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Accuracy and Predictability in Use of AO
Three-Dimensionally Preformed Titanium Mesh Plates for
Posttraumatic Orbital Reconstruction: A Pilot Study
Paolo Scolozzi, MD, DMD,*Armen Momjian, MD, DMD,*Joris Heuberger,ÞElene Andersen,þ
Martin Broome, MD, DMD,§ Andrej Terzic, MD, DMD,*and Bertrand Jaques, MD, DMD§
Abstract: The aim of this study was to prospectively evaluate
the accuracy and predictability of new three-dimensionally pre-
formed AO titanium mesh plates for posttraumatic orbital wall
reconstruction.
We analyzed the preoperative and postoperative clinical and
radiologic data of 10 patients with isolated blow-out orbital frac-
tures. Fracture locations were as follows: floor (N = 7; 70%), medial
wall (N = 1; 1%), and floor/medial wall (N = 2; 2%). The floor
fractures were exposed by a standard transconjunctival approach,
whereas a combined transcaruncular transconjunctival approach was
used in patients with medial wall fractures. A three-dimensional
preformed AO titanium mesh plate (0.4 mm in thickness) was
selected according to the size of the defect previously measured on
the preoperative computed tomographic (CT) scan examination and
fixed at the inferior orbital rim with 1 or 2 screws. The accuracy of
plate positioning of the reconstructed orbit was assessed on the
postoperative CT scan. Coronal CT scan slices were used to measure
bony orbital volume using OsiriX Medical Image software.
Reconstructed versus uninjured orbital volume were statistically
correlated.
Nine patients (90%) had a successful treatment outcome without
complications. One patient (10%) developed a mechanical limita-
tion of upward gaze with a resulting handicapping diplopia requir-
ing hardware removal. Postoperative orbital CT scan showed an
anatomic three-dimensional placement of the orbital mesh plates in
all of the patients. Volume data of the reconstructed orbit fitted that
of the contralateral uninjured orbit with accuracy to within 2.5 cm
3
.
There was no significant difference in volume between the re-
constructed and uninjured orbits.
This preliminary study has demonstrated that three-dimensionally
preformed AO titanium mesh plates for posttraumatic orbital wall
reconstruction results in (1) a high rate of success with an acceptable
rate of major clinical complications (10%) and (2) an anatomic
restoration of the bony orbital contour and volume that closely ap-
proximates that of the contralateral uninjured orbit.
Key Words: Orbital fractures, enophthalmos, titanium mesh
plates, volume measurement, computed tomography
(J Craniofac Surg 2009;20: 00Y00)
‘‘Bone graft means re-operation’’
<Paul Manson, AO Advanced Course on Orbital
Reconstruction 20Y22 March 2003
Oberdorf, Switzerland
Orbital fractures are extremely common and are found in almost
half of all craniomaxillofacial traumas. They can occur either in
isolation or in combination with fractures of adjacent facial bones
such as orbitozygomatic and naso-orbital-ethmoid fractures. The
spectrum of severity ranges from simple linear fractures, which can
be treated conservatively, to more complex comminuted fractures,
whose reconstruction can be demanding and challenging. Incor-
rectly restored orbital fractures can result in unpleasant and handi-
capping functional and cosmetic impairments, such as visual
alteration, diplopia, hypoesthesia of the infraorbital nerve, and
enophthalmos.
1Y9
Although there is no international consensus on
the ideal material to be used for orbital reconstruction, the final goal
of all orbital fracture repairs must be the primary restoration of
the preoperative bony orbital volume and shape.
1Y22
Previous studies
have demonstrated that the increase of orbital volume rather than
changes in periorbital fat seems to be linearly correlated with
the development and the degree of late enophthalmos.
10Y16
En-
ophthalmos, which is defined as a difference of greater than 2 mm
between the 2 eyes along an anteroposterior axis as measured by
an exophthalmometer, still represents one of the most delicate path-
ologic conditions to deal with by craniofacial surgeons.
