Outcomes of Orbital Floor Reconstruction After Extensive ...

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SURGICAL ONCOLOGY AND RECONSTRUCTION

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Outcomes of Orbital Floor ReconstructionAfter Extensive Maxillectomy Using theComputer-Assisted Fabricated Individual

Titanium Mesh Technique

eived

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*Reside

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Wen-Bo Zhang, MD,* Chi Mao, MD,y Xiao-Jing Liu, MD,z Chuan-Bin Guo, MD, PhD,xGuang-Yan Yu, MD, DDS,k and Xin Peng, MD, DDS{

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Purpose: Orbital floor defects after extensive maxillectomy can cause severe esthetic and functional de-formities. Orbital floor reconstruction using the computer-assisted fabricated individual titaniummesh tech-

nique is a promising method. This study evaluated the application and clinical outcomes of this technique.

Patients and Methods: This retrospective study included 10 patients with orbital floor defects after

maxillectomy performed from 2012 through 2014. A 3-dimensional individual stereo model based on

mirror images of the unaffected orbit was obtained to fabricate an anatomically adapted titanium mesh us-

ing computer-assisted design and manufacturing. The titanium mesh was inserted into the defect using

computer navigation. The postoperative globe projection and orbital volume were measured and the inci-

dence of postoperative complications was evaluated.

Results: The average postoperative globe projection was 15.91 � 1.80 mm on the affected side and

16.24 � 2.24 mm on the unaffected side (P = .505), and the average postoperative orbital volume was

26.01 � 1.28 and 25.57 � 1.89 mL, respectively (P = .312). The mean mesh depth was 25.11 �2.13 mm. The mean follow-up period was 23.4 � 7.7 months (12 to 34 months). Of the 10 patients, 9did not develop diplopia or a decrease in visual acuity and ocular motility. Titanium mesh exposure was

not observed in any patient. All patients were satisfied with their postoperative facial symmetry.

Conclusion: Orbital floor reconstruction after extensive maxillectomy with an individual titanium meshfabricated using computer-assisted techniques can preserve globe projection and orbital volume, resulting

in successful clinical outcomes.

� 2015 American Association of Oral and Maxillofacial Surgeons

J Oral Maxillofac Surg -:1.e1-1.e15, 2015

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Maxillary defects created after tumor ablation can

cause severe functional and esthetic deformities. The

orbit is located adjacent to the maxillary bone, and

the orbital floor often requires removal, if involved.Orbital floor defects also result in esthetic and func-

tional deformities, including enophthalmos, hypo-

from the Department of Oral and Maxillofacial Surgery,

iversity School and Hospital of Stomatology, Beijing,

nt.

sor.

ate Professor.

sor.

sor.

sor.

rkwas supported by grants from the Science and Technol-

ittee of Beijing, China (Z131107002213116) and the Na-

1.e1

FLA 5.2.0 DTD � YJOMS56896_proof �

phthalmos, diplopia, and impaired visual acuity. The

reconstruction of post-traumatic orbital defects has

been well documented in recent years.1-3 However,

the reconstruction of total orbital floor defects afterextensive maxillectomy remains a challenge

for surgeons.

tional Supporting Program for Science and Technology

(2014BAI04B06).

Address correspondence and reprint requests to Prof Peng:

Department of Oral and Maxillofacial Surgery, Peking University

School and Hospital of Stomatology, Beijing 100081, People’s Repub-

lic of China; e-mail: [email protected]

Received May 27 2015

Accepted June 24 2015

� 2015 American Association of Oral and Maxillofacial Surgeons

0278-2391/15/00906-4

http://dx.doi.org/10.1016/j.joms.2015.06.171

15 July 2015 � 4:05 pm � CE AH

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Delta:1_given name

Delta:1_surname

Delta:1_given name

Delta:1_surname

Delta:1_given name

Delta:1_surname

mailto:[email protected]

http://dx.doi.org/10.1016/j.joms.2015.06.171

3

1.e2 COMPUTER-ASSISTED ORBITAL FLOOR RECONSTRUCTION Q1

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Currently, various types ofmaterials, such as titanium

meshes, hydroxyapatite, silica gel, Teflon, and Medpor,

and autogenous bones, such as the iliac and cranial

bones and ribs, are used for orbital reconstruction.4-8

However, reports on the reconstruction of orbital

floor defects resulting from tumor resection are few.

