Treatment of Orbital Medial Wall Fractures with Titanium Mesh Plates Using Retrocaruncular Approach: Outcomes with Different Techniques

Abstract

Surgical management of medial wall orbital fractures should be considered to avoid diplopia and posttraumatic enophthalmos. Treatment of these fractures remains a challenge for the maxillofacial surgeon because of complex anatomy and limited vision. This article aims to retrospectively evaluate the outcomes in the repair of medial orbital wall fractures using a retrocaruncular approach and titanium meshes, comparing the placement of the titanium mesh with three different techniques: (1) conventional free hand under direct vision, (2) with the assistance of an endoscope, and (c) with the assistance of a navigation system. Eighteen patients who underwent surgery for orbital medial wall fracture were enrolled in the study. On the basis of the implant placement technique, three groups were identified: group 1 (CONV), conventional free hand under direct vision; group 2 (ENDO), endoscopically assisted; group 3 (NAVI), a navigational system assisted (BrainLab, Feldkirchen, Germany). The postoperative quality of orbital reconstruction was assessed as satisfactory in 12 cases, good in 4 cases, and unsatisfactory in 2 cases. Particularly in group 1 (CONV) in four patients out of eight, the posterior ledge of the fracture was not reached by the implant and in one patient the mesh hinged toward the ethmoid. In group 3 (NAVI), in one patient out of five, the posterior ledge of the fracture was not reached. In conclusion, titanium orbital mesh plates and retrocaruncular approach are a reliable method to obtain an accurate orbital medial wall reconstruction. The use of endoscopic assistance through the surgical incisions improves accuracy of treatment allowing better visualization of the surgical field. Navigation aided surgery is a feasible technique especially for complex orbital reconstruction to improve predictability and outcomes in orbital repair.

A Medial Orbital Wall Fracture From Cricket Bat During Training: Surgical Approach

“…Gerbino et al [ 8 ], Bly et al [ 13 ], and Markiewicz et al [ 14 ] supported that navigation-aided surgery improves predictability and outcomes in complex orbital reconstruction. The use of titanium orbital mesh plates placed through a transconjunctival retrocaruncular approach allows safe and accurate orbital reconstruction in patients with MOWF.…”

“…Recent advances in endoscopic techniques allowed fractured medial orbital walls to be repositioned with excellent visualization and complete dissection of the circumference through the endoscopic transnasal approach [ 8 ].…”

Orbital medial wall fractures: purely endoscopic endonasal repair with polyethylene implants

“…For years, the standard approach for medial wall fractures involved an external transcutaneous ‘Lynch’ incision or, preferably, a transconjunctival with retrocaruncular approach, the latter still being considered as the gold standard.Some recent papers focused on endoscopic management of medial wall fractures. The first one is a case series published by Gerbino and colleagues: they compared the results achieved through an external approach or with a transnasal endoscopic check of the procedure. Interestingly, the authors verified that the most predictable results were those obtained with the endoscopic check, with a better control of the posterior and the upper margin of the fracture.…”

“…Use of resorbable panels or autologous materials (bony fragments or septal cartilage) has been proposed in case reports only. Non‐resorbable materials, such as titanium meshes, have been traditionally limited to transfacial approaches, implementing also computer‐aided design for better aesthetic results …”

“…2 Use of resorbable panels or autologous materials (bony fragments or septal cartilage) has been proposed in case reports only. Non-resorbable materials, such as titanium meshes, have been traditionally limited to transfacial approaches, 5 implementing also computer-aided design for better aesthetic results. 3 Given the superior stability given by non-resorbable implants and the chances provided by modern biocompatible materials, we introduced a new purely endoscopic technique employing a porous polyethylene implant (Medpor, Stryker, Kalamazoo, MI, USA).…”