| Background:Orbital blowout fracture is one of the common types of orbital fracture. In recent years, with the rapid development of society, many factors make the orbital blowout fracture incidence increased year by year. Such as China’s car ownership in blowout growth, industrial manufacturing rapid development, the social life rhythm speeding up, the traffic accident injury, work injury, violence against injury and so on. Orbital blowout fractures usually only affect the orbital wall. However the orbital margin usually without any influence. Fractures can happen at any orbital walls, mainly in orbital floor wall and orbital medial wall which happens most. Orbital blowout fractures usually accompany with orbital and orbital soft tissue injuries. Such as extraocular muscle and orbital fat tissue displacement, herniation into the maxillary sinus, ethmoid sinus and other neighboring sinus cavity, orbital nerve contusion, etc. The hard and soft tissue injuries caused by orbital blowout fractures mainly with clinical manifestations of diplopia, enophthalmos, eye movement disorder, eye migration, innervation area under orbital hypoesthesia, which seriously affect the patients quality of life. The treatment for orbital blowout fracture can be divided into conservative treatment and surgical treatment. Although conservative treatment has certain curative effect for some degree of orbital blowout fracture, but for the patients whose extraocular muscle and orbital soft tissue embedded larger fail early time to reset and miss the best treatment time, which will cause the injured eye subsidence, limited eye movements or other irreversible consequences. So appropriate timing for surgery is still the most effective method for the treatment of orbital blowout fracture. The purpose of surgical treatment is to recover normal orbital volume and anatomical morphology. The effect of early surgery is satisfactory. Through resetting the shift of orbital soft tissue, repairing the defect of orbital wall, and filling of artificial materials, these methods can correct enophthalmos, relieve eye movement disorder, correct and improve diplopia symptom. For those who lost the early surgery opportunity and invalid of conservative treatment for orbital fracture. Late surgery still can achieve good curative effect. In the traditional surgical treatment of orbital blowout fracture, performer in the intraoperative process through observing fracture zone form and on the basis of personal experience to trim titanium mesh. Because of the narrowness of peri-orbit approach surgery, performer cannot accurately observe the morphology of fracture area. After the fracture normal anatomical structures are destroyed, so performer cannot accurately shape and trim titanium mesh. During the operation performer need to contrast in the area of the operation and to repeated adjustment of titanium mesh. However it is difficult to restore the normal anatomy of the orbital wall form. During the operation performer remove the titanium mesh in and out of fracture zone, which increases the risk of soft tissue injury.Mandilular body defect caused by tumor ablation or traumatic injuries is one of the common diseases of oral and maxillofacial surgery. Wide range of mandibular defect can lead to severe facial deformities, chewing function and language barriers, which needs to repair in time. In the human body, the thickness of the ilium and its’ natural curvature is similar to mandibular body, which is an ideal autograft bone mandibular body repair material. When using the free ilium to repair mandibular body defect, titanium plate for reconstruction must be reshaped along the outer side of the mandible before amputated lower jaw, in order to make sure to restore the patient’s jaw occlusal accurately and maxillofacial morphology after the mandibular excision and iliac transplantation repair. However, for the patients who have neuroma uplift or tumor invasion in the excision of mandibular lateral cannot shape the titanium plate for reconstruction before mandibular excision according to the lateral mandibular radian. In these cases surgeons usually shape the titanium plate intraoperative after mandibular excision according to the experience of performer. So it’s difficult to accurately recover occlusal and maxillofacial morphology of patients.Three-dimensional (3D) printing technology is a new technology which develops rapidly in the area of manufacturing. This technology is to use computer software to design out of a 3D model in advance, then through specific molding equipment (3Dprinters), using liquid, powder, silk materials to print out the physical model step by step.3D printing technology can produce any shape of the object by increasing the material. This method possesses many advantages, such as simplified production process, shorten development cycle, high efficiency, and low cost. Because of the advantages of above,3D technology presents rapid development momentum. This technology was first applied in the engineering field, then extending to medical field. Now it is widely used in orthopedics, neurosurgery, oral and maxillofacial surgery in the preoperative diagnosis, surgical planning and simulation at various stages. Doctors use 3D printing technology to make personalized denture, bone substitutes and the performance of bionic implants. Now in the clinical treatment of orbital blowout fracture 3D printing technology is mainly used in the application of copy orbital model, then according to orbital model as a template to design the personalized implants, and apply them in the orbital wall defect repair. In the application of mandibular defect repair its’mainly use the mandibular model and jaw plate, and on the basis of the guide plate to shape titanium plate