blowout fractures. Reconstruction materials used were iliac bone, absorbable plates, and titanium mesh in 12, 2, and 1 patient, respectively. None of the patients showed a difference of more than 2 mm on Hertel exophthalmometry. Only one patient had diplopia after surgery. The average preoperative and postoperative HAR% were 83.1 and 90.6, respectively. HAR% was more than 85% in 6 of 7 postoperative cases., Conclusions: This method can be applied for surgery using various reconstructive materials and can be a useful method, especially in patients with a wide range of orbital bone defects., Competing Interests: Declaration of competing interest None declared., (Copyright © 2020. Published by Elsevier Ltd.)

Background: Enophthalmos is one of the most distressing complications of orbital fracture, and when faced with a blowout fracture, plastic surgeons often find it difficult to determine the need for surgical correction. Although a number of studies have been conducted on this topic, no study has yet been performed using a set of measurable parameters., Methods: We quantitatively measured orbital fracture areas (OFA), volumes (OFV), and medial rectus muscle cross-sectional ratios in patients with an isolated medial orbital wall fracture defect during a 5-year period from 2014 to 2018. Only conservatively treated patients constituted the study cohort. Enophthalmos was measured by two plastic surgeons at ≥6 months after trauma. We analyzed correlations between various parameters and degrees of late enophthalmos in the study cohort., Results: Significant correlations were observed between several parameters and late enophthalmos. Multiple regression analysis resulted in the following coefficients: -0.449 is constant (p = 0.017), 0.596 and 0.460 for OFA (p = 0.000) and OFV (p = 0.005), respectively. However, no significant relationship was observed between enophthalmos and medial rectus muscle cross-sectional ratios (p = 0.340)., Conclusions: The results of this study enable the degree of late enophthalmos in conservatively treated patients to be predicted using OFV and OFA values. We suggest five indications that require surgical correction without long-term clinical follow-ups: (1) OFA ≥ 1.90 cm 2 , (2) OFV ≥ 1.00 cm 3 , (3) 1.30 OFA + OFV > 5.32, (4) signs of muscle incarceration, and (5) signs of severe retrobulbar hematoma. The more satisfactory the five indications are, the greater is the need for surgery., Competing Interests: Declaration of Competing Interest None declared., (Copyright © 2019 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Background: Performing accurate anatomical reconstruction is a challenging task in the treatment of internal orbital floor fractures. Compared with traditional transcutaneous incisions, endoscopic transmaxillary approaches have the advantage of avoiding complications related to external scars, and provide direct access to the orbital floor. Autogenous bone provides the ideal material for defect reconstruction, but determination of the correct size and shape of the graft is crucial for a stable support. This study introduces a new protocol for the treatment of internal orbital floor fractures that combines endoscopy, virtual reality, and 3D printing. The authors also investigated the impact of computer-aided surgery (CAS) on the overall accuracy of reconstruction in aiming to achieve the triple objective of restoring anatomy, volume, and function., Materials and Methods: Fourteen patients with orbital floor fractures were recruited for this study. High-resolution CT scans provided appropriate imaging for detailed orbital floor defect visualization. A virtual reconstruction of the orbital floor defect was developed and a 3D printed template was fabricated to provide intraoperative guidance in the graft harvesting phase, according to the orbital defect. Virtual analyses were conducted to evaluate the accuracy of reconstruction both in terms of graft size and graft orientation., Results: Postoperative CT scans showed that in all cases orbital floor reconstruction was successfully performed, resulting in restoration of the correct globe position. No intraoperative complications occurred. Correspondence of graft size was evaluated using color-coded maps and RMSE, while comparison of angular measurements allowed the authors to relate simulated and actual reconstruction., Conclusions: Orbital floor reconstruction performed via transmaxillary endoscopy is a safe technique, which allows for detailed visualization of the fracture rim, avoids external scars, and permits an easier reduction of the prolapsed orbital content into the overlying orbital cavity. Virtual planning plays an important role in defining the appropriate geometry of the bone graft and establishing the optimal reconstruction strategy. Our preliminary results indicate that virtual planning and 3D printing should become part of an integrated protocol for the endoscopic treatment of orbital floor fractures., (Copyright © 2019 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

