Elsevier

Acta Biomaterialia

Volume 7, Issue 9, September 2011, Pages 3248-3266
Acta Biomaterialia

Review
Biomaterials and implants for orbital floor repair

https://doi.org/10.1016/j.actbio.2011.05.016Get rights and content

Abstract

Treatment of orbital floor fractures and defects is often a complex issue. Repair of these injuries essentially aims to restore the continuity of the orbital floor and to provide an adequate support to the orbital content. Several materials and implants have been proposed over the years for orbital floor reconstruction, in the hope of achieving the best clinical outcome for the patient. Autografts have been traditionally considered as the “gold standard” choice due to the absence of an adverse immunological response, but they are available in limited amounts and carry the need for extra surgery. In order to overcome the drawbacks related to autografts, researchers’ and surgeons’ attention has been progressively attracted by alloplastic materials, which can be commercially produced and easily tailored to fit a wide range of specific clinical needs. In this review the advantages and limitations of the various biomaterials proposed and tested for orbital floor repair are critically examined and discussed. Criteria and guidelines for optimal material/implant choice, as well as future research directions, are also presented, in an attempt to understand whether an ideal biomaterial already exists or a truly functional implant will eventually materialise in the next few years.

Introduction

Orbital floor fractures, alone or in conjunction with other facial skeletal damage, are the most commonly encountered midfacial fractures, second only to nasal ones. According to Ng et al. [1] and Chang and Manolidis [2], orbital floor fractures were first described by MacKenzie in 1844 in Paris. More than a century later, in 1957, Smith and Regan [3] described inferior rectus muscle entrapment with decreased ocular motility in the setting of an orbital fracture and coined the term “blow-out fracture”. Since the 1960s different surgical routes have been proposed for the effective management of orbital floor fractures [4], [5], [6], [7], [8], [9], [10], [11].

It should be taken into account that the management of orbital floor injuries is complicated not only by their technical difficulty per se, but also by the required extensive medical competencies, ranging from the maxillofacial to otolarygological to ophthalmic fields, and by the multitude of factors necessary to make a correct decision as to the proper timing of the repair.

In addition to timing- and surgery-related issues, another key factor in the treatment of orbital fractures is the choice of the material used for tissue(s) reconstruction. A wide number of studies describing orbital fracture repair with a considerable variety of autogenous, allogenic and alloplastic materials are available in the literature. However, direct comparison between different materials are rather rare and, therefore, it is not trivial to draw definite conclusions as to which material is best suited to repair these injuries. The present review addresses this issue: specifically, the advantages and limitations of currently adopted biomaterials and implants are critically examined and possible new research directions towards a truly ideal device are described and discussed.

The article can be divided into three parts, devoted to presenting an essential medical background, a comprehensive materials/implants review and some indications/remarks for material choice/prospective research, respectively. The first part, Section 2, gives the reader a concise overview of the features, treatment and complications of orbital floor fractures. In this context Table 1 provides a short glossary of the medical terms that are not explained directly in the text or that may be unclear or unknown to non-specialist readers. The second part, Sections 3–8, gives the different classes of biomaterials and implants used to treat orbital floor fractures are extensively reviewed. The third part, Sections 9–11, critically compares and discusses the performances of the different materials and implants in current use and forecasts about future challenges are presented.

Section snippets

Aetiology and features

Damage to the facial skeleton is usually the result of low, medium or high velocity trauma due, for instance, to a motor vehicle or traffic accident. A fracture in the orbital floor commonly causes herniation of the orbital fat and other orbital content into the maxillary sinus(es), which results in an increase in the orbital volume (Fig. 1). Orbital floor fractures can occur as isolated injuries or in combination with extensive facial bony disruption. The orbital floor is most vulnerable to

Materials for orbital floor reconstruction

Basically, the goal of an orbital floor implant is to repair the traumatic defect, lifting the eyeball into its correct position and thereby avoiding enophthalmos. An ideal implant biomaterial should be (i) biocompatible, (ii) available in sufficient quantities, (iii) strong enough to support the orbital content and the related compressive forces, (iv) easy to shape to fit the orbital defect and regional anatomy, (v) easily fixable in situ, (vi) not prone to migration, (vii) osteoinductive and

Biological materials

Over the years a wide range of biological materials has been tested in the field of orbital floor repair. They have been derived from human or animal tissues and could be used as transplants (autografts, allografts and xenografts) or treated to obtain suitable substances to be used as implant materials. In general, biological materials have problems, such as limited availability and morbidity at the harvest site for autologous tissues and the risk of viral infection and disease transmission

Hydroxyapatite and other calcium phosphates

Hydroxyapatite (HA), due to its chemical and crystallographic similarity to bone mineral, is an excellent material for bone defect repair [87]. Since the early 1990s HA and carbonated apatite cements have been commercially available as mouldable bone substitutes in the broad field of craniofacial reconstruction [88], [89], [90], [91]. Mathur et al. [92] reported an interesting overview of the use of HA cements in the context of craniofacial surgery, including orbital floor repair.

