Professor of Oral and Maxillofacial Surgery, Faculty of Dentistry, Suez Canal University, Ismaillia, Egypt
Corresponding author details:
Tamer Abd El-Bari Hamed, Professor
Department of Oral and Maxillofacial Surgery Faculty of Dentistry
Suez Canal University
Ismaillia,Egypt
Copyright:
© 2020 Hamed T. This is an
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Repair of orbital floor damages following traumatic facial injuries represents a challenging practice in oral and maxillofacial practice. Management of associated ocular complications such as diplopia and Enophthalmos along with proper reconstruction for bony deficits are the main surgical goals. The current article represents a surgical reconstruction of the orbital floor using an autologous cartilaginous graft harvested from the nasoseptalcartilage of a thirty two years old male following a road traffic accident.
The objective of this case report was to evaluate clinically and radiodensometrically
the repair of orbital floor fractures using autologous cartilaginous graft obtained from
thenasoseptalcartilage.
Orbital floor reconstruction; Autogenous; Cartilaginous graft
Orbital floor fractures alone or in conjunction with other facial skeletal damage, are the most frequently encountered midfacial fractures, second only to nasal ones. Diplopia is the most repeatedly complication caused by orbital defects, others include limitation of ocular movement, infraorbital numbness, enophthalmos, and compromised vision [1]. Prompt therapy to restore the anatomic structure of the orbit and improve visual function and orbital appearance is therefore essential [2]. The orbital floor is most vulnerable to fracture because of the thinness of the roof of the maxillary sinuses, the existence of the infraorbital canal and the curvature of the floor [3]. The goals of surgical intervention for orbital fractures include anatomic reduction of bony fragments, release of entrapped, crushed, or prolapsed tissues, and accurate restoration of orbital volume [4]. Numerous techniques and implant materials were investigated for the repair of orbital floor injuries, each of them came with their advantages and disadvantages [5]. Abundant host materials have been used to reconstruct the internal orbit, including autologous bone or cartilage, allogeneic bone and cartilage, and metal sheets or mesh [6]. Now a days we suffer from increase rate of accidents and violence, which leads to increase rate of maxillofacial fractures, we need to increase cooperation between different departments of the collage in order to gain more benefits to the patient.
Thirty two years old male patient represented to the emergency room at Oral and Maxillofacial Surgery, Faculty of Dentistry, Suez Canal University. Following a road traffic accident. The patient disclosed a facial trauma after he was stroked by a moving vehicle. The patient was fully conscious with normal vital signs. Upon clinical examination periorbital edema, ecchymosis and subconjunctival hemorrhage of the right eye were detected. No paresthesia of the infra orbital region, ocular examination showed slight diplopia of the affected side with upward and lateral gaze. Computed tomography examination revealed multiple fracture lines with around 7 mm defect involving the orbital floor and one fracture line of the inferior orbital rim.
The patient was informed about the nature of the injury and the required surgical procedure and an informed consent was signed including his approval for the treatment protocol and the use of the radiographs and the photographs for international publication.
It is our belief that all patients undergoing orbital approaches for traumatic injury should be observed in an inpatient facility overnight formanagement of postoperative pain or determination of any increase in the intraocular pressure.
Clinical and radiographic examination were performed for a period of 12 months follow up period, No donor or recipient site morbidity were detected such as postoperative infection, nasal obstruction or graft extrusion or resorption.
No permanent postoperative diplopia was recorded apart from only transient period of temporary diplopia was detected for only four days postoperatively in extreme lateral movement. No postoperative enophthalmos was found and the patient was within the normal accepted range (1-2 mm) compared to the normal unaffected eye using Hertelexophthalmometer during postoperative ophthalmological examination in the follow up periods. Radio densometeric evaluation revealed that no changes were found in nasoseptal graft (NSG) thus the NSG remained static in place during the follow up period. From the data in Table 1 it could be noticed that no significant changes of the NSG density was detected along the study period (Figure 4,5).
Table 1: Radio densometric measurement of NSG density at different
time intervals
Figure 1: Preoperative axial CT view showing fracture of the
orbital floor and the inferior orbital rim
Figure 2: Harvesting the Nasoseptal cartilage graft
Figure 3: Application of the cartilaginous graft for reconstruction
of the orbital floor
Figure 4: Changes of the NSG density at different time intervals
of the follow up periods
Figure 5: Twelve months postoperative C.T axial view
The management of orbital floor injuries is complicated not only by their technical difficulties, but also by the required extensive medical competencies, ranging from the maxillofacial to otolarygological to ophthalmic fields. In addition to timing of repair and surgery related issues, another key factor in the treatment of orbital fractures is the choice of the material used for tissue(s) reconstruction [6]. In a bulk of previous published articles [7-9] the use of titanium mesh for repair of orbital floor injuries was strongly advocated, the technique was described as effective easy and fast method for reconstruction of the orbital floor. The outcome of the current case report was in agreement with Taheri et al. [10] who examined the effectiveness of nasoseptal cartilaginous graft for repairing orbital floor defects, there was no donor site morbidity and no grafts became infected or extruded. This study confirmed that nasoseptal cartilage is readily accessible autologous tissue that should be considered when an autologous graft is needed for reconstruction of the orbital floor.
From the results and clinical experience of the current case
report,the following may be concluded, the nasoseptal cartilaginous
graft (NSG) was proved to be effective and reliable in adequately
restoring the small to medium size orbital floor defects with
maintaining the normal function and satisfactory esthetic outcome
with minimal donor site morbidity. The NSG is easy to harvest and
shape and can provide long term support to the surrounding tissues
without undergoing resorption.
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