Objective: To determine the association of "pure" orbital fractures (POF) and "impure" orbital fractures (IOF) with ocular and periocular injuries., Materials and Methods: A retrospective study of patients with orbital fractures was designed. The predictor variable was the orbital's fracture configuration (pure versus impure). The primary outcome variables were ocular and periocular injuries classified as mild, moderate, and severe. The secondary outcome was the need for surgical repair. Standard statistics for patient characteristics, the Fisher exact test for categorical variables, and the Mann-Whitney U test for continuous variables were computed to compare fractures., Results: The sample was composed of 473 patients (220 POF and 253 IOF). No significant association between the two groups with regard to ocular and periocular injuries was found. Combined medial wall and floor fractures and naso-orbito-ethmoidal (NOE) fractures had the highest incidence of severe injury (34.5%, p = 0.02). Le Fort fractures were associated with moderate ocular and periocular injuries (36.4%, p = 0.01). Impure orbital fractures were more frequently associated with the need for surgical treatment (p = 0.04) than were POF., Conclusion: The present study has demonstrated that the pure and impure distinction of orbital fractures was not clinically relevant with respect to ocular and periocular injuries. However, our findings seem to suggest that other parameters such as the direction of the impact and/or its magnitude, rather than merely the pure or impure configuration, could be involved in determining the risk of developing concomitant ocular and periocular injuries., (Copyright © 2019 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

Purpose: Management of orbital fractures continues to present some difficulties, particularly regarding the prediction of late complications. Radiographic assessment provides a detailed evaluation, but the results lack consistency to be considered a standard factor in the decision-making process. Studies focusing on reliability of post-operative imaging are lacking., Materials and Methods: We performed a retrospective study using patients from a major trauma center with unilateral orbital floor fracture who underwent surgery. Using three-dimensional volume assessment software, we performed a volume calculation and determined the intra- and interreader variation by intraclass correlation coefficient analysis., Results: Twenty-four orbits were assessed. Mean orbital volume (SD) was 24.02 (2,43) cm 3 for reader 1 and 24.08 (2,51) cm 3 for reader 2. The intraclass correlation coefficient (95% CI) was 0.95 (0.91-0.98) between readers and 0.96 (0.91-0.98) for intra-reader variability. Normal and reconstructed orbits assessed separately also showed very high correlation coefficient for both intra- and inter-subject variability., Conclusion: Results show an almost perfect agreement of volume assessment between readers. The presence of reconstruction material does not seem to add variability. Although reproducible and reliable, radiological volume assessments have not yet shown a clear correlation with clinical outcomes and post-operative management decisions should be based mainly on clinical findings., (Copyright © 2019 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

Objective: To determine the predictive value of vertical incomitance for diplopia outcome in orbital fracture patients., Patients and Methods: A prospective cohort study composed of patients with orbital fractures was designed. The predictor variable was vertical incomitance, and the primary outcome variable was diplopia. Incomitance was calculated in prism diopters (Δ) as the difference of the maximum absolute deviation between the upper and lower three gaze directions. Standard statistics for patient characteristics, the Fisher exact test for categorical variables and the Wilcoxon rank sum test for continuous variables were computed., Results: The sample was composed of 188 patients grouped as follows: non-operated (n = 124) and operated (n = 64). Fifty-one patients showed vertical incomitance of whom 10 (19.6%) had persistent diplopia at the 1-year follow-up. The mean incomitance was 9.6Δ in the diplopia group versus 2Δ in the non diplopia group (OR = 1.13; p < 0.001). There was a statistically significant association between vertical incomitance of >2Δ and persistent diplopia at 1 year after adjusting for the surgery variable (OR = 1.07; p < 0.04)., Conclusion: The present study has demonstrated that in orbital fracture patients, vertical incomitance was associated with (1) persistence of long-term diplopia, (2) the decision to perform surgery, and (3) the severity of the fracture., (Copyright © 2018 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

Purpose: To determine the incidence of craniocerebral injuries in patients who experienced upper facial or midfacial traumas associated with the disorders of consciousness. To find which types of craniofacial traumas predisposed to craniocerebral injuries. To analyze a relationship between the site of the force application and the type of resultant craniocerebral injury., Materials and Methods: The study included 3,481 patients with upper facial and midfacial traumas. All 425 patients with craniofacial traumas and disorders of consciousness at the time of the event or hospital admission, were qualified for computed tomography (CT) of the head., Results: In 85/425 patients (20%), 70 men and 15 women (age 14-71 years), craniofacial trauma coincided with a craniocerebral injury. Upper facial dislocation and zygomatic-orbital-maxillary complex fracture significantly more often co-existed with skull, dura mater or cranial nerve injuries, and zygomatico-orbital fracture with the injuries of the brain. Application of force both centrally and laterally to the horizontal plane predisposed to skull, dura mater and cranial nerve injuries., Conclusion: The recommendation to perform head CT in each patient with craniofacial trauma who experienced the disorders of consciousness is as simple as possible, yet provides high diagnostic sensitivity, facilitating proper management at initial stages post-injury., (Copyright © 2018 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

