Titanium Mesh versus Medpor Implant in Orbital Floor Reconstructions: A Comparative Study.

BACKGROUND: Treating orbital injuries is interesting and difficult in the facial trauma. The balance in facial proportions and also the facial esthetics are required to achieve an anatomical harmony.
OBJECTIVE: To compare the functional results of individual reconstruction of orbital floor using either titanium mesh or Medpor in terms of various factors.
MATERIALS AND METHODS: There were two study groups including eight subjects with orbital floor fracture, namely A (Medpor) and B (titanium mesh). Various parameters were analyzed postoperatively at intervals of 1 week, 3 week, 6th week, and 3 months after the surgery. STATISTICAL ANALYSIS: Comparison of the different time points with respect to pain scores in the two study groups by Wilcoxon matched pairs test was done. P value was significant in the study Group A with P = 0.0431* and was insignificant in the study Group B with P = 0.1088.
RESULTS: All three cases of titanium mesh in orbital floor reconstruction had signs of infection, tenderness, and radiographic proof after 1 week in two subjects and 3 weeks in one patient. Pain was seen in all eight patients 1 week postoperatively.
CONCLUSION: Although orbital reconstruction is a technique sensitive procedure both Medpore and Titanium mesh functions. Copyright:

INTRODUCTION

Orbital wall fractures are common in facial trauma with a prevalence of around 3%–32%.[1] Due to its complex anatomic structure, we are sometimes unable to visualize minor anatomical details. Etiologic factors are traffic accident, assault, fall, and sports.[1] Such defects cause functional impairment and require reconstruction.[2] To manage the orbital injuries is a difficult task in the facial trauma.[3] Injuries of the face can range from the indistinct blowout fracture following the low velocity trauma, simple blunt, or to the highly complex comminuted orbital fractures, which results from the motor vehicle accidents and the projectiles and thereby these injuries commonly result in destruction of the integrity of orbital skeleton.[4] Such orbital trauma and surrounding facial fractures often result in orbital deformity as well as the incapacitating visual dysfunction.[5] The orbital fracture may lead to the limitation of orbital movement, diplopia, anesthesia or paresthesia, and enophthalmos.[6] The present study aims to evaluate and also compare the titanium mesh and Medpor implant in the orbital floor reconstructions in terms of pain, swelling, enophthalmos, diplopia, subconjunctival hemorrhage, infraorbital paresthesia, graft failure, and infection.

MATERIALS AND METHODS

The study group included eight subjects with the orbital wall fracture. Each subject has been explained about the procedure to be performed, followed by written informed consent. A detailed case history with particular regard toward the medical history was recorded in a prepared case history proforma. Evaluation methods were visual analog scale, swelling, subconjunctival hemorrhage, diplopia, clinical enophthalmos (Luedde exophthalmometer), infraorbital paresthesia, implant/autograft failure, and infection. Follow-up was done at 1st, 3rd, and 6th week and 3 months after surgery. The inclusion criteria in the present study were subjects with orbital trauma defects, imaging (pre- and post-operative radiographs), and subjects who are medically fit for general anesthesia, whereas the exclusion criteria were subjects with systemic disease contraindicated for general anesthesia, subjects not willing for surgery, and the areas where strength of the graft was not required. The surgical technique for the orbital floor was as follows: the subject was anesthetized using the nasotracheal intubation and an incision for an infraorbital approach. Before infiltration of a vasoconstrictor, the incision line was marked. About 4–6 mm subcutaneous dissection was done toward the inferior orbital rim. For the retraction of the lower lid, tarsorrhaphy suture was used. The fracture site was exposed and the debris was removed. Depending on the extent and site of the defect, titanium mesh and Medpor were placed as per requirement in subperiosteal plane and rigid fixation was done. Nonabsorbable sutures were used in subcuticular motion [Figures 1 and 2]. The subjects were given with the IV antibiotics for 5 days and followed by the oral for another 5 days. Thorough medicated irrigation was done twice daily for the postoperative period of about 5 days. The subjects were evaluated both intraoperatively and at the intervals of 1st, 3rd, and 6th week and 3 months after surgery.

Figure 1

Pre-, intra-, and postoperative pictures of the orbital reconstruction with titanium mesh

Figure 2

Pre-, intra-, and postoperative pictures of the orbital reconstruction with Medpor