Several materials, such as autografts, allografts, xenograft,
and metallic or nonmetallic material alloplastic bone substitutes,
have been reported for use in plastic reconstruction of orbital walls,
ORIGINAL ARTICLE
The Journal of Craniofacial Surgery &Volume 20, Number 4, July 2009 1
From the *Service of Oral and Maxillofacial Surgery, Departments of Surgery
and †Medical Images and Information Science, Ho
ˆpitaux Universitaire de
Gene
`ve, Geneva; ‡School of Dental Medicine, University of Geneva, Geneva;
and §Division of Oral and Maxillofacial Surgery, Department of Otolaryn-
gology/Head and Neck Surgery, Centre Hospitalier Universitaire Vaudois,
Lausanne, Switzerland.
Received March 23, 2009.
Accepted for publication April 8, 2009.
Address correspondence and reprint requests to Paolo Scolozzi, MD, DMD,
Service of Oral and Maxillofacial Surgery, Department of Surgery,
Ho
ˆpitaux Universitaire de Gene
`ve, 1211 Genee
`ve, Switzerland;
E-mail: scolozzi-paolo@diogenes.hcuge.ch
The authors have received no financial support for this research and do not
have any financial or commercial interest in any of the products described
in this article.
Copyright *2009 by Mutaz B. Habal, MD
ISSN: 1049-2275
DOI: 10.1097/SCS.0b013e3181abb44b
Copyright @ 2009 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
with varying degrees of success in the past 20 years.
1Y9,18,19
Clas-
sification, surgical planning for correction of orbital defects, and
the ability to calculate orbital volume have been dramatically im-
proved since the 1980s as three-dimensional computed tomographic
(CT) scanning techniques have progressed and become more ef-
ficient.
10Y17,20Y23
Moreover, prediction of secondary enophthalmos
and the planning of precise secondary volume reduction for its cor-
rection have also been revolutionized by the sophisticated software
for computer-assisted orbital volume measurement, which makes
it more accurate and predictable.
10Y17,20Y23
Current efforts are
aimed at developing specific alloplastic implants that match three-
dimensionally, as anatomically as possible, the residual orbital bone
defect.
4,6Y9
The recent introduction of individually or industrially
preformed titanium meshes allows precise three-dimensional shap-
ing as opposed to conventional implants, which require major in-
traoperative manipulations. Thus, the outcome can be a less precise
reconstruction and in an increase of the length of time required for
the operation.
4,6Y9
The purpose of this pilot study was to evaluate prospectively
the accuracy, reliability, and safety of posttraumatic orbital wall
reconstruction with AO industrially three-dimensionally preformed
titanium orbital mesh plates. To the best of our knowledge, no other
similar cases regarding the use of these specific implants in orbital
reconstruction have been reported previously.
PATIENTS AND METHODS
Patients
Ten consecutive patients treated using AO three-dimensionally
preformed orbital titanium mesh plates (7 patients at the Ho
ˆpitaux
Universitaire de Gene
`ve and 3 patients at the Centre Hospitalier
Universitaire Vaudois, Switzerland), between May 2007 and January
2008 were included in this prospective study. Inclusion criteria
included (1) unilateral isolated blow-out fracture, (2) contralateral
healthy orbit, (3) no previous history of orbital trauma, (4) age older
than 18 years, and (5) a follow-up of at least 6 weeks. All patients were
assessed with a preoperative and postoperative ophthalmologic
examination. Orthoptic examination was based on the red-green
Hess and Lancaster screening test. A Hertel exophthalmometer was
used to evaluate enophthalmos clinically. The variables reviewed
included age and sex, mechanism of injury, delay between admission
to the hospital and surgery, location of the fracture, surgical approach,
status of healing, and complications. Postsurgical complications that
were recorded as minor did not require surgical intervention and
included hypoesthesia of V2 and diplopia in extreme gaze. Major
complications required further surgical intervention and included
diplopia that interfered with daily activities, enophthalmos of greater
than 2 mm by Hertel exophthalmometry, and decreased visual activity.