Background: The orbital floor (OrF) and infraorbital rim (IOR) repair in cases of complete destruction is challenging mainly due to the fact that the defect length cannot be measured. The aim of the current study is to develop a method of calculating the Orf length by using the gender and the lengths of the medial, superior and lateral orbital walls (OrW) of the same orbit., Material and Methods: Ninety-seven (59 male and 38 female) European adult dry skulls were classified according to age: 20-39, 40-59 and 60 years and above. The length of each OrW was measured by using the direct distance between the optic foramen and a landmark in each orbital rim., Results: A side asymmetry was detected for the lengths of the inferior, superior and medial OrW. Although a gender dimorphism was detected, no correlation with the age was found. Using the Stepwise multiple regression analysis two formulas were developed, one for the right and one for the left OrF with coefficient of determination R 2 0.43 and 0.57, respectively., Conclusions: The proposed formulas represent a simple, applicable and individualized method to calculate the OrF linear length in cases of complete destruction of the IOR and OrF, with accuracy and without the use of expertise material. Such data may improve the surgery planning of orbital floor fractures and complex orbital reconstructions., (Copyright © 2018. Published by Elsevier Ltd.)

The purpose of the study was to analyze and describe the retrocaruncular approach to access medial orbital wall. A retrospective analysis was performed in patients referred for the treatment of orbital fractures between January 1st 2011 and July 31st 2017. The study included patients over 18 years old with isolated fractures of the medial orbital wall or combined with the orbital floor who underwent a transconjunctival approach with retrocaruncular extension and lateral canthotomy, and with a minimum follow-up of 6 months. Patients with fractures to the roof and/or lateral orbital wall were excluded. From a total of 319 orbits, 30 medial wall fractures were treated using a retrocaruncular approach, transconjunctival extension and lateral canthotomy. 7 of them were pure medial wall fractures and 23 were combined with orbital floor. Except for one case that required delayed reconstruction with customized orbital implant, all orbital reconstructions were successful in the first surgery. Only one patient developed a conjunctival granuloma in relation to the caruncle. No others patients had complications. This study concluded that this approach is a successful access for surgical treatment of medial orbital wall fractures because of their broad visibility without damaging structures, allowing adequate orbital reconstruction and excellent aesthetic results., (Copyright © 2018 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

Objective: The anatomy of the head and neck region is complex as are its implications for maxillofacial pathologic conditions and their surgical treatments. We hypothesize that the assessment of the surgical management of orbital floor fractures by using titanium mesh could represent an appropriate first experimental field for the use of the Anatomage Table in maxillofacial surgery., Study Design: Patients with unilateral orbital floor fractures were searched for in the hospital database of Novara University Hospital, Novara, Italy. The Digital Imaging and Communications in Medicine data of preoperative and postoperative computed tomography examinations were retrieved and were uploaded in the Anatomage Table device. Then, a workstation was used to create anatomic dissection coronal and sagittal images together with the corresponding computed tomography scans. Finally, 10 maxillofacial surgery residents and young surgeons were involved in the assessment of the images., Results: The young surgeons reported a higher clarity of anatomic dissection images in comparison with computed tomography scans both in preoperative and postoperative images., Conclusions: The fields of application of this new technology are wide and promising, ranging from the education, to the follow-up, to patient informed consent., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Purpose: Despite the advantages and broad applications of alloplastic resorbable implants, postoperative radiological control is challenging due to its radiolucency. The aim of the present study was to evaluate the radiographic visibility of newly developed materials for orbital floor reconstruction., Materials and Methods: The radiographic visibility of four different material combinations consisting of poly-(L-lactic acid)/poly-glycolic acid (PLLA/PGA) or poly(D,L-lactic acid) (PDLLA) enriched with magnesium (Mg), hydroxyapatite (HA) or β-tricalcium phosphate (β-TCP) with various layers of thicknesses (0.3, 0.6, and 1 mm), surgically placed above the orbital floor of a human head specimen, was evaluated using computed tomography (CT) and cone beam computed tomography (CBCT). The visibility was rated on a scale of 0-10 in CT/CBCT and by Hounsfield Units in CT for each subject., Results: All of the materials were clearly detectable in CT scans. Visibility was significantly higher (p < 0.001) in the standard soft tissue window (mean score: 7.3, ranging from 2 to 10) in comparison to the standard bone window (mean score: 5.2, ranging from 1 to 10). In CBCT (mean score: 3.3, ranging from 0 to 7), there was significantly lower but still sufficient visibility of the materials compared to the CT soft tissue window (p < 0.001) and CT bone window (p < 0.001). Comparing the different materials' visibility among the group of same layer thicknesses with each other, in the majority of cases, PDLLA enriched with β-TCP appeared to be most visible in both CT and CBCT., Conclusion: The incorporation of radiopaque elements to PLLA/PGA and PDLLA polymers is a promising strategy to improve their visibility in CT and CBCT. Our data suggest that the reconstruction of the orbital floor with these new materials could provide an advantageous postoperative radiographic control., (Copyright © 2018 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