or bone graft materials, which can accurately restore mandibular defect or mandibular continuity. In addition, in the field of dental planting,3D printing technology can make personalized titanium mesh which can be used for vertical or horizontal mandibular bone incremental technology. However, using 3D printing technology to directly print out the orbital implant and mandibular substitute is still in research stage.Based on the above factors, we hope to combine the 3D printing technology with titanium mesh reconstruction the orbital wall defect technology for the precise repair treatment of orbital blowout fracture and iliac crest for mandibular defect. Through the check of preoperative and postoperative imaging examination indexes and patients feeling, to evaluate the feasibility of this method using in orbital blowout fracture treatment. By clinical examination, imaging examination, patients’occlusion and facial shape recovery, we evaluate the feasibility of this method using ilium to repair the mandibular defect.Research 1:An clinical research of orbital blowout fracture reconstruction using three-dimensional pre-bent titanium mesh with computer aided rapid prototyping technologyObjective:This study through the computed tomography (CT) data transform into a special format data, using the 3D printer to print out physical model, then based on this model to bend titanium mesh, which use for the repair of orbital blowout fracture and provides convenient surgery procedures for accurate repair orbital wall defect caused by orbit blowout fracture in clinic. And based on these digital measurement technology was used in the quantitative diagnosis of orbital volume after orbital blowout fracture and the change of eyeball protrusion. By summarizing the experimental data, analysis the statistical differences of the healthy side and side, preoperative and postoperative orbital volume and eyeball protrusion change, to provide a reference basis for patients with clinically accurate recovery of orbital volume and the eyeball protrusion, to reduce postoperative complications. Then it can be widely used in the individualized precise treatment in orbital blowout fracture and provide accurate and convenient treatment for clinical surgery.Methods:1. The general information:Our department of stomatology in may 2014 to September 2015 all treated 12 cases of orbital blowout fracture, including the male 9 cases, female 3 cases, age 19-51 years old, average 33.6 years. Causes:traffic accident injury in 6 cases, violent injury in 5 cases, falling injury in 1 case. Fracture position:under the orbital wall 8 cases, orbital medial wall 2 cases and the complex fracture of under the orbital wall with orbital medial wall 2 cases. Clinical manifestations include enophthalmos, diplopia and limited eye movement. Inclusion criteria:(1) CT examination showed the orbital wall fracture, (2) Bilateral eyeballs were not damaged, (3) Whitout other maxillofacial fractures. Surgical indications:(1) limited eye movements, (2) diplopia, (3) CT examination clearly showed fracture under the orbital wall and/or orbital medial wall. Operation time:9 cases surgery within 1 week of injury,1-3 weeks surgery in 3 cases.2. Orbital volume measurement:All patients needed to accept orbital CT scanning in the preoperative and 3 months after postoperative. The thickness on CT images of axial and coronary layer is 0.75 mm. In order to determine the orbital volume, we used SIEMENS Syngo via VB30 image processing software to analysis the CT data. Lateral orbital wall leading edge to orbital medial frontal attachment for the former world, back to the optic nerve holes along the edge of orbital bony, depicting all levels of boundary, multiplied by each layer area is the sum of each scanning thickness of the orbital volume. By this measurement to obtain the orbital volume of preoperative and postoperative patients with side and healthy side eye. Normal people left and right sides of the orbital volume exactly equal. Therefore, using destroyed side of orbital volume to minus the healthy side of orbital volume is the orbital volume difference.3. Eyeball protrusion measurement:In CT axial images displayed the largest diameter of eyeball. If the injured eyeball had any invagination, then we selected a level in the maximum diameter between two sides of the eyeball to make the eye section symmetry on both sides. We measured the vertical distance between the highlight point of corneal and the front side of bilateral orbital rim, as eyeball protrusion values. Then we measured the two sides of eyeball protrusion in 1 day preoperative and 3 months after postoperative. Therefore, using healthy side of eyeball protrusion to minus the destroyed side is the eyeball protrusion difference.4.3D printing model preparation and titanium mesh shape:According to preoperative orbital CT scan data, using Geomagic Studio 12.0 software and images and reverse technology, we reshaped the lateral orbital normal form using the healthy eye socket as a template on the computer. Then we converted the data which obtained from the reshaped side of orbital model to the STL format and sent it to 3D printers (Makerbot Replicator 2 x, the United States) to print out the orbit model of the resin. Comparing with the resin model we shape the titanium mesh to make its size 1-2 mm beyond the fracture zone. The method for the disinfection of titanium mesh was to use ultrasonic oscillation cleaning and high temperature.5. Surgical method:Under general anesthesia, we used the eyelid margin incision, cut the skin, subcutaneous tissue, and the orbicularis oculi muscle, to show edge of orbital periosteum. Then cut the periosteum to expose the orbital wall and the medial orbit fracture zone. We reset the embedded soft