Image Acquisition
Preoperative and postoperative CT scans (coronal, axial, and
sagittal views) with the following parameters were obtained for all of
the patients: matrix, 512 512 pixels; slice thickness, 1.0 mm; seed
per rotation, 1.0 mm; reconstructed slice increment, 1.0 mm; and
reconstruction algorithm bone gantry tilt, 0 degrees.
Fig 1 4/C
FIGURE 1. Illustration showing a preformed MatrixORBITAL
plate. Note the anatomic preformed retrobulbar slope
(arrow; Synthes).
TABLE 1. Clinical Data on Patients
Patient
No. Sex Age, y
Preoperative Examination Follow-Up Examination
Fracture Location
Visual
Activity Diplopia Enophthalmos
Follow-Up,
mo
Visual
Activity Diplopia Enophthalmos
1 F 71 Left orbital floor + No No 3 + No No
2 M 37 Right medial orbital
wall + orbital floor
+ Yes Yes 5 + No No
3 F 69 Right orbital floor + Yes No 7 + No No
4 M 19 Left medial orbital
wall + orbital floor
+ Yes No 10 + No No
5 M 53 Left orbital floor + Yes No 2 + No No
6 M 29 Left orbital floor + No Yes 5 + Yes No
7 M 70 Left orbital floor + Yes No 8 + No No
8 M 26 Right medial orbital
wall + orbital floor
+ Yes Yes 10 + No No
9 M 21 Right orbital floor + Yes No 11 + No No
10 M 20 Right orbital floor + Yes Yes 7 + No No
Scolozzi et al The Journal of Craniofacial Surgery &Volume 20, Number 4, July 2009
2*2009 Mutaz B. Habal, MD
Copyright @ 2009 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
Computer Image Analysis
Digital Imaging and Communications in Medicine data were
processed using OsiriX Medical Image software (Version 3.3.2;
www.osirix-viewer.com) running on an iMac computer (Apple
Computer, Inc., Cupertino, CA; www.apple.com).
23
The details of the technique used for volume segmentation
and calculation in the present series have been described previously
by Scolozzi and Jaques.
24
Preoperative and postoperative computed orbital volume mea-
surements were performed on both orbits, and the volume of the
contralateral uninjured orbit was used as a control for comparison.
Surgical Technique
All of the operations were performed under general anes-
thesia. Upon admission, all patients were placed on parenteral anti-
biotics (either 1 g of amoxicillin 3 times a day or 1.2 g of amoxicillin
and clavulonic acid 3 times a day intravenously), which were main-
tained for 3 days postoperatively.
The floor fractures were exposed by a standard transconjunc-
tival approach, whereas a combined transcaruncular transconjuncti-
val approach was used in patients with medial wall fractures. The
fracture site was circumferentially exposed after repositioning of the
incarcerated periorbital tissues. A large or small three-dimensionally
preformed MatrixORBITAL (0.4 mm in thickness; Synthes,
Oberdorf, Switzerland; Fig. 1)
25
was selected according to the size
of the defect previously measured on the preoperative CT scan
examination. In a few cases, the size and the contour of the meshes
were revised to match the patient’s anatomy perfectly. The medial
wall portion of the plate was inserted first, then the remainder the
plate was turned until the implant was in the correct anatomic
position, with the lateral edge along the inferior orbital fissure. The
mesh plate was finally fixed at the inferior orbital rim with 1 or 2
monocortical holes (length, 6 mm; diameter, 1.3 mm) inserted
through selected screw holes in the plate. A forced duction test was
completed to ensure the complete release of the periorbital tissues
and unrestricted lateral and medial movement of the globe. The
periorbita was sutured to the periosteum over the inferior orbital rim
using uninterrupted 5-0 Vicryl sutures. The inferior conjunctiva and
the caruncle were closed with a running 6-0 Maxon suture.
Statistical Analysis
A paired Student’s t-test was used to compare orbital volume
differences between the reconstructed and uninjured side. Statistical
analysis was performed using SPSS software (Windows, version
12.0; SPSS, Inc., Chicago, IL). PG0.05 was accepted to confirm
statistical significance.