Introduction: Treatment decisions for fractures of the orbital floor are based on clinical appearance, ophthalmological examination, and computed tomography (CT) scans. In extensive fractures, decisions are easily made between conservative and surgical treatment. However, objective parameters are rare in inconclusive cases., Materials and Methods: Our retrospective study included 106 patients with unilateral isolated orbital floor fractures. Correlations between preoperative ophthalmological examinations and specific CT parameters were performed., Results: The defect size of the fracture appeared to be significantly associated with the presence of diplopia. CT-morphological parameters and preoperative ophthalmological results showed statistical significance for diplopia and incarceration of inferior rectus muscle (IRM), diplopia and displacement of IRM, decreased mobility and incarceration of IRM, and decreased mobility and displacement of IRM., Discussion: Our clinical assessment scheme for CT scans of orbital floor fractures is aimed at facilitating treatment decision making using four CT-based variables. As critical size defects of the orbital floor of ≥2 cm 2 are likely to cause clinically significant posterior displacement of the globe, resulting in enophthalmos, the proposed parameters offer a readily accessible and easy to evaluate scheme that helps to identify patients in need of surgical intervention., (Copyright © 2018 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

Fractures of the orbital floor and medial orbital wall (blowout fractures) are common midface injuries. Diagnostic methods and treatment options have improved over recent years, due to threedimensional image processing and the use of patient-specific implants. Nonetheless, the indications for orbital reconstructive surgery are still controversial. Previous authors have reported a linear correlation between post-traumatic increases in orbital volume and enophthalmos and diplopia. Post-traumatic increases in orbital volume are often considered to be predictive of long-term symptoms; therefore, it is commonly recommended that orbital volume increases be treated as an indication for early reconstructive surgery. However, the results of this study did not show any statistically significant long-term linear correlation between increased orbital volume and enophthalmos or diplopia, and the performance of orbital volume as a predictor of ocular symptoms was poor. Hence, we do not consider increased post-traumatic orbital volume to be particularly useful for predicting late enophthalmos or diplopia. However, a statistical correlation between fractures of the anterior and medial thirds of the orbital floor and double vision was found. As such, fractures of the middle and anterior third should be regarded as problematic, and surgical reconstruction should be considered in these cases., (Copyright © 2018 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