Furthermore, the irregular contour of the orbit makes

it difficult to precisely rehabilitate orbital defects, andcomplications, such as diplopia, malpositioning of the

globe, restriction of ocular motility, and a decrease in

visual acuity, become inevitable in some cases.

Although the use of a titanium mesh, which is flexible

and can easily simulate the orbital bone structure, is

well accepted as the primary choice for orbital

fracture repair, there are no reports on its use for

orbital floor reconstruction after maxillarytumor resection.

Computer-assisted design and manufacturing tech-

niques combined with intraoperative navigation have

been widely used for various craniomaxillofacial sur-

geries.9-11 Preoperative designing and intraoperative

navigation can provide additional accuracy and safety

during orbital floor reconstruction, with improved

clinical outcomes. The aim of this study wasto evaluate the clinical procedure and outcomes

of orbital floor reconstruction after extensive

maxillectomy using the computer-assisted fabricated

individual titanium mesh technique.

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Patients and Methods

PATIENT DEMOGRAPHICS

This retrospective study included 10 consecutivepatients (5 men and 5 women; mean age, 42.1 yr;

Table 1. PATIENT CHARACTERISTICS (N = 10)

Patient

Number Gender

Age

(yr)

Affected

Side

Primary

Diagnosis

Reconstru

Optio

1 F 75 Right Adenocarcinoma ALT

2 M 71 Left Myoepithelial

carcinoma

ALT

3 F 10 Left Ameloblastoma ALT

4 M 51 Right Osteosarcoma FFF

5 F 18 Left Osteofibroma FFF

6 M 9 Left Osteosarcoma RAM

7 F 56 Left Adenoid cystic

carcinoma

ALT

8 M 31 Left Osteofibroma FFF

9 M 75 left Osteosarcoma ALT

10 F 25 Right Myxoma FFF

Abbreviations: ALTF, anterior lateral thigh flap; ANED, alivewithouttherapy; DOD, dead of disease; F, female; FFF, free fibula flap; GKR,rectus abdominis muscle flap.

Zhang et al. Computer-Assisted Orbital Floor Reconstruction. J Oral Max


age range, 9 to 75 yr) who underwent orbital floor

reconstruction using an individual titanium mesh

fabricated using computer-assisted techniques after

maxillectomy at the authors’ institution from April

2012 to March 2014. This study followed the Declara-

tion of Helsinki onmedical protocol andwas approved

by the institutional ethic committee and review board.

All patients were diagnosed with maxillary tumorsrequiring resection with extensive maxillectomy

including the orbital floor. The tumors were benign

in 4 patients and malignant in 6. None of the patients

presented with ocular symptoms, such as diplopia,

enophthalmos, impaired visual acuity, and restricted

globe movements. All orbital defects were limited to

the orbital floor. The primary maxillary defects were

restored with a free fibula flap (n = 4), an anteriorlateral thigh flap (n = 5), or a rectus abdominis muscle

flap (n = 1), and the orbital floor defects were recon-

structed with an individual titanium mesh fabricated

using computer-assisted techniques (Table 1).

VIRTUAL SURGICAL PLANNING

All patients underwent spiral computed tomo-

graphic (CT) scanning of the head and neck region

before surgery (field of view, 20 cm; pitch, 1.0; slice,0.75 mm; 120Y280 mA), Qand all imaging data were im-

ported to iPlan CMF (BrainLAB, AG, Feldkirchen, Ger-

many) and ProPlan CMF (Materalise, Leuven,

Belgium). Then, tumor resection and maxillectomy

were simulated on the computer. A 3-dimensional im-

age of the orbital floor was reconstructed from a

mirror image of the unaffected side (Fig 1), after which

a 3-dimensional resin stereo model was printed basedon the mirror image using rapid prototyping