tissue of maxillary sinus and ethmoid sinus. In the process of operation we needed to protect the nasolacrimal duct, orbital nerve and the optic nerve. After these we implanted the shaped titanium mesh into the fracture zone and using 2～4 titanium nail to fix the titanium mesh under the eye socket. Performer promoted the patient eye move to prove eyeball passive activities freely, then layered sutured the wound.6. Statistical analysis:IBM SPSS Statistics20 packages were used to analysis the data. All values were expressed as means±standard deviations.Paired t test was used to compare the lateral orbital volume and eyeball protrusion change quantity in preoperative and postoperative, to detect the recovery of orbital volume and eyeball protrusion after surgical treatment. P values of less than 0.05 were judged to be statistically significant.7. Evaluation index:Through clinical and CT examination and patients’subjective feeling to evaluate diplopia, eye movement, the recovery of enophthalmos and orbital volume and titanium mesh.Results:1.The operation of all cases went smoothly. Preoperative bending titanium mesh did not need to reshape or trim again intraoperative. CT examination showed that the implanted titanium mesh jointed closely with orbital wall. After 3-12 months follow-up, all patients’diplopia symptom disappeared, lateral orbital volume, eyeball protrusion recovered ideal. Patients’enophthalmos achieved ideal correction without any limitation of eye movement. All patients did not appear these complications, such as lower eyelid retraction, orbital nerves or ligament damage, nasolacrimal duct injury, implant materials infection, eliminate or shift after operation.2.Preoperative risk of lateral orbital volume difference (2.57±0.43mL), postoperative for (-0.09±0.60 mL), which had significant difference (P< 0.001). Preoperative of eyeball protrusion difference (2.21±0.90 mm), postoperative for (0.16±0.50 mm),which had significant difference (P<0.001).Conclusions:1. Using three-dimensional pre-bent titanium mesh with computer aided rapid prototyping technology is suitable for the repair of orbital blowout fracture, which can accurately restore the anatomical morphology, orbital volume and eliminate the enophthalmos.2. Using three-dimensional pre-bent titanium mesh with computer aided rapid prototyping technology is suitable for the repair of orbital blowout fracture.The treatment process is convenient, safe and effective.Research 2:Outcomes of mandilular body defect reconstruction after surgical excision of mandibular tumors using the computer-assisted pre-bent individual reconstruction plate and nonvascularized iliac crest bone graft.Objective:To evaluate the application and clinical outcomes of mandilular body defect reconstruction after surgical excision of mandibular tumors using the computer-assisted pre-bent individual reconstruction plate and nonvascularized iliac crest bone graft.Methods:1. The general information:Our department of stomatology in October 2013 to October 2015 all treated 6 cases of patients with mandibular tumor, including the male 4 cases, female 2 cases, aged 24-56 years old, average 45.1 years. Mandibular glaze cell type 4 cases, mandibular center squamous carcinoma in 2 cases, confirmed by pathology. Clinical manifestation:submandibular uplift, such as lower lip numbness and loose teeth. Panoramic radiographs and CT examination:mandibular body cancellous bone destruction with insect damage shape or multilocular cystic shadow.2.3D printing model preparation and titanium mesh shape:According to preoperative orbital CT scan data, using Geomagic Studio 12.0 software and images and reverse technology, we reshaped the affected side of mandibular form using the healthy lateral mandibular as a template on the computer. Then we converted the data which obtained from the reshaped side of mandibular model to the STL format and sent it to 3D printers (Makerbot Replicator 2 x, the United States) to print out the mandibular model of the resin. On this model, we shape and trim the implanted titanium plate in order to fit mandibular surface completely. Then we get the individualized titanium plate. The method for the disinfection of titanium mesh was to use ultrasonic oscillation cleaning and high temperature.3. Surgical method:Under general anesthesia, according to the preoperative CT scan to determine the tumor boundary and bone cutting line to carry on the extensive tumor resection and mandibular condyle segment resection, we use the shaped titanium for reconstruction to connect the bone defect. Then take ipsilateral iliac bone graft to the defect area and use titanium screw for internal fixation.4. Evaluation index:Postoperative through clinical, X-ray and CT examination, observation of patients’facial appearance, occlusal recovery, language, chewing and swallowing function recovery, as well as wound healing and bone graft survival.Results:In 6 cases,5 cases operation smoothly, the reconstruction of the bending titanium plate does not need to intraoperative shaping again and implanted titanium plate with defect on both ends of the mandibular lateral fitting tightly. Postoperative follow-up of 3-12 months, there is no tumor recurrence after clinical and CT examination. The recovery of facial appearance on both sides is good and basic symmetry. The occlusal relationship of the remaining teeth recovered well. Patients’ chewing function recovered well, voice clarity and no limited mouth opening.Conclusions:Mandilular body defect reconstruction after surgical excision of mandibular tumors using the computer-assisted pre-bent individual reconstruction plate and nonvascularized iliac crest bone graft can result in successful clinical outcomes. |
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