Objective: Fractures of the zygoma and orbit are common facial skeleton injuries. Inadequate reduction and internal fixation may result in functional and aesthetic impairment. The aim of this study was to assess the use of intraoperative 3-dimensional (3-D) cone beam computed tomography (CBCT) for determining the intraoperative revision rate and the need for additional reconstruction of the orbit., Study Design: We conducted a retrospective analysis of 48 consecutive patients (15 females, 33 males) suffering from simple or complex zygomatic fractures, seen between June 2015 and October 2016. Intraoperative 3-D CBCT (Xoran Technologies, Ann Arbor, MI) was performed, and the intraoperative image was overlaid on the preoperative image by using iPlan software (Brainlab, Feldkirchen, Germany) for quality control. Categorical variables were cross-tabulated and compared using Fisher's exact test. P values and 95% confidence intervals were assessed., Results: In 6 of 48 patients, intraoperative revision was deemed necessary on the basis of the superimposition on the preoperative images. Five of these 6 patients had comminuted fractures (P = .001). In 7 patients, the indication for orbital reconstruction was revised after intraoperative 3-D CBCT., Conclusions: Intraoperative 3-D CBCT allows for immediate revision and prevents unnecessary orbital reconstruction., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Orbital reconstruction in cases of trauma is usually performed using the unaffected side orbital volume as a reference, but this measurement does not fully consider the anatomical characteristics of orbital surfaces. We propose a novel procedure based on the registration of 3D orbital segmented surfaces. Reconstructed orbits from 20 patients and healthy orbits from 13 control subjects were segmented from the post-operative CT-scans. The 3D orbital model from the unaffected orbit was "mirrored" according to the sagittal plane and superimposed onto the reconstructed one, with calculation of volumes, asymmetry index and point-to-point RMS (root mean square) distances. Inter- and intra-observer errors were tested through Bland-Altman plot. Differences in volume, asymmetry index and RMS value between the control group and the treated patients were assessed through two-way ANOVA and Student's t-test (p < 0.05). According to Bland-Altman test, intra- and inter-operator repeatability was respectively 87% and 89%. No significant differences in volume or asymmetry index between the control group and the treated patients were observed (p > 0.05), but the RMS value was significantly larger in the latter ones (on average, 0.90 ± 0.26 mm vs. 0.67 ± 0.17 mm, p < 0.05). Results show that the reconstructed orbits present a morphologically different surface from the unaffected ones., (Copyright © 2018 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

Introduction: Bone defect reconstruction in orbital wall fractures with absorbable alloplastic such as the unsintered hydroxyapatite and poly L-lactide composite (u-HA/PLLA) system is gaining popularity. The u-HA/PLLA material has osteoconductive and osteosynthetic properties. However, quantitative, long-term outcome data after the use of u-HA/PLLA for orbital wall fractures are lacking., Patients and Methods: We retrospectively analyzed 115 patients who underwent surgical repair of orbital wall fractures with a u-HA/PLLA sheet from 2011 to 2016. A chart review was performed, and the time-dependent changes at fracture sites were assessed by imaging. The immediate postoperative and the latest follow-up bony orbital volumes of the affected side were compared., Results: Seventy patients were eligible for this study (mean age, 44.6 ± 22.1 years; 48 men and 22 women; mean follow-up period, 29.7 ± 12.8 months). Except for one case of hematoma, there were no postoperative wound complications. Of the 70 patients, 10 had postoperative diplopia and 2 had enophthalmos; these conditions were presumably caused by the extension and severity of the fracture. Satisfactory reduction in the entire orbital wall, without pathological changes, was demonstrated. There were no significant differences in the mean bony orbital volumes of the affected side immediately after surgery (24.774 ± 3.092 cm 3 ) and at the latest follow-up (24.749 ± 3.205 cm 3 ) (p = 0.756)., Conclusion: The u-HA/PLLA sheet is useful for orbital wall fracture reconstruction because of its desirable handling characteristics, initial mechanical strength, long-term maintenance of structural stability, radiopacity, and few associated complications. Future randomized controlled trials need to be performed to compare u-HA/PLLA with other conventional materials., (Copyright © 2018. Published by Elsevier Ltd.)

Purpose: To determine if conservatively treated blowout fractures of the orbit undergo spontaneous improvement based on radiologic findings., Design: Prospective, noncomparative series., Participants: Patients with conservatively treated orbital blowout fractures in a single tertiary institution from 2012 through 2016 with initial and follow-up computed tomography (CT) scans., Methods: Comparison of initial and follow-up CT to assess for smoothening of bony contour, joining of bony edges, reduction in herniation of orbital contents, and new bone formation. Orbital and fracture volumes were calculated using a 3-dimensional reconstruction software program (3D Workstation; TeraRecon, Foster City, CA)., Main Outcome Measures: Change in bony contour, new bone formation, and decrease in orbital and fracture volumes., Results: Our study comprised 41 patients and 44 orbits, with 38 unilateral and 3 bilateral cases. Most were men (65.9%; n = 27), and the mean age was 34.3±13.5 years. The mean time from injury to follow-up scan was 4.6 months (range, 1-15 months). All orbits showed changes in bony contour from initial to follow up CT, including smoothening of the orbital contour (88.6%), joining of bony edges (90.9%), and reduction in herniation of orbital contents (65.9%). Most of the orbits (n = 41; 93.2%) showed features of neobone formation. Of the 44 orbits, 91.4% showed a decrease in orbital volume, whereas 94.3% showed a decrease in fracture volume. The reduction in volume was statistically significant for both orbital (from 23.7±4.0 to 21.8±3.9 ml) as well as fracture (from 1.2±0.8 to 0.7±0.6 ml) volumes from initial to follow-up scans, respectively (P < 0.001)., Conclusions: A large proportion of patients showed improvement in radiologic findings despite being treated conservatively. This highlights the spontaneous improvement that can occur in untreated blowout fractures not just clinically, but radiologically, in terms of soft tissue and bony findings., (Copyright © 2018 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.)