ction

n Recurrence

Adjuvant

Treatment

Follow-Up

(mo) Outcome

F No None 34 ANED

F No None 30 ANED

F Yes Surgery 30 AWD

Yes Rad + chemo 12 DOD

No None 27 ANED

F No None 27 ANED

F Yes Rad + GKR 26 AWD

No None 18 ANED

F No None 16 ANED

No None 14 ANED

evidence of disease; AWD, alivewith disease; chemo, chemo-gamma knife radiosurgery; M, male; Rad, radiotherapy; RAMF,

illofac Surg 2015.

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FIGURE 1. Preoperative virtual planning. A, Maxillectomy was simulated on the computer. (Fig 1 continued on next page.)

Zhang et al. Computer-Assisted Orbital Floor Reconstruction. J Oral Maxillofac Surg 2015.

ZHANG ET AL 1.e3

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techniques. The model was used to pre-bend a tita-

nium mesh (0.6 or 0.4 mm; AO CMF, Synthes,

Switzerland) that would be used to rehabilitate the

contour of the orbital floor in each patient (Fig 2).

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SURGICAL PROCEDURE

Tumor resection and maxillectomy were performed

according to the virtual plan completely under the

guidance of a computerized navigation system (Brain-

LAB; Fig 3). The prefabricated titanium mesh was

trimmed and fitted to the orbital floor defect. The po-

sition and depth of the mesh were guided and

controlled by the navigation system (Fig 4). After con-firming the final position, the mesh was fixed to the

nasal bone and zygoma using 4- to 5-mm microscrews.

Extensive maxillary defects were reconstructed with

bony or soft tissue free flaps; the dead space under


the mesh was filled by the fat tissue or muscles present

on the flap. The surface of the mesh was completely

covered by the flap tissue.

OUTCOME EVALUATION

All patients were followed for at least 6 months.

Postoperative complications, such as diplopia, restric-

tion of ocular motility, a decrease in visual acuity, and

exposure of the titaniummesh, were evaluated by clin-

ical examination. Facial symmetry was self-evaluated

and scored by the patients, and the results were classi-

fied as satisfactory (8 to 10), fair (4 to 7), and poor (0 to

3). The postoperative globe projection and orbital vol-ume on the reconstructed and unaffected sides were

measured using iPlan CMF (BrainLAB) based on the

spiral CT images obtained 6 months after the primary

surgery. Globe projection was measured on an axial

15 July 2015 � 4:05 pm � CE AH

web4C=FPO

FIGURE1 (cont’d). B, The mirror image of the unaffected side was used to rehabilitate the contour of the orbital floor and facial symmetry.


1.e4 COMPUTER-ASSISTED ORBITAL FLOOR RECONSTRUCTION

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slice with the largest diameter of the eye globe. A base-line was drawn from the anterior point of the lateral

orbital rim to the median sagittal line, and the distance

from the most projecting point of the cornea to the

baseline was defined as the globe projection (Fig 5).

Orbital volumewasmeasured based on a series of axial

CT slices. The bony border between the optic nerve fo-

ramen and the connecting line between the zygomati-

cofrontal suture and the nasomaxillary suture wereoutlined, and the volume of the outlined area was

calculated as the orbital volume using a computer

(Fig 6). The depth of the titanium mesh also was

measured on a sagittal CT slice. The distance from

the orbital rim to the deepest point at the posterior

end of the titanium mesh was defined as the depth

of the titanium mesh (Fig 7).

Differences in globe projection and orbital volumebetween the unaffected and reconstructed sides

FLA 5.2.0 DTD � YJOMS56896_proof � 15 July 2015 � 4:05 pm � CE AH

were determined using paired sample t tests with SPSS17.0 (SPSS, Inc, Chicago, IL). A P value less than .05

was considered statistically significant.

