Download Use of Demineralized Bone Sheets in Reconstruction of Orbital Floor Trap... Fracture

Journal of Applied Sciences Research, 6(6): 653-658, 2010
© 2010 INSInet Publication
Use of Demineralized Bone Sheets in Reconstruction of Orbital Floor Trap Door
Fracture
1
Maha M.Sallam, 2 Hesham A. Hashem and 3 Hanan.M.R Shokier
1
Ass.Prof. Oral and Maxillofacial Unit, Research Institute of Ophthalmology, Ministry of Scientific
Research, Cairo, Egypt.
2
Ass.Prof. of ophthalmology, Research Institute of Ophthalmology, Ministry of Scientific Research,
Cairo, Egypt.
3
Lecturer of Oral and Maxillofacial Department, Faculty of Oral and Dental Medicine, Azhar
University
Abstract: In this study medical history and computed tomography (CT) scans of 12 patients with pure
orbital floor trap door fracture were recorded. The age range was 13-30 years. They were all from the
out patients of the Research Institute of Ophthalmology, Cairo – Egypt.All patients were investigated and
recorded. Among the cases 10 patients were recently truamatized and suffering from soft tissue (inferior
rectus muscle) entrapment and only 2 patients were delayed and suffering from fibrous tissue ingrowths
at the fracture site.Limitation of ocular motility was graded on a numerical scale of 0 to -4, with 0
representing no limitation and -4 representing no movement in the field of gaze. Surgery was determined
mainly on the basis of clinical evidence of muscle entrapment and CT confirmation of trapdoor fracture.
Surgical repair was performed through transconjunctival incision under general anesthesia.After dissecting
in the preseptal plane to the inferior orbital rim and elevating the periosteum off the floor, the entrapped
tissue was gently freed from fracture site.In delayed cases with fibrous tissue formation, dissection and
removal of the fibrous tissue was done. Forced duction test was repeated at this point to confirm if tissue
entrapment was released completely. Demineralized bone sheet was damped in normal saline for ten
minutes and formed to be adapted and positioned to the fracture site. Postoperatively the patients were
treated with systemic antibiotics and anti-inflammatory drugs for 1 week.Postoperative follow up, with
clinical examination, after one and two weeks, then after one, two and three months was done, then CT.
Coronal scan three months postoperative. Results: Clinical examination of the patients after one week
revealed mild edema and periorbital ecchymosis of the eye lids, slight subconjunctival hemorrhage. Full
rang motility with slight restriction in upward gaze of the eye was encountered and slight diplopia remains
in all patients. Two weeks later clinical examination revealed resolution of edema,ecchymosis and the
subconjunctival hemorrhage.Diplopia was relieved in the first ten patients, who were immediately presented
to the hospital and operated as soon as possible, however, it remains only in the two delayed cases.One
month later diplopia was relieved in all patients and there was no any other complication throughout the
follow up period.Radiographic examination using CT coronal scan revealed intact orbital floor without any
herneiation in all cases). Conclusions:-Early surgical repair within 7 days or 14days of injury resulted in
more rapid improvement of ocular motility and diplopia. Meticulous freeing of the entrapped tissue,taking
care of the infraorbital neurovascular bundle, positioning appropriate implant material as Demineralized
human bone sheets and shortening the operation time could prevent any complication and relieves motility
restriction and diplopia. This form of the material is very thin to reconstruct the thickness of the orbital
floor when enophthalmos exists and weak to support the ocular tissue when the gap exceeds one mm.
Key words: Orbital Floor trap door fracture, transconjuctival incision, diplopia,CT coronal scan.
Rehabilitation of the patient requires an understanding
of the alteration in form and function of the orbit,
including the intra- orbital and intraocular tissues, and
the different materials available for repair [1 ] .
The indications for surgery in orbital floor
INTRODUCTION
Trauma to the orbital region can result in facial
deformity with affection of vision, eye movement, and
the sensory and motor innervations of the face.
Corresponding Author: Maha M.Sallam, Ass.Prof. Oral and Maxillofacial Unit, Research Institute of Ophthalmology,
Ministry of Scientific Research, Cairo, Egypt.
653
J. Appl. Sci. Res., 6(6): 653-658, 2010
fractures are controversial. Strong indications include
enophthalmos greater than 2mm,significant hypoglobus,
diplopia, herniation of orbital tissue and entrapment of
the extraocular muscles (inferior rectus muscle) or their
fascia into a fracture gap in the orbital floor causing
motility limitation [2 ] . De Man and coworkers have
suggested that young patients with severely restricted
eyeball motility, an unequivocally positive forced
duction test, and CT findings indicating a blow-out
fracture of the orbital floor should undergo operation as
soon as possible after injury, whereas a wait and see
policy, keeping the patient under observation, seems to
be appropriate for blow-out fractures in adults [3 ].