RESULTS
This study included 10 patients, 7 (70%) with an isolated
orbital floor fracture, 2 (20%) with a combined orbital floor and
medial wall fracture, and 1 (10%) with an isolated medial wall frac-
ture. There were 2 women and 8 men (7 Caucasians and 3 Africans),
TABLE 2. Volumetric Data of the Reconstructed and Uninjured Sides
Patient No. Sex Age, y Fracture Location
Orbital Volume, cm
3
Volume
Difference*
Reconstructed Side Uninjured Side cm
3
%
1 F 71 Left orbital floor 21.01 21.18 j0.17 j0.8
2 M 37 Right medial orbital wall + orbital floor 27.51 25.01 2.5 10
3 F 69 Right orbital floor 22.66 24.85 j2.19 j8
4 M 19 Left medial orbital wall + orbital floor 21.55 22.27 j0.72 j3
5 M 53 Left orbital floor 14.80 15.46 j0.66 j4.3
6 M 29 Left orbital floor 22.38 22.44 j0.06 j0.3
7 M 70 Left orbital floor 23.44 25.33 j1.89 j7
8 M 26 Right medial orbital wall + orbital floor 19.32 18.73 0.59 3
9 M 21 Right orbital floor 23.37 21.20 2.17 10
10 M 20 Right orbital floor 21.87 20.63 1.24 6
*Negative and positive values indicate a reconstructed orbit respectively smaller or larger than the contralateral.
Fig 2 4/C
FIGURE 2. Patient 1: a 53-year-old man with a left orbital wall blow-out fracture. Preoperative documentation: coronal (A),
sagittal (B), and three-dimensional (C), CT scan view showing the orbital defect (outlined in red).
The Journal of Craniofacial Surgery &Volume 20, Number 4, July 2009 Ti Mesh Plates in Orbital Reconstruction
*2009 Mutaz B. Habal, MD 3
Copyright @ 2009 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
and their ages ranged from 19 to 71 years (mean age, 41.5 y). The
time of follow-up ranged from 6 weeks to 9 months. A combined
transcaruncular/transconjunctival approach was used in 3 patients
(30%) with medial wall fracture. Isolated floor fractures in 7 patients
(70%) were treated via a standard transconjunctival approach. Or-
bital floor mesh plates were fixed with one or two 1.3 AO screws.
There were no intraoperative complications. Two patients developed
transitory postoperative diplopia. One patient rapidly presented a
handicapping upward diplopia with a vertical motility limitation in
the operated eye after surgery. The mesh plate was removed 6 weeks
after its placement, without having caused any complication. No
periorbital tissue entrapment was identified during surgery, and the
patient progressively recovered from diplopia within a few weeks.
None of the patients developed enophthalmos by Hertel exophthal-
mometry (Table 1). In all of the patients, postoperative orbital CT
scan showed an anatomic three-dimensional placement of the orbital
mesh plates, and volume data of the reconstructed orbit fitted that of
the contralateral uninjured orbit with an accuracy to within 2.19 cm
3
(ranged from j2.19 to 2.5 cm
3
; Table 2; Figs. 2Y5).
These values correspond to the difference in volume between
the reconstructed orbit versus the contralateral uninjured orbit.
Negative and positivevalues indicate a reconstructed orbit smaller or
larger, respectively, than the contralateral orbit.
There was no statistically significant difference (P90.05) in
mean orbital volume between the reconstructed (21.690 cm
3
) and
the contralateral uninjured side (21.600 cm
3
; Table 3).
DISCUSSION
Primary restoration of preinjury normal three-dimensional
(horizontal, vertical, and transverse) bone contouring is the
fundamental prerequisite for complete orbital cosmetic and func-
tional recovery and integrity.
1Y9,18,19,24
This is of paramount impor-
tance, especially for large defects or defects involving more than
one orbital wall, which continues to be a difficult and challenging
procedure in most patients.
1Y9,18,19,24
Although autogenous bone
is still considered the criterion standard by many craniofacial
surgeons, literature abounds with reports describing the use of a
myriad of bone substitutes and different reconstructive orbital
techniques.
