The Evaluation of Complications of Titanium Mesh Reconstruction in Orbital Floor Fractures

INTRODUCTION: The orbit is the bony socket of the eye encloses and protects the eye and its appendages. The configuration of the bony structure of the orbit is that of a pyramid with its base facing anteriorly, with each orbit having an intrabony volume of approximately 35 ml. Each bony orbit is composed of seven bones (frontal bone, zygomatic bone, maxilla bone, lacrimal bone, ethmoid bone, sphenoid bone and palatine bone) (Fonseca, 2013). In craniomaxillofacial trauma orbital structures are involved in up to 40% of the cases due to its exposed position and its limited bone thickness (Hoffmann et al., 1998). A summary of possible clinical findings in isolated orbital floor fractures (Perry et al., 2016):


INTRODUCTION:
The orbit is the bony socket of the eye encloses and protects the eye and its appendages. The configuration of the bony structure of the orbit is that of a pyramid with its base facing anteriorly, with each orbit having an intrabony volume of approximately 35 ml. Each bony orbit is composed of seven bones (frontal bone, zygomatic bone, maxilla bone, lacrimal bone, ethmoid bone, sphenoid bone and palatine bone) (Fonseca, 2013). In craniomaxillofacial trauma orbital structures are involved in up to 40% of the cases due to its exposed position and its limited bone thickness (Hoffmann et al., 1998)  Periorbital ecchymosis  Subcojunctival haemorrhage  Diplopia  Limitation of eye movement especially in upward gaze  Enophthalmos  Ipsilateral epistaxis especially when it is part of zygomatic complex or Le Fort fructures.  Paresthesia within distribution of infraorbital nerve. Historically, there has been debate as to whether the mechanism of injury result in a blow to the globe transmitted to the orbital floor (hydrostatic theory) or a blow to the lower orbital margin (buckling theory) (Brennan et al, 2017

BACKGROUND:
The facial symmetry is a specific measure of bodily symmetry and it influences judgements of aesthetic traits, therefore special attention and care must payed during orbital fracture treatment to consider every detail in the scenario of surgical reconstruction. Many materials have been used for treatment of orbital bones fractures and titanium mesh is widely used implant for this purpose therefore it worthwhile to study it.

AIM OF STUDY:
Evaluate the complications of using titanium mesh in the treatment of orbital floor fractures.

MATERIALS AND METHODS:
The study included 13 patients (11 males and 2 females) presented to Oral and Maxillofacial Surgical Department in Al-Yarmook Teaching Hospital Iraq/ Baghdad in the period from January 2018 to June 2019 with traumatic orbital floor fracture and they underwent reconstruction with titanium mesh.

RESULTS:
The results showed that the most common cause for trauma was road traffic accident (53.8%). Preoperative diplopia found in 12 patients (92.31%) followed by persistent diplopia found in only one (7.69%). Preoperative enophthalmos was (61.5%) in eight patients, six of them improved after treatment and returned to the normal condition but only two had postoperative enophthalmos with less severity.

CONCLUSION:
The reconstruction of orbital floor using titanium mesh was successful in most of the cases and the resulted was good and satisfactory aesthetic and functional results. KEYWORDS: Orbital fracture, titanium mesh, diplopia, enophthalmous, Hertel exophthalmometer Titanium plates are thin, stiff and easy to contour. They are easily stabilized, maintain their shape, and have the unique ability to compensate for volume without the potential for resorption. When titanium plates were introduced, it believed that they needed no removal, since titanium is a highly biocompatible material (Breme et al., 1988). Rubin and coworkers (1992) compared the use of custom-shaped orbital floor titanium plates or vitallium mesh with autogenous bone grafts. They reported no significant complications related to the orbital implants. Metal implants were easier to use than autogenous bone grafts.

MATERIALS AND METHODS Patient's Sample:
This was a prospective study included patients who underwent reconstruction of orbital floor and inferior orbital rim using performed in the department of maxillofacial surgery in Al-Yarmouk Teaching Hospital, Baghdad, Iraq from January 2018 to June 2019. Eleven patients were males and two females. Patient's ages ranged between 18 years. The mean age was 29.77 years. Preoperative evaluation: History and examination: The information the patient and the injury were collected case sheets. Patient chief complain, past m and surgical history had taken. Inspection is echymosis, subconjectival hemorrhage, chemosis or glob rupture. Palpation if there is any foreign body and to check bony defor and tenderness. Diplopia is tested by holding a finger or an object arm's length in front of the eyes and asking the patient to report double vision as the finger is moved. It was in, stiff and easy to contour. They are easily stabilized, maintain their shape, and have the unique ability to compensate for volume without the potential for resorption. When titanium plates were introduced, it believed that they needed no removal, since titanium is a highly biocompatible material Rubin and coworkers (1992) compared the use of shaped orbital floor titanium plates or vitallium mesh with autogenous bone grafts. They reported no significant complications to the orbital implants. Metal implants use than autogenous bone grafts.