Several materials are available for reconstruction of
orbital floor, and there is no consensus about which is
preferable; however, there is consensus that the ideal
material should be biocompatible,and strong enough to
support the orbital content[4 ] . Autogenous bone were
am o ng the first materials used ,,calvarial,iliac
c rest,m a nd ib le ,m a xilla a nd rib have been
used [5 ,6 ,7 ,8 ,9 ,1 0 ,1 1 ] . Currently,calvarial bone seems to be the
best choice for orbital reconstruction [1 2 ,1 3 ]. Many other
materials used as cartilage,dermis,dura mater, fascia
–autogenous, allogenic and xenogenic grafts [1 4 ,1 5 ,1 6 ,1 7 ].
Alloplasts were also used either in,resorbable form [1 8 ]
as biodegradable polymers and nonresorbable form as
titanium, silicon, hydroxyapatite and bioactive
glass[1 9 ,2 0 ,2 1 ] . All these materials have advantages and
disadvantages [2 2 ,2 3 ,2 4 ] . Demineralized bone matrix
(DBM), a form of allograft, possesses the properties of
osteoinductivity and osteoconductivity. A large body of
data obtained from extensive preclinical studies has
clearly supported the utility of DBM in human clinical
settings. However, it is now recognized that various
DBM configurations may differ considerably with
regard to their bone inductive activity [2 5 ] . Demineralized
bone sheet was used to bridge a large circumferential
osteoperiosteal gap in the diaphysis of the ulna of
rabbits,the animals revealed bone formation and
complete bridging of the gap. The new bone was laid
on the surface and in the substance of the matrix,
suggesting that the inductive principle was acting
locally. Demineralized bone-matrix proved to be a
highly osteoinductive and readily osteoconductive
material. The graft did not evoke any appreciable local
foreign-body or immunogenic reaction. The high degree
of success in bridging massive bone defects justifies
further serious studies and hopes for a useful substitute
for massive autologous bone grafts[2 6 ,2 7 ] . The aim of our
study was to evaluate the role of Demineralized bone
sheets, as a reconstructive material, for orbital floor
trap door fracture.
scans for 12 patients with pure orbital floor trap door
fracture were recorded (Fig.3).patients age range was
13-30 years(table 1). They were all from the out
patients of the Research Institute of Ophthalmology,
Cairo – Egypt.
The cause of injury, clinical signs and symptoms,
radiologic finding, associated ocular injury and the time
interval between injury and presentation to the institute
was recorded. Among the 12 cases, 10 patients were
recently traumatized (since 2- 3 days) (Fig.1) and only
2 patients were old cases (since 6 and 12 months) (fig
7). The main complain of all cases was restriction in
the ocular motility, mainly the upward gaze and
diplopia with absence of any other sign and symptoms.
Limitation of ocular motility was graded on a
numerical scale of 0 to -4, with 0 representing no
limitation and -4 representing no movement in the field
of gaze[2 8 ] . Severe limitation of ocular motility was
defined as -3 or -4.
Fig. 1: Preoperative photo showing motility restriction
of the left eye
Fig. 2: Forced duction test during the operation.
W hen patients were admitted to the hospital,
surgery was scheduled as soon as possible (within 3-4
days). Surgery was determined mainly on the basis of
clinical evidence of muscle entrapment and CT
confirmation of trapdoor fracture. Surgical repair was
performed under general anesthesia; forced duction test
was performed at fist before the incision. Then
transconjunctival incision was performed, followed by
dissection in the preseptal plane to the inferior orbital
rim and elevating the periosteum of the floor. The
M ATERIALS AND M ETHOD
Medical history and computed tomography (CT)
654
J. Appl. Sci. Res., 6(6): 653-658, 2010
Fig. 3: Preoperative CT. Coronal cut showing muscle
entrapment in the orbital floor fracture line.
Fig. 6: Postoperative photo showing free movement in
the upward gaze.
Fig. 4: Postoperative CT. of the same case9sagittal
view
Fig. 7: Preoperative photo showing motility restriction
of the right eye in the upward gaze.
Fig. 8: Postoperative photo showing free movement of
the right eye.
Fig. 5: Postoperative CT. of the same case coronal cut.