Results

Themean follow-up durationwas 23.4� 7.7months

(range, 12 to 34months). During the follow-up period,

1 patient developed a local recurrence of adenoid

cystic carcinomawith invasion of the extraocular mus-

cles and extension to the intracranial area. Distant

metastasis to the lung also was detected. This recur-

rence resulted in postoperative diplopia and visualproblems. Salvage treatment was performed using

gamma knife radiosurgery, and the patient survived

with the tumor until the end of follow-up. Another pa-

tient who presented with recurrent osteosarcoma in

web4C=FPO

FIGURE 2. Fabricated individual titanium mesh. A 3-dimensional stereo model based on the mirror plan was printed using the rapid prototyp-ing technique to fabricate an individual titanium mesh to reconstruct the orbital floor of the affected side.


ZHANG ET AL 1.e5

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the inferior temporal fossa and received salvage che-

moradiotherapy died of the disease a year after the pri-

mary surgery, and a young patient with an

ameloblastoma who presented with local recurrence

in the infraorbital region 14 months after the primarysurgery underwent titaniummesh removal with tumor

resection in the secondary surgery. However, neither

of these 2 patients complained of specific complica-

tions, such as diplopia or a decrease in visual acuity

and ocular motility, before tumor recurrence (Table 2).

Thus, 9 of the 10 patients exhibited normal visual

acuity and ocular motility after orbital floor recon-

struction. There was no mesh rejection or exposurein any of the 10 patients (Table 2). Globe projection

was 15.91 � 1.80 mm on the reconstructed side and

16.24 � 2.24 mm on the unaffected side (P = .505).

The orbital volume was 26.01� 1.28 mL on the recon-

structed side and 25.27 � 1.89 mL on the unaffected

side (P = .312). The 2 parameters showed no statistical

differences between the reconstructed and unaffected

sides, consistent with the clinical findings of no post-operative diplopia or enophthalmos (Table 3). The

mean depth of the titanium mesh was 25.11 �2.13 mm, with no indication of damage to the optic

nerve. All patients were satisfied with their postopera-

tive facial symmetry (Fig 8, Table 2).


Discussion

Maxillary defects after trauma or tumor resection

can cause severe functional and esthetic disturbances.The orbital floor forms the roof of the maxilla and is

usually involved in extensive maxillectomy for midfa-

cial tumors. The orbital floor is a very important

bony structure in the midfacial region that is respon-

sible for supporting the eye globe, midfacial projec-

tion, and facial symmetry. Orbital floor defects also

result in various deformities and functional distur-

bances, such as diplopia, enophthalmos, restrictionof globe movement, a decrease in visual acuity, and

depression of the infraorbital region. The reconstruc-

tion of post-traumatic orbital defects has been well

documented in recent years.1-3 However, the

reconstruction of total orbital floor defects after

extensive maxillectomy remains a challenge

for surgeons.

Several materials and methods have been used for

orbital floor reconstruction, including autogenousbone grafts, alloplastic materials, and other manufac-

tured materials.4-8,12-14 Previous studies have

reported the use of nonvascularized autogenous

bones, such as the iliac bone, ribs, and calvaria, as

grafts for orbital floor reconstruction.15,16 However,

15 July 2015 � 4:05 pm � CE AH

web4C=FPO

FIGURE 3. Intraoperative navigation-guided tumor resection and maxillectomy. A, The intraoperative navigation system was used to controlthe accuracy of the surgery. B, The probe was used to detect the points on the bone. C, The navigation system showed the exact position of theosteotomy plane as the virtual plan before surgery.




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FIGURE4. Intraoperative navigation-guided titaniummesh placement. The titaniummeshwasA, trimmed and B, placed into the defect.C, Thenavigation provided the position and depth guidance. B, Afterward, the mesh was fixed to the nasal bone and zygoma.



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FIGURE5. Globe projection measurements. An axial slice with the largest diameter of the eye globe is obtained using spiral computed tomog-raphy. Then, a baseline is drawn from the anterior point of the lateral orbital rim to the median sagittal line. The distance from the most projectingpoint of the cornea to the baseline is defined as the globe projection.