MATERIALS AND METHODS:
was a prospective study included 1٣ econstruction of orbital using titanium mesh the department of maxillofacial Yarmouk Teaching Hospital, Baghdad, Iraq from January 2018 to June 2019. Eleven patients were males and two were ages ranged between 18-47 years.
information about the patient and the injury were collected in the . Patient chief complain, past medical Inspection if there jectival hemorrhage, Palpation if there is any foreign body and to check bony deformity Diplopia is tested by holding a finger or an object arm's length in front of the eyes and asking the patient to report double on as the finger is moved. It was recorded in each of the nine positions of gaze. The vertical globe level was checked by using a short clear plastic ruler, which is held horizontally with reference to symmetric landmarks, and the ruler must pass through the pupil of the uninjured eye. Vertical displacement of the injured eye can be noted with respect to the other side duction test was performed for all cases intraoperatively. Evaluation of neurosensory changes in the infraorbital nerve had using two objects (first using cotton stick then using pin of needle) each one pressed gently on multiple areas of the nerve distribution while the patient closed his eyes to rise his hand if he felt anything. This test repeated post operatively in each follow up visit. The study depended on Hertel exopthalmometer for measuring enophthalmos as Fig. (1). Surgical technique: The approach that used in all cases was infraorbital approach. Forced duction test done for each patient intraoperatively twice, before the beginning and after completion the surgery to checking the releasing of the ocular muscle. Tarsorrhaphy was used for corneal protection in fig. (2). Incision at the transition between the thin eyelid skin and the thicker cheek skin. The skin, orbicularis oculi muscle (step technique), and the periosteum are incised. The fracture site was visualized with freeing the entrapped tissues until reaching a stable bone. Measuring the defect by using the graduated globe retractor to know the size of mesh required. Preparing the titanium mesh slightly larger than the defect and manipulate it to accommodate the floor anatomy. mesh in the position by its microscrews on the orbital rims again forced duction test to ensure completely freeing the muscle before closing the surgical site. Closing with two layers, the periosteum and the muscle by simple interrupted with 4/0 polyglactin suture (Vicryl), and the skin by subcuticular suturing with 6/0 polyprolene. The vertical globe level was checked by using a short clear plastic ruler, which is held horizontally with a reference to symmetric landmarks, and the ruler must pass through the pupil of the uninjured eye.
injured eye can be noted with respect to the other side. Forced s performed for all cases ation of neurosensory been done using two objects (first using cotton stick then using pin of needle) each one pressed gently on multiple areas of the nerve distribution while the nd if he felt anything. This test repeated post operatively in each follow up visit. The study depended on Hertel exopthalmometer for measuring enophthalmos as Fig. (1).
The approach that used in all cases was infraorbital approach. Forced duction test done for each patient intraoperatively twice, before the beginning and after completion the surgery to checking the releasing of the ocular for corneal protection as Incision at the transition between the thin eyelid skin and the thicker cheek skin. The rbicularis oculi muscle (step ladder incised. The sualized with freeing the entrapped tissues until reaching a stable bone. Measuring the defect by using the graduated globe retractor to know the size of mesh the titanium mesh slightly larger than the defect and manipulate it to anatomy. Fixing the screws on the forced duction test to ensure completely freeing the muscle before closing the with two layers, the imple interrupted glactin suture (Vicryl), and the skin by subcuticular suturing with 6/0 polyprolene.

RESULTS:
In this study there were 13 patients, 11 males (84.62%) and only 2 females (15.38%). The male to female ratio was (5.5:1). The ages of the patients ranged from 18 to 47 years with mean age range 32.5 years. The highest percentage of patients was found in age group 20-29 years (30.76%). The main cause of orbital floor fractures was the road traffic accident in 7 patients. Most of the cases in the study presented with orbital floor fracture as part of zygomatic complex (impure type) 12 patients (92.3%) and only one patient (7.7%) had pure blow out fracture. Patients with preoperative diplopia were 12 (92.3%) and 8 patients presented with enophthalmos (61.5%), 7 patients of them (53.8%) had both enophthalmos and diplopia as in table (1). During the follow up, one week post operatively, ten patients diplopia improved within days postperatively, one improved after one month and another one had persistent diplopia (table 2). The eight patients those had enophthalmos improved postoperatively except two which had reduced the posterior displacement of the globe but did not improve completely.