Purpose: Reconstruction of orbital wall fractures is demanding and has improved dramatically with the implementation of new technologies. True-to-original accuracy of reconstruction has been deemed essential for good clinical outcome, and reasons for unfavorable clinical outcome have been researched extensively. However, no detailed analysis on the influence of plate position and surface contour on clinical outcome has yet been published., Materials and Methods: Data from a previous study were used for an ad-hoc analysis to identify predictors for unfavorable outcome, defined as diplopia or differences in globe height and/or globe projection of >2 mm. Presumed predictors were implant surface contour, aberrant implant dimension or position, accuracy of reconstructed orbital volume, and anatomical fracture topography according to the current AO classification., Results: Neither in univariable nor in multivariable regression models were unfavorable clinical outcomes associated with any of the presumed radiological predictors, and no association of the type of implant, i.e., standard preformed, CAD-based individualized and non-CAD-based individualized with its surface contour could be shown., Conclusion: These data suggest that the influence of accurate mechanical reconstruction on clinical outcomes may be less predictable than previously believed, while the role of soft-tissue-related factors may have been underestimated., (Copyright © 2018 The Authors. Published by Elsevier Ltd.. All rights reserved.)

In this study, details of the infraorbital nerve's (ION's) anatomical course variants were compared using computed tomography (CT), and relationships between the variants and fracture patterns in the orbital floor were investigated. Fifty-two normal individuals and 50 patients with unilateral isolated orbital floor fractures were enrolled in this study. Four measurements in normal individuals and five measurements in fracture patients were obtained in parasagittal sections. The anatomical variations of the ION were categorized into three types according to the classification by Ferences et al. Among the normal individuals, 42 orbits were classified as type 1 ION, 48 orbits as type 2, and 14 orbits as type 3. The distance from the inferior orbital rim to the upper border of the inferior orbital foramen and the length of descension portion of the ION in type 1 ION were significantly shorter than in type 2 and type 3 IONs. In patients with orbital floor fractures, the distance from the inferior orbital rim to the upper border of the inferior orbital foramen was positively correlated with herniation level of bone and soft tissue. The ION had three anatomical variants according to the degree of descension in the anterior portion of the orbit. When fracture of the orbital floor occurs in patients with type 1 ION, inferior displacement of the fractured orbital bone and orbital soft tissue may be less severe than in patients with other ION types., (Copyright © 2017 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

For this study we developed an anatomical thin titanium mesh (ATTM) plate for Asian zygomaticomaxillary complex (ZMC) fracture repair with reduction guidance and fixation function. The ATTM plate profile was designed as an L-shape to fix at the anterior maxilla and lateral buttress of the ZMC. Computer-aided stamping analysis was performed on four screw-hole patterns in the ATTM plate - a control without screw-holes, square screw-holes, double screw-holes, and large-diameter, double screw-holes - using upper/lower dies of averaged ZMC reconstruction models. A regular ATTM plate of 0.6 mm thickness was manufactured and pre-bent using a patient-matched stamping process to verify its feasibility on three ZMC fracture models with one, two, and three fracture segments. The stamping analysis found that the double screw-holes design resulted in the most favorable performance among all the designs because of maximum von Mises stress (408 MPa) under the ultimate tensile strength. Positioning practice showed that the stamped, pre-bent ATTM plate can be used as a reduction guide to provide precise ZMC segment fixation in a completely passive fashion while limiting redundant rotation/micromovement between the separate bones in all directions. This study concluded that the ATTM plate with double screw-hole pattern design, using a patient-matched, pre-bent technique, can fit the ATTM plate/ZMC interface well, decrease mobility of unstable fracture segments, and provide good original facial contour recovery, while improving reduction efficiency., (Copyright © 2017 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