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the rate of infection and resorption with these

materials is high. In addition, donor-site morbidity is

a potential disadvantage of these materials. The goals

of orbital floor reconstruction include restoration of

the shape and framework of the orbit, provision of

support and maintenance of the position of the eye

globe, rehabilitation of the orbital volume, and restora-

tion of facial esthetics. However, the thinness andirregular contour of the orbit make it difficult to find

an appropriate material for precise reconstruction of

orbital defects, and complications, such as diplopia,

enophthalmos, and restriction of ocular mobility,

become inevitable in some cases.

Titanium meshes are commonly used for recon-

struction of the midface and skull base defects after

ablative surgery and trauma, and they are currentlythe first choice of material for post-traumatic orbital

reconstruction.17-19 Convenience of fabrication,

stability, flexibility, no donor-site morbidity, and a

decreased surgical duration have increased the popu-

larity of titanium meshes for maxillofacial surgeries.

However, there are some differences between post-

traumatic orbital floor reconstruction and postmaxil-

lectomy orbital floor reconstruction.


The major difference between the 2 procedures is

the extent of the defect. Complex midfacial defects,

including the maxilla, part of the zygoma, and the

orbital floor, always remain after tumor resection and

maxillectomy as opposed to small defects, including

the orbital walls, after post-traumatic surgery. Exten-

sive defects require a completely different clinical pro-

tocol for reconstruction. As an example, a much largertitanium mesh is required, in addition to a free flap

with enough volume for reconstruction of the maxil-

lary defect and prevention of mesh exposure. In the

present study, a large prefabricated titanium mesh

was used to cover the entire orbital floor defect in

each patient. A free fibula flap (n = 4), an anterior

lateral thigh flap (n = 5), and a rectus abdominis mus-

cle flap (n = 1) were used for complex defects. Allthese flaps included an adequate soft tissue volume

(fat tissue or muscles) to fill in the defects and shield

the titanium mesh.

The success of orbital floor reconstruction with a ti-

tanium mesh depends on 2 critical factors. First is the

restoration of the shape of the individual orbital floor,

and second is the definition of the appropriate posi-

tion of the titanium mesh, including the level and

15 July 2015 � 4:05 pm � CE AH

web4C=FPO

FIGURE 6. Orbital volume measurements. A series of axial computed tomographic slices is obtained. A, Then, the bony border between theoptic nerve foramen and the connecting line between the zygomaticofrontal suture and the nasomaxillary suture is outlined. B, The orbitalvolume is calculated by the computer.



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FIGURE 7. Measurement of the depth of the titanium mesh. A sagittal slice of the deepest position of the titanium mesh is obtained using post-operative computed tomography. The depth of the titaniummesh is calculated as the distance from the orbital rim to the posterior end point of thetitanium mesh.



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depth. Preoperative virtual surgical planning and intra-

operative navigation provide a useful solution to

achieve these requirements. These computer-assisted

protocols have been widely used for various types ofcraniomaxillofacial surgeries, including osteotomy, or-

Table 2. OUTCOMES OF ORBITAL FLOOR RECONSTRUCTIONUSING COMPUTER-ASSISTED TECHNIQUES

Patient

Number

Primary

Diagnosis

Depth of Titanium

Mesh (mm) Diplopia

1 Adenocarcinoma 26.12 No N

2 Myoepithelial

carcinoma

21.03 No N

3 Ameloblastoma 25.32 No N

4 Osteosarcoma 24.26 No N

5 Osteofibroma 22.04 No N


7 Adenoid cystic

carcinoma

27.24 Yes A

8 Osteofibroma 26.56 No N


10 Myxoma 26.01 No N

Zhang et al. Computer-Assisted Orbital Floor Reconstruction. J Oral Max


thognathic surgery, fracture reduction, and bony flap

reconstruction.20,21 Zhang et al19 and Yu et al22 used

this procedure for post-traumatic orbital wall recon-

struction and achieved satisfactory clinical outcomes.Therefore, in the present study, the outcomes of this

USING AN INDIVIDUAL TITANIUM MESH FABRICATED

Postoperative Complications

Ocular

Mobility

Visual

Acuity

Titanium

Mesh Exposure Facial Symmetry

ormal Normal No Satisfactory






bnormal Decrease No Satisfactory




illofac Surg 2015.