1Y9,18,19,24
The advantages and disadvantages of every
reported material have been well documented in the literature, but
the optimal and consensual material for orbital reconstruction still
remains controversial and a source of debate.
1Y9,18,19,24
During
the past 20 years, the use of titanium meshes has become in-
creasingly popular in orbital reconstruction with encouraging
results. Initially used to improve the stability of bone grafts, titanium
meshes have rapidly proven to be more accurate than bone grafts in
posttraumatic orbital volume reconstructions, especially in the
posteromedial region, as described in several studies. Titanium mesh
design has also evolved into more specific and adapted shapes,
which have greatly facilitated their manipulation and insertion
within the complex and tortuous three-dimensional orbital
anatomy.
1Y9,18,19,24
Thus far, mainly 2 techniques have been de-
scribed to reconstruct orbital defects using titanium mesh plates. The
first technique is to use mesh plates, which are trimmed and molded
intraoperatively to contour the conical shape of the orbits.
1Y3
The
success with this approach is highly dependent on both the surgeon’s
capacity and ability to visualize the geometry of the bony defect
spatially and to tailor meshes so that they fit the defect as precisely
as possible and on the design of the plate. The radial or the more
recently introduced AO funnel-shaped orbital titanium meshes re-
present the better available configurations for recreating an ana-
tomically correct orbital architecture with adequate volume.
4,5,24
The following advantages associated with the use of titanium
mesh plates in craniofacial reconstruction over bone grafts have
been well documented: flexibility (allowing conformation and
molding even to a complex bone contour), a modulus (degree of
elasticity or stiffness) adapted to match that of cortical bone easily,
Fig 3 4/C
FIGURE 3. Postoperative documentation: coronal (A), sagittal (B), and three-dimensional (C), CT scans showing the anatomic
positioning of the mesh plate. Note the restoration of the anatomic retrobulbar slope (arrow).
Fig 4 4/C
FIGURE 4. Patient 2: a 19-year-old man with a left combined orbital floor and medial wall blow-out fracture. Preoperative
documentation: coronal (A), sagittal (B), and three-dimensional (C), CT scans view showing the orbital defect (outlined in red).
Scolozzi et al The Journal of Craniofacial Surgery &Volume 20, Number 4, July 2009
4*2009 Mutaz B. Habal, MD
Copyright @ 2009 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
three-dimensional rigidity and stability, no donor site morbidity,
and little risk of infection even when exposed to the paranasal
sinuses.
2,3,18,19,24
Moreover, titanium offers biological as well as
mechanical properties that make it probably the best material
available in the craniomaxillofacial area. It definitely eliminates the
main concern associated with the use of autogenous bone grafts,
which is the unpredictable degree of bone resorption.
2,3,18,19,24
Bone
graft resorption is often the reason a second surgery is needed.
However, the drawback of titanium, as well as for all alloplastic
materials, is related to the potential of postoperative infection and
risk of extrusion.
2,3,18,19,24
The AO funnel-shaped orbital titanium
meshes have been specifically developed for improving the fit of
the normal orbital shape and conical contour. Since their introduc-
tion to the medical market in Switzerland in 2003, they have been
used routinely in our department with good results.
24
In a preli-
minary study of 12 patients, we found that posttraumatic orbital
wall reconstruction using free hand bending and placement of these
mesh plates resulted in a high success rate in reestablishing preinjury
bony volume closely approximating that of the contralateral
uninjured orbit.
24
The second technique is to use individual preformed titanium
mesh plates. First described by Metzger et al,
7Y9
the procedure for
individual preforming of titanium mesh plates for orbital repair has
the great advantage of preoperatively tailoring the plates to the exact
size and shape of the orbital defect. They reported on the clinical use
of individually preformed titanium meshes by using computer-
assisted preoperative planning. The meshes were preformed on
individual orbital cavities produced by stereolithography and then
placed by navigation-guided procedures. The disadvantages include
the high cost of the technical infrastructure needed (software, hard-
ware, and navigation system), an extensive preoperative planning
process, which makes this technique far from being useful routinely,
and the impossibility of obtaining an accurate replica of all the thin
orbital walls with the current stereolithographic techniques. How-
ever, such an approach undoubtedly contributes to a more precise
reconstruction of extensive orbital defects, thus improving the
chances of avoiding the development of a secondary enophthalmos.