HA was also

Titanium

For many decades titanium has been successfully and extensively used in orthopaedics and dentistry to manufacture bone screws, joint endoprostheses and dental implants [108], [109], as well as in the field of craniofacial reconstruction and orbital floor repair [54], [110], [111], [112], [113], [114], [115], [116], [117], [118]. Titanium is highly biocompatible and, thanks to its physico-mechanical properties, is an ideal candidate for the reconstruction of bone defects requiring substitutes

Silicone

Silicone has been extensively proposed for almost 50 years as a suitable material for various surgical applications due to its attractive properties, including biological/chemical inertness, flexibility, ease of handling and low cost. In retinal detachment surgery, for instance, silicone elements for scleral buckling are the unique scleral implants approved for clinical use and commercially available worldwide [123].

In 1963 silicone was introduced by Lipshutz and Ardizone [124] in the management

Composites

HA-reinforced high density composite (HAPEX™) has been marketed and successfully used for several years as a bone replacement material in the context of orbital floor repair [177], [178] and middle ear prostheses [179]. Zhang et al. [180] recently suggested the use of a HA/PE composite material as a skull implant for the repair of cranial defects. The combination of stiff, osteoinductive but brittle HA with low modulus, tough and bioinert PE produces a biomedical composite exhibiting attractive

Overview of comparative studies – does an ideal biomaterial exist?

No generally recognised consensus exists on the best choice of biomaterials/implants for orbital floor reconstruction, but several options are at the surgeon’s disposal and available in the marketplace (Table 2). The choice of an optimal material for orbital skeleton repair is influenced by many factors, including the specific characteristics of the injury, cost, the patient’s clinical history and the experience/opinion of the surgeon.

It is worth underlining once more that a careful history and

Summary and indications for material choice

Orbital fractures due to trauma usually result in damage to the floor and the medial wall, the thinnest bone in the body. In some cases surgical treatment is not mandatory and drug therapy may be recommended, as previously discussed in Section 2.2. Clinical indications for fracture repair are the patient’s symptoms and generally include severe diplopia, entrapment of extraocular muscles, large fractures (>50% of the wall) and enophthalmos greater than 2 mm [2], [8], [12], [17]. If surgical

Concluding remarks and promises for the future

The data from the existing literature demonstrate that orbital floor reconstruction is often a complex issue and, at present, none of the biomaterials used in clinical practice can be really considered the ideal one. In the next few years the development of new biomaterials and implants exhibiting superior performance with respect to the existing commercial solutions would be highly desirable. These new products should be easily sterilizable and have ease of use by the surgeon. Specifically,

Acknowledgement

Dr Daniela Dolcino, Head of the Ophthalmology Ward at Ss. Antonio e Biagio Hospital, Alessandria, Italy, is gratefully acknowledged for stimulating and supporting the author in writing this article.

References (205)

  • I. Iatrou et al.

    Use of membrane and bone grafts in the reconstruction of orbital fractures

    Oral Surg Oral Med Oral Pathol Oral Radiol Endod

    (2001)
  • S. Sakakibara et al.

    Reconstruction of the orbital floor with sheets of autogenous iliac cancellous bone

    J Oral Maxillofac Surg

    (2009)
  • V.T. Ilankovan et al.

    Experience in the use of calvarial bone grafts in orbital reconstruction

    Br J Oral Maxillofac Surg

    (1992)
  • J. Al-Sukhun et al.

    A comparative study of 2 implants used to repair inferior orbital wall bony defects: autogenous bone graft versus bioresorbable poly-L/DL-lactide [P(L/DL)LA 70/30] plate

    J Oral Maxillofac Surg

    (2006)
  • E. Ellis et al.

    Assessment of internal orbital reconstruction for pure blowout fractures: cranial bone versus titanium mesh

    J Oral Maxillofac Surg

    (2003)
  • M. Kraus et al.

    Post-traumatic orbital floor reconstruction with nasoseptal cartilage in children

    Int J Pediatric Otorhinolaryngol

    (2002)
  • M. Bayat et al.

    Comparison of conchal cartilage graft with nasal septal cartilage graft for reconstruction of orbital floor blowout fractures

    Br J Oral Maxillofac Surg

    (2010)
  • B. Celikoz et al.

    Reconstruction of the orbital floor with lyophilized tensor fascia lata

    J Oral Maxillofac Surg

    (1997)
  • P.D. Waite et al.

    Orbital floor reconstruction with lyophilized dura

    J Oral Maxillofac Surg

    (1988)
  • J.M. Chen et al.