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Table 3. POSTOPERATIVE GLOBE PROJECTION AND ORBITAL VOLUME

Reconstructed Side Unaffected Side Difference P Value

Postoperative globe

projection (mm)

15.91 � 1.80 16.24 � 2.24 0.34 � 1.53 .505

Postoperative orbital

volume (mL)

26.01 � 1.28 25.57 � 1.89 0.44 � 1.29 .312


web4C=FPO

FIGURE8. Q7Clinical outcome of a selected case.A-C, The patient had extensive recurrent ameloblastoma of the left maxilla with the orbital floorinvolved and she underwent left maxillectomy including the orbital floor. (Fig 1 continued on next page.)



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web4C=FPO

FIGURE8 (cont’d). D-F, Using the computer-assisted individual fabricated titaniummesh technique with free fibula flap reconstruction, a sym-metrical appearance was achieved and normal function of the globe was preserved after surgery.




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technique were evaluated in patients who underwent

orbital floor reconstruction after extensive

maxillectomy.

All tumor-related orbital defects in this study were

unilateral, and all defects were limited to the orbital

floor without involvement of the other orbital walls.

Therefore, rehabilitation of the individual position

and contour of the orbital floor using a computerizedmirror image of the unaffected side was ideal,

presuming individual symmetry of the facial bone struc-

ture. Although measurable differences in facial symme-

try exist in all individuals, the differences are small and

minor in appearance and function.21,23 An essential

parameter for maxillary reconstruction with good

esthetic results is recovery of the contour and volume

of the maxilla. In this study, an individual fabricatedtitanium mesh not only supported the eye globe but

also rehabilitated the contour and projection of the

infraorbital region. Furthermore, the soft tissue on

the flaps filled the dead space under the titanium

mesh and restored the volume of the defects. Esthetic

results were assessed by the patients and surgeons,

who were satisfied with the postoperative facial

symmetry in all cases.The normal position of the eye globe is maintained

by a balance between the orbital volume and the intra-

orbital soft tissue. A disturbance in this balance from

expansion of the orbital volume or a decrease in the

orbital contents can lead to enophthalmos.19 In most

post-traumatic cases, particularly those of delayed

orbital fracture repair, changes in the orbital volume

and globe projection develop because of absoluteexpansion of the orbital volume or a decrease in the

orbital contents. Enophthalmos is always the chief

complaint of such patients. The role of the titanium

mesh is to restore the orbital volume and globe projec-

tion by anatomic reconstruction.19 However, during

reconstruction of the orbital floor after tumor resec-

tion, the periorbital fat pad and extraocular muscles

are preserved. In general, there are no changes in theorbital contents, and the purpose of the titanium

mesh is to maintain the anatomic position of the orbital

floor. In the present study, the orbital contents and ex-

traocular muscles were preserved during primary sur-

gery in all patients, none of whom complained about

preoperative enophthalmos or problems with visual

acuity and ocular motility. Therefore, rehabilitation of

the orbital volume was critical for normal function ofthe eye globe. Migliori and Gladstone24 measured the

globe projection in 681 patients without any orbital le-

sions and found that the difference was less than 2 mm

in all patients. Koo et al25 also reported that clinically

important enophthalmos can be evaluated by differ-

ences in globe projection, with a difference less than

2 mm considered clinically minor. Some investigators

have developed the relation between changes in the


orbital volume and changes in the globe projection or

enophthalmos.19,26,27 Sun et al28 reported the use of

a fabricated titanium mesh for orbital floor reconstruc-

tion after maxillectomy in 19 patients, although a nav-

igation protocol was not included and there was no

related analysis of the postoperative globe projection

and orbital volume. The results of the present study

indicated no statistical differences in the orbital volumeand globe projection between the reconstructed and

unaffected sides. Postoperative examinations also

showed a low rate of complications, such as diplopia

and restriction of ocular motility.