Although the authors have commented that the intraoperative time is
probably reduced compared with the free hand techniques, they
have not provided the mean duration of the surgeries or compared
the 2 techniques. The approach that we have reported using the
first available industrially preformed titanium mesh plates represents
a third option, which is a balanced compromise between the 2
previously reported techniques. These plates have been designed
from CT scan data of the general population, thus approximating
the mean topographical anatomy of the human orbital and medial
wall. The main advantage of this approach over the conventional
nonpreformed orbital mesh plates is that these meshes are three-
dimensionally preformed with the posterior retrobulbar bulge
already designed, which seems to play a crucial role in supporting
and projecting the ocular globe, thus providing a better chance to
prevent postoperative enophthalmos. Moreover, these plates also
minimize the need for major intraoperative manipulations, such as
bending, trimming, and repetitive fittings of the modified plates,
which could considerably increase the operative time and possibly
damage the periorbital soft tissues. The advantages over the computer
navigationYassisted procedure include bending and placement without
requiring highly sophisticated and expensive technical support, no
preoperative technical procedures, shortening of intraoperative time,
and finally cost-effectiveness. A fourth option is the fabrication of
computer-designed custom-made alloplastic implants. These so-called
patient-specific implants have already revolutionized the concep-
tualization and approach to complex cranioplasties.
26Y28
The main
advantage is that the implants are preoperatively tailored to
measure to the exact size of the bony defect, based on individual
three-dimensional computer-based models. Thus, the operative time
and the number of intraoperative modifications are reduced guaran-
teeing postoperative stability and incomparable cosmetic and func-
tional results. It is not yet possible to reproduce the precise limits of the
orbital wall fractures accurately, however, because the thinness of the
orbital floor and the medial wall bone (G1 mm) is beyond the resolution
limit of current three-dimensional CT scanning techniques. Therefore,
such implantsare not yet realizable. The present resultshave confirmed
that orbital reconstruction using the AO three-dimensionally pre-
formed titanium orbital mesh plates results in accurate volume resto-
ration that is not statistically different from the volume of the uninjured
side, when accounting for intraindividual volume differences. In fact,
the volume difference between the 2 orbits revealed in our study was in
accordance with the values found in previous reports on bony orbit
volume as measured by CT scan in healthy persons.
This pilot study has demonstrated that the use of industrially
three-dimensional preformed AO orbital mesh plates has the poten-
tial for accurate posttraumatic orbital wall reconstruction with a high
rate of success. This report, although encouraging, should be inter-
preted cautiously given the limited number of patients. Also, no
definitive conclusions should be drawn until the end of the ongoing
prospective study.
Fig 5 4/C
FIGURE 5. Coronal (A), sagittal (B), and three-dimensional (C), CT scans showing the anatomic positioning of the mesh plate.
TABLE 3. Reconstructed Versus Uninjured Orbital Volume
Analysis
Group N Mean (SD) P
Reconstructed orbit, cm
3
10 21.791 (3.491) 0.873*
Uninjured orbit, cm
3
10 21.710 (2.961)
*No statistically significant differences (P90.05).
The Journal of Craniofacial Surgery &Volume 20, Number 4, July 2009 Ti Mesh Plates in Orbital Reconstruction
*2009 Mutaz B. Habal, MD 5
Copyright @ 2009 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
ACKNOWLEDGMENTS
The authors thank Stephane Mu¨ller and Carolyn Schaub
(Synthes, Oberdorf, Switzerland) for their valuable collaboration.
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Scolozzi et al The Journal of Craniofacial Surgery &Volume 20, Number 4, July 2009
6*2009 Mutaz B. Habal, MD