traumatized cases, dissection and removal of the fibrous
tissue was done. Forced duction test was repeated at
this point to confirm the release of tissue entrapment
and fibrous union. (Fig.2). Demineralized bone sheet
(Pacific Cost Tissue Bank.size 15X 40mm. Thickness
100-300 micron)* was damped in normal saline for
entrapped tissue was gently freed from fracture site in
the recently traumatized cases. W hile in the delayed
cases fibrous tissue formation was prominent at the
trap door fracture site in comparison to the recently
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J. Appl. Sci. Res., 6(6): 653-658, 2010
Discussion: Before puberty trapdoor fracture is
predominant, and risk of muscle or soft tissue
entrapment is higher[2 8 ] . It is postulated that at this age,
a large area of the orbital floor consists of immature
bone that overlies a small maxillary sinus. Because of
this greater elasticity of the orbital bone,when it is
subjected to force,it is more likely to bend and break
in a linear pattern along the obliquely situated
infraorbital canal resulting in trapdoor type fracture.The
antromedial floor then goes inferiorly to the
postrerolateral floor.As the orbital rim moves back into
its natural position, the prolapsed orbital tissue is
caught and trapped in the fracture site.The most
common symptom associated with trapdoor fracture is
restriction of ocular motility.Supraduction limitation is
more severe in patients with trapdoor fractures than in
those without trapdoor fractures [2 9 ] . Nausea and
vomiting are other important symptoms. Nausea and
vomiting coupled with severe restriction of ocular
motility suggests the increased possibility of the
trapdoor fracture in pediatric patients, and are promptly
relieved after surgery[2 9 ] . Indications for surgery are
clinical evidence of muscle entrapment and CT
confirmation. However, if there is no clinical evidence
of muscle entrapment, existence of the trapdoor fracture
is not an indication for surgery. In this study, ten
patients, who presented immediately to the hospital and
had trapdoor fracture with soft tissue and muscle
entrapment with severe gaze limitation, undergo
surgical intervention as soon as possible. In those
patients, gaze limitation and diplopia was resolved
early than in the other two patients who presented 6-12
months after trauma, as fibrous tissue ingrowths at the
fracture site appeared to be the main reason for the
gaze limitation. This delay could be attributed to the
time in which the long term entrapped muscle needs
for rehabilitation after being free.
In trapdoor fracture, entrapment of muscle or soft
tissue induces not only limitation of ocular motility but
also ischemia of the extraocular muscle by impaired
blood supply and results in subsequent loss of muscle
function and permanent gaze restriction, therefore,
earlier surgical intervention should be considered [2 8 ,29 ] .
Demineralized human bone(DHB) sheets, were
selected for covering the trap door fracture as it is
biocompatible, resorbable sheets that is available in
sufficient quantities.It was also proved that DHB in all
its forms are an osteoinductive and osteoconductive
material in agreement with Drosos. GL et al. and Tuli
SM et al[2 5 ,26 ] , Moreover, they provide a source of type
1 collagen which is the sole organic component of
bone in agreement with Hoexter DL [3 0] . In addition to
that the demineralization process may expose a
particular protein b o ne m o rp ho ge nic p ro tein
(BMP),which is known for its osteoinductive properties
Fig. 9: Postoperative CT. Coronal cut of the same
case.
ten minutes and formed to be adapted and positioned
to the fracture site without any fixation,only the eye
content rest over the bone sheet helps in its fixation.
Then the wound was closed and the patients were
treated with systemic antibiotics and anti-inflammatory
drugs for 1 week postoperatively.
Postoperative follow up, for one and two weeks,
then at one, two and three months postoperatively.
Using the clinical evaluation of upward eye movement
according to the previously mentioned scale.
Three months postoperative. CT. Scan (Coronal
cut) for all cases was done.
Results:
One W eek Postoperatively: Clinical examination of
the patients revealed mild edema and periorbital
ecchymosis of the eye lids, slight subconjunctival
hemorrhage.
Full range motility with slight restriction in upward
gaze of the eye was encountered and slight diplopia
remains in all patients.
Two W eeks Postoperatively: Clinical examination
revealed resolution of edema,ecchymosis and the
subconjunctival hemorrhage. D iplopia and eye
movement restriction was relieved in the first ten
patients who were immediately presented to the
hospital and operated as soon as possible; however, it
remains only in the two delayed cases.
One M onth Postoperatively: Diplopia and limitation
in eye movement was relieved in all patients and there
was not any other complication throughout the follow
up period.
Radiographic Examination Using CT Scan: Coronal
cut revealed intact orbital floor without any herneiation
in all cases (Fig.4, 5, 9)
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J. Appl. Sci. Res., 6(6): 653-658, 2010
as it was proved by Schwartz Z. et al.[3 1 ] . So it
accelerates bone formation at the site of the trapdoor
fracture, prevents any fibrous tissue ingrowths through
the orbital floor from the underlying structures and
interferes with any adhesions that may restrict the eye
movement during healing.
6.
7.
Conclusions:
Early surgical repair within 7 days or 14days of
injury resulted in more rapid improvement of
ocular motility and diplopia..
Meticulous freeing of the entrapped tissue,taking
c a r e o f t h e in fr a o r b ita l n e u r o v a s c u l a r e
bundle,positioning appropriate implant material as
Demineralized human bone sheets and shortening
the operation time could prevent any complication
and relieves motility restriction and diplopia.
This form of the material is very thin to
reconstruct the thickness of the orbital floor when
enophthalmos exists and weak to support the
ocular tissue when the gap exceeds one mm.
Case no
1
2
3
4
5
6
7
8
9
10
11
12
Age
13
16
16
17
14
19
19
17
13
15
29
30
Sex
M ale
-
M .R.
-3
-2
-3
-3
-3
-2
-2
-3
-3
-2
-3
-2
Im m
*
*
*
*
*
*
*
*
*
*
8.
9.
10.
11.
D elayed
12.
13.
14.
*
*
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