Preservation and protection of the optic nerve are

essential for any orbital surgery. The depth of the in-

serted implant should always be accurate. In post-

traumatic cases, the depth of the implant depends onthe position of the fracture. Therefore, the implant is

occasionally inserted very deeply and close to the

apex. Zhang et al19 reported 21 post-traumatic cases

in which an individual fabricated titanium mesh was

used for orbital wall reconstruction, with an implant

depth of 29.33 mm. However, the depth of the implant

after tumor resection depends on the extent of the de-

fects. In the present study, the optic nerve was notaffected in any patient, and no patient complained

about problems with visual acuity before surgery. CT

scanning showed a safe distance existed between the

apex and the tumor. Therefore, the posterior region

of the orbital floor close to the apex remained during

tumor resection. The depth of the titanium mesh in

the present series was 25.11 mm,which was shallower

than that reported for post-traumatic cases. As reportedpreviously for post-traumatic reconstruction,22,26,27

the depth of the implant can be controlled by

intraoperative navigation. By matching the contour of

the mobile segment with the preoperative virtual

plan, the individual fabricated titanium mesh can be

inserted into the ideal position, after which the

orbital apex can be checked to determine

overextension. Thus, surgical safety can be obtainedby navigation. According to the present results, no

visual impairment associated with mesh insertion

was recorded.

Although titaniummesh is an ideal choice for orbital

floor reconstruction, some risks remain. The major

risk is infection and exposure of the titanium mesh,

particularly in patients with malignant tumorswho un-

dergo adjuvant radiotherapy. The presence of hypo-vascular irradiated tissue and extensive fibrosis that

progresses after radiotherapy considerably increases

the risk of infection and exposure of the titanium

mesh.28-31 Several previous studies have reported the

use of the titanium mesh and soft tissue flaps or free

bone grafts for maxillary reconstruction; infections

and exposure were not uncommon in these

studies.29-31 Nakayama et al30 reported radiotherapy-

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related titanium mesh exposure in 27.8% of patients

who underwent maxillary reconstruction with soft tis-

sue flaps and a titanium mesh. Sun et al31 used a radial

forearm flap and a titanium mesh for maxillary and

orbital floor reconstruction and reported exposure in

15.8% of patients (3 of 19) during the follow-up

period. An inadequate soft tissue volume for covering

the mesh is responsible for these complications. In thepresent patients, a titanium mesh was used with free

flaps containing an adequate soft tissue volume, such

as an anterior lateral thigh flap, a rectus abdominis

muscle flap, or a free fibula flap with the flexor hallucis

longus. Furthermore, 2 of the 5 patients with malig-

nancies received radiotherapy, none of whom ex-

hibited mesh exposure or infection during long-term

follow-up.In this study, a preliminary clinical protocol was pro-

vided for the application of an individual fabricated ti-

tanium mesh for reconstruction of tumor-related

orbital floor defects. Although satisfactory clinical re-

sults were achieved, some limitations should be noted.

Although the use of a titaniummesh for reconstruction

after the resection of benign tumors can be well

accepted, its use for reconstruction after the resectionof malignant tumors remains controversial and re-

quires long-term follow-up data. In addition, the error

of the navigation technique should be considered.

The technical accuracy of the navigation system used

in this study is reportedly less than 1 mm, with an

intraoperative accuracy less than 2 mm for some pa-

tients.32-34 Therefore, the results are acceptable

according to these values. However, various factorsinfluence this accuracy, including the imaging

resolution, accuracy of registration, and accuracy of

the computer algorithm.35 Further prospective studies

with a larger sample are required to clarify these issues.

The results of this study suggest that orbital floor

reconstruction after extensive maxillectomy using

the computer-assisted fabricated individual titanium

mesh technique is a feasible and acceptable proce-dure. Intraoperative navigation combined with preop-

erative virtual surgical planning can precisely preserve

the globe projection and orbital volume; furthermore,

complications such as diplopia, restriction of ocular

motility, and a decrease in visual acuity can be pre-

vented, thus resulting in successful clinical outcomes.

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