Objective: Advanced three-dimensional (3D) diagnostics and preoperative planning are the first steps in computer-assisted surgery (CAS). They are an integral part of the workflow, and allow the surgeon to adequately assess the fracture and to perform virtual surgery to find the optimal implant position. The goal of this study was to evaluate the accuracy and predictability of 3D diagnostics and preoperative virtual planning without intraoperative navigation in orbital reconstruction., Methods: In 10 cadaveric heads, 19 complex orbital fractures were created. First, all fractures were reconstructed without preoperative planning (control group) and at a later stage the reconstructions were repeated with the help of preoperative planning. Preformed titanium mesh plates were used for the reconstructions by two experienced oral and maxillofacial surgeons. The preoperative virtual planning was easily accessible for the surgeon during the reconstruction. Computed tomographic scans were obtained before and after creation of the orbital fractures and postoperatively. Using a paired t-test, implant positioning accuracy (translation and rotations) of both groups were evaluated by comparing the planned implant position with the position of the implant on the postoperative scan., Results: Implant position improved significantly (P < 0.05) for translation, yaw and roll in the group with preoperative planning (Table 1). Pitch did not improve significantly (P = 0.78)., Conclusion: The use of 3D diagnostics and preoperative planning without navigation in complex orbital wall fractures has a positive effect on implant position. This is due to a better assessment of the fracture, the possibility of virtual surgery and because the planning can be used as a virtual guide intraoperatively. The surgeon has more control in positioning the implant in relation to the rim and other bony landmarks., (Copyright © 2018 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

Background: The management of combined orbital floor and medial wall fractures involving the inferomedial strut is challenging due to absence of stable cornerstone. In this article, we proposed surgical strategies using customized 3D puzzle implant preformed with Rapid Prototype (RP) skull model., Methods: Retrospective review was done in 28 patients diagnosed with combined orbital floor and medial wall fracture. Using preoperative CT scans, original and mirror-imaged RP skull models for each patient were prepared and sterilized. In all patients, porous polyethylene-coated titanium mesh was premolded onto RP skull model in two ways; Customized 3D jigsaw puzzle technique was used in 15 patients with comminuted inferomedial strut, whereas individual 3D implant technique was used in each fracture for 13 patients with intact inferomedial strut. Outcomes including enophthalmos, visual acuity, and presence of diplopia were assessed and orbital volume was measured using OsiriX software preoperatively and postoperatively., Results: Satisfactory results were achieved in both groups in terms of clinical improvements. Of 10 patients with preoperative diplopia, 9 improved in 6 months, except one with persistent symptom who underwent extraocular muscle rupture. 18 patients who had moderate to severe enophthalmos preoperatively improved, and one remained with mild degree. Orbital volume ratio, defined as volumetric ratio between affected and control orbit, decreased from 127.6% to 99.79% (p < 0.05) in comminuted group, and that in intact group decreased from 117.03% to 101.3% (p < 0.05)., Conclusion: Our surgical strategies using the jigsaw puzzle and individual reconstruction technique provide accurate restoration of combined orbital floor and medial wall fractures., (Copyright © 2017 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Facial fractures often result in changes of the orbital volume. These changes can be measured in three-dimensional (3D) computed tomography (CT) scans for preoperative planning and postoperative evaluation. The aim of this study was to analyze the orbital volume and shape before and after surgical treatment of unilateral orbital fractures using semi-automatic image segmentation and registration techniques. The orbital volume in 21 patients was assessed by a semi-automatic model-based segmentation method. The fractured orbit was compared relative to the contralateral orbit. The same procedure was performed for the postoperative evaluation. Two observers performed the segmentation procedure, and the inter- and intraobserver variability was evaluated. The interobserver variability (mean volume difference ± 1.96 SD) was -0.6 ± 1.0 ml in the first trial and 0.7 ± 0.8 ml in the second trial. The intra-observer variability was -0.2 ± 0.7 ml for the first observer and 1.1 ± 0.9 ml for the second observer. The average volume overlap (Dice similarity coefficient) between the fractured and contralateral side increased after surgery, while the mean and maximum surface distance decreased, indicating that the surgery contributed to a re-establishment of size and shape. In conclusion, our study shows that the semi-automatic segmentation method has precision for detecting volume differences down to 1.0 ml. The combination of semi-automatic segmentation and 3D shape analysis provides a powerful tool for planning and evaluating treatment of orbital fractures., (Copyright © 2018 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