    Early surgical intervention for orbital floor fractures: a clinical evaluation of lyophilized dura and cartilage reconstruction

    J Oral Maxillofac Surg

    (1992)
  • K. Webster

    Orbital floor repair with lyophilized porcine dermis

    Oral Surg Oral Med Oral Pathology

    (1988)
  • R.Z. LeGeros

    Biodegradation and bioresorption of calcium phosphate ceramics

    Clin Mater

    (1993)
  • L.L. Hench

    Biomaterials: a forecast for the future

    Biomaterials

    (1998)
  • P. Ng et al.

    Imaging of orbital floor fracture

    Australas Radiol

    (1996)
  • E.W. Chang et al.

    Orbital floor fracture management

    Facial Plast Surg

    (2005)
  • W.L. Walter

    Early surgical repair of blowout fractures of the orbital floor by using the transantral approach

    South Med J

    (1972)
  • M.E. Sachs

    Orbital floor fractures: the maxillary approach

    Adv Opthalmol Plast Reconstr Surg

    (1981)
  • B.C. Patel et al.

    Management of complex orbital fractures

    Facial Plast Surg

    (1998)
  • B. Hammer

    Orbital fractures. diagnosis, operative treatment, secondary corrections

    (1995)
  • G.R. Holt et al.

    Management of orbital trauma and foreign bodies

    Otolaryngol Clin North Am

    (1988)
  • M.E. Hartstein et al.

    Update on orbital floor fractures: indications and timing for repair

    Facial Plast Surg

    (2000)
  • S. Manolidis et al.

    Classification and surgical management of orbital fractures: experience with 111 orbital reconstructions

    J Craniofac Surg

    (2002)
  • M.A. Burnstime

    Clinical recommendations for repair of isolated orbital floor fractures: an evidence-based analysis

    Ophthalmology

    (2002)
  • B.S. Sires et al.

    Oculocardiac reflex caused by orbital floor trapdoor fracture: an indication for urgent repair

    Arch Ophthalmol

    (1998)
  • B.S. Wachler et al.

    The missing muscle syndrome in blowout fractures: an indication for urgent repair

    Ophthal Plast Reconstr Surg

    (1998)
  • D.R. Jordan et al.

    Intervention within days for some orbital floor fractures: the white-eyed blowout

    Ophthal Plast Reconstr Surg

    (1998)
  • G.A. Boush et al.

    Progressive infraorbital nerve hypesthesia as a primary indication for blow-out fracture repair

    Ophthal Plast Reconstr Surg

    (1994)
  • J.H. Kwon et al.

    Clinical analysis of surgical approaches for orbital floor fractures

    Arch Facial Plast Surg

    (2008)
  • P. Cole et al.

    Comprehensive management of orbital fractures

    Plast Recnstr Surg

    (2007)
  • S.C. Carroll et al.

    Outcomes of orbital floor fractures in children and adolescents

    Br J Ophthalmol

    (2010)
  • Gosau M, Schoneich M, Draenert FG, Ettl T, Driemel O, Reichert TE. Retrospective analysis of orbital floor fractures –...
  • J.M. Neigel et al.

    Use of demineralised bone implants in orbital and craniofacial surgery

    Ophthal Plast Reconstr Surg

    (1996)
  • K. Chowdhury et al.

    Selection of materials for orbital floor reconstruction

    Arch Otolaryngol Head Neck Surg

    (1998)
  • D. Mok et al.

    A review of materials currently used in orbital floor reconstruction

    Can J Plast Surg

    (2004)
  • M.W. Betz et al.

    Challenges associated with regeneration of orbital floor bone

    Tissue Eng B

    (2010)
  • W. Schlickewei et al.

    The use of bone substitutes in the treatment of bone defects–the clinical view and history

    Macromol Symp

    (2007)
  • V.L. Young et al.

    Intracerebral hematoma complicating split calvarial bone-graft harvesting

    Plast Reconstr Surg

    (1990)
  • R.M. Kline et al.

    Complications associated with the harvesting of cranial bone grafts

    Plast Reconstr Surg

    (1995)
  • S.M. Mintz et al.

    Contralateral coronoid process bone grafts for orbital reconstruction: an anatomic and clinical study

    J Oral Maxillofac Surg

    (1998)
  • E.P. Johnson et al.

    In situ splitting of a rib graft for reconstruction of the orbital floor

    Plast Reconstr Surg

    (1999)
  • Cited by (116)

    View all citing articles on Scopus

    This article is dedicated to Prof. Giuseppe Heer, a great ophthalmologist and Head Emeritus of the Ophthalmology Ward at Maria Vittoria Hospital, Turin, Italy, on occasion of his 60 years of clinical activity and 85th birthday.

    View full text