RESULTS

The clinical as well as radiographic investigations with three-dimensional sections of paranasal sinus view along with the waters view or occipitomental view showed herniation of orbital fat. Thereby, all the eight subjects were planned for open reduction and internal fixation (ORIF) and reconstruction with the titanium mesh (3 subjects) and Medpor (5 subjects) for the orbital floor defects. All the subjects were followed up for 3 months for pain, swelling, subconjunctival hemorrhage, enophthalmos, infraorbital paresthesia, diplopia, infection, and extrusion of graft. Out of 3 cases of titanium mesh in orbital floor reconstruction all three cases had infection and tenderness. In all the eight subjects, pain was seen 1 week postoperatively. The comparison of different time points with respect to pain scores in the two study Groups A (Medpor) and B (titanium mesh) by Wilcoxon matched pairs test was done. The P value was significant in the study Group A with P = 0.0431* and was insignificant in the study Group B with P = 0.1088. A (*P < 0.05) [Table 1]. The comparison of different time points with respect to enophthalmos scores in the two study Groups A (Medpor) with 5 cases and B (titanium mesh) with 3 cases was done by Wilcoxon matched pairs test. The P value was significant in the study Group A with P = 0.0431* and was insignificant in the study Group B with P = 0.1088. A (*P < 0.05) [Table 1]. Swelling was present 1 week postoperatively in four patients out of five subjects in Group A and 2 subjects out of three subjects in Group B. Swelling was absent in both the groups at 3 weeks, 6 weeks, and 3 months postoperatively. Subconjunctival hemorrhage was present 1 week postoperatively in four out of five subjects in Group A and 3 out of three subjects in Group B. Swelling was absent in both the groups at 3 weeks, 6 weeks, and 3 months. Diplopia was present 1 week postoperatively in three subjects in Group A out of five subjects and none of the three subjects showed signs of diplopia in Group B. Diplopia was absent in both the groups at 3 weeks, 6 weeks, and 3 months postoperatively. Infraorbital paresthesia was present 1 week postoperatively in two subjects out of five subjects in Group A and one subject out of three subjects in Group B. Infraorbital paresthesia was absent in both the groups at 3 weeks, 6 weeks, and 3 months. Infection was present for all in Group B and 1 week postoperatively in two subjects and 6 weeks postoperatively in 1 subject in Group B. None of the subjects in Group A showed any signs of infection at 1 week, 3 weeks, 6 weeks, and 3 months postoperatively. None of the groups shown implant failure at different time points [Table 2].

Table 1

Comparison of different time points with respect to pain scores (i) and to enophthalmos (mm) (ii) in the two study groups (a and b) by Wilcoxon matched pairs test

Groups	Time points	Mean (I)	SD (I)	P (I)	Mean (II)	SD (II)	P (II)
Group A	1 week	2.40	0.55	2.48	0.84
	3 weeks	0.00	0.00	0.0431*	2.22	0.90	0.0431*
	1 week	2.40	0.55	2.48	0.84
	6 weeks	0.00	0.00	0.0431*	2.16	0.96	0.0431*
	1 week	2.40	0.55	2.48	0.84
	3 months	0.00	0.00	0.0431*	2.02	1.11	0.0431*
Group B	1 week	2.67	0.58	0.93	0.47
	3 week	0.00	0.00	0.1088	0.73	0.40	0.1088
	1 week	2.67	0.58	0.93	0.47
	6 weeks	0.00	0.00	0.1088	0.53	0.42	0.1088
	1 week	2.67	0.58	0.93	0.47
	3 months	0.00	0.00	0.1088	0.33	0.40	0.1088

SD: Standard deviation, *P<0.05

Table 2

Comparison two groups (a and b) with respect to status of implant failure at different time points

Time point	Group A		Group B
	Present (%)	Absent (%)	Present (%)	Absent (%)
1 week	0 (0.00)	5 (100.00)	0 (0.00)	3 (100.00)
3 weeks	0 (0.00)	5 (100.00)	0 (0.00)	3 (100.00)
6 weeks	0 (0.00)	5 (100.00)	0 (0.00)	3 (100.00)
3 months	0 (0.00)	5 (100.00)	0 (0.00)	3 (100.00)
1 week	Mann–Whitney U, Z=0.0000, P=1.0000
3 weeks
6 weeks
3 months
Comparison between time points by McNemar Chi-square test
Between 1 week versus 3 week	P=1.0000		P=1.0000
Between 1 week versus 6 week	P=1.0000		P=1.0000

DISCUSSION

The facial trauma often includes the orbital fracture.[7] However, there is no consensus for most of the effective treatment.[8] Orbital fractures can also occur in high-velocity injuries such as traffic accidents or accidental falls.[910] Orbital floor fractures the most in such cases.[11] The fracture of orbital floor fractures may cause functional as well as the cosmetic problems such as diplopia, enophthalmos, and residual dystopia. Important is to regain function with synthetic implants or bone grafts.[12] There are various biomaterials for the reconstruction of the original bony contour as well as to restore the proper orbital volume. The autogenous, allogenic grafts, or alloplastic implants are used for the reconstruction. Furthermore, various grafts such as contralateral coronoid process and wall of the antrum have also been used.[13] Recently, in cases of orbital fracture, good results have been shown by the metallic implants, such as titanium. Titanium has good compatibility with the tissues. Titanium is visible in computed tomography and magnetic resonance imaging.[1314] It undergoes osseointegration on a molecular level without developing intervening fibrous tissue.[1314] Further studies are needed with larger sample size for a generalized statements.

CONCLUSION

Both Medpor and titanium mesh function are well for internal reconstruction with minimal complication for orbital floor fracture.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.