The aim of the study was to assess the mid-term effectiveness and safety of an original technique consisting of reconstructing fractures of the medial wall of the orbit with porous polyethylene implants with an exclusive transnasal approach. Twenty-five patients were treated. Each patient underwent a pre-operative ophthalmologic evaluation and a CT scan. The surgery started with an anteroposterior ethmoidectomy of the fractured side; all the fractured bone fragments were removed and all usual landmarks of healthy bony margins were identified. A Medpor sheet was placed endoscopically to reconstruct the fractured wall. Each patient received an immediate postoperative CT scan, and was evaluated at day 1, 7, 30 and 6 months after surgery clinically and with an endoscopic examination. In all patients, preoperative enophthalmos and/or diplopia were corrected. The CT scans showed excellent reconstruction of the fractured bony walls. The immediate postoperative period was characterized by a very high degree of subjective comfort. No perioperative complications were detected. At the 6 months follow up, all meshes appeared covered by epithelialized mucosa at the endoscopic inspection, and clinical results were stable. Scars or lid complications are always prevented. The technique described has become the standard to treat medial wall fractures in our department., (Copyright © 2017. Published by Elsevier Ltd.)

Enophthalmos is caused by an increase of orbital volume after blowout fracture and is one of the most critical complications of such fractures, but is often masked by swelling soon after injury. If surgery is performed after swelling resolves, it becomes more difficult to treat enophthalmos because of atrophy and fibrosis. Accordingly, it is important to estimate the severity of enophthalmos soon after injury. We developed a new criterion for determining whether orbital fractures are indicated for surgery in Asian patients using analysis of orbital volume. We retrospectively calculated the orbital volume of patients treated surgically or conservatively and analyzed the correlation between changes of orbital volume and the severity of enophthalmos. Regression analysis of the correlation between enophthalmos and increased orbital volume (y = 0.8x + 0.2; correlation coefficient: 0.92) showed that enophthalmos of 2.0 mm corresponded to an increase in orbital volume of 2.25 cm 3 . This result is similar to data reported previously for Caucasian patients - enophthalmos of 2.0 mm is a common surgical indication worldwide. Our results suggest that an increase of orbital volume of >2.25 cm 3 could be a new criterion for surgical treatment of blowout fractures in Asians., (Copyright © 2017 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

Background: This study evaluated the accuracy of blow out fracture reduction using 3D-printed rapid prototyping (RP) skull modeling., Patients and Methods: Retrospective review was performed for 82 patients who underwent post-traumatic orbital wall fracture reduction between 2012 and 2014. Patients were divided into two groups according to the use of 3D-printed RP skull model reproduced by mirroring technique, onto which a titanium mesh was anatomically molded. Using computed tomographic scans, the areas of pre- and post-operative orbital wall defect, the layout angles of the titanium mesh, and the gap lengths between the implant and fracture margin were compared between the two groups., Results: Of the 82 patients identified, 46 and 36 were diagnosed with medial and inferior orbital wall fractures, respectively. Bone defect area of the RP group was significantly reduced in comparison with that of the conventional group (8.03 ± 3.5% versus 18.7 ± 15.41% for medial wall fractures, 7.14 ± 5.74% versus 12.8 ± 4.92% for inferior wall fractures, respectively, p < 0.01). Satisfactory results were achieved regarding the layout angles and the gap lengths, presenting significantly reduced values in the RP group compared to that in the conventional group (p < 0.01)., Conclusions: More accurate restoration of traumatic orbital wall fractures can be achieved using patient-specific 3D-printed RP skull models., (Copyright © 2017 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

Purpose: To determine the correlation between the degree of enophthalmos and interpalpebral fissure (IPF) measurements in a group of patients with unilateral orbital wall fractures., Materials and Methods: The medical charts of 45 patients diagnosed with unilateral enophthalmos resulting from an orbital wall fracture were reviewed. Demographic characteristics were investigated, including patient age, sex, medical history, and type of orbital wall fracture. The correlation between the degree of enophthalmos and IPF was determined, adjusting for confounding demographic factors., Results: In the group with orbital wall fractures, the correlation between the degree of enophthalmos and the IPF measurements was positive and significant (R = 0.299, p = 0.046, Pearson's correlation). The correlation coefficient increased after adjusting for age, sex, medical history, and type of orbital wall fracture (R = 0.316, p = 0.044)., Conclusion: The patient group with more severe enophthalmos tended to have lower IPF values., (Copyright © 2017 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)