Surgical interventions in blow out fractures are generally indicated in cases of alterations in orbital function (e.g. diplopia)and for aesthetic reasons (e.g. enophthalmos). In assessing the severity of the injury, the clinician often uses parameterssuch as changes in visual acuity, patient-reported diplopia, changes in globe position and evaluation of the extraocularmuscles in association with imaging exams. Computed tomography has been the modality of choice for detailed imagingdiagnosis and surgical planning of orbital trauma. High density polyethylene may be successfully used in orbital floorreconstruction to restore function and esthetics. Taking into account the follow up of six months, the availability and theadvantages of high density polyethylene implants, it can be concluded that their use in reconstruction of orbital floordefects is a good choice

Daniel Pozza

Diego Blaya

Marcos André Oliveira

Marília Gerhardt de Oliveira

Nelson Ribeiro Neto

Revista de Ciências Médicas e Biológicas

Open Repository of the University of Porto

83R. Ci. méd. biol. 2010; 9(1):83-86
Daniel Humberto Pozza, et al.
Orbital floor reconstruction with high density polyethylene
Reconstrução de assoalho orbital com polietileno de alta densidade
Daniel Humberto Pozza1, Diego Segatto Blaya2, Marcos André Matos de Oliveira3, Nelson Ribeiro Neto4,Marília
Gerhardt de Oliveira5
1Doctor of Laser - Universidade Federal da Bahia/Universidade Federal de Paraíba; Specialist in Oral and Maxillofacial Surgery
(OMS) - Centro Baiano de Estudos Odontológicos, Salvador, BA; 2Master in OMS - Pontifícia Universidade Católica do Rio
Grande do Sul; Specialist in OMS - PUCRS; 3Doctor of Immunology - UFBA; 4Doctor of Laser - UFBA/UFPB; Specialist in OMS -
Universidade Federal do Ceará; Specialist in Implantodonty - Escola de Aperfeiçoamento Profissional - Associação Brasileira de
Odontologia/BA; 5PhD Associate Professor Post-graduate Program in OMS - School of Dentistry – PUCRS; CNPq fellow
Abstract
Surgical interventions in blow out fractures are generally indicated in cases of alterations in orbital function (e.g. diplopia)
and for aesthetic reasons (e.g. enophthalmos). In assessing the severity of the injury, the clinician often uses parameters
such as changes in visual acuity, patient-reported diplopia, changes in globe position and evaluation of the extraocular
muscles in association with imaging exams. Computed tomography has been the modality of choice for detailed imaging
diagnosis and surgical planning of orbital trauma. High density polyethylene may be successfully used in orbital floor
reconstruction to restore function and esthetics. Taking into account the follow up of six months, the availability and the
advantages of high density polyethylene implants, it can be concluded that their use in reconstruction of orbital floor
defects is a good choice.
Keywords: Orbital fractures – Surgery – High density polyethylene.
Resumo
Justifica-se intervir cirurgicamente em fraturas do tipo blow out naqueles casos em que haja alterações da função orbital,
como a diplopia, ou mesmo por razões estéticas, como a enoftalmia. Clinicamente, as fraturas do tipo blow out revelam
alterações estéticas e funcionais que, associadas aos exames complementares por imagem, como a tomografia
computadorizada, indicam o procedimento cirúrgico reparador. A utilização do polietileno de alta densidade (PAD) na
reconstrução do assoalho orbital reduz a morbidade do enxerto autógeno, apresentando estabilidade e biocompatibilidade.
Este artigo discute um caso cirúrgico de evolução favorável após seis meses de reconstrução do assoalho orbital com PAD.
Palavras-chave: Fraturas orbitárias – Tratamento cirúrgico – Polietileno de alta densidade.
RELATO DE CASO
ISSN 1677-5090
© 2010 Revista de Ciências Médicas e Biológicas
Recebido em 08 de setembro de 2009; revisado em 10 de fevereiro de
2010 Correspondência / Correspondence: Dr. Marília Gerhardt de
Oliveira. Rua Lucas de Oliveira, 1841/203. CEP: 90.460-001 – Porto
Alegre – RS - Brazil. Phone: +55 (51) 3330-9545. E-mail:
mogerhardt@yahoo.com.br
INTRODUCTION
The orbital cavity is comprised of the frontal,
sphenoid, and ethmoid bones do neurocranium, and the
maxillary, palatine, zygomatic and lacrimal bones of the
visceral cranium. These bilateral cavities house the
ocular globes, muscles, cranial nerves (II, III, IV, V and
VI), vascular and connective tissue and fat 1,2. Knowledge
of orbital anatomy is fundamental in making a better
diagnosis of periorbital fractures and a correct imaging
assessment in traumatized patients.3
Signs associated with orbital fractures include
periorbital ecchymosis, edema and subconjunctival
ecchymosis, ophthalmoplegia, enophthalmia, hemosinus
and bone rupture, revealed by imaging exams; and the
symptoms are infraorbital paresthesia and
diplopia.4,5,6,7,8,9,10
Bourguignon Filho and collaborators 7 reported that
among orbital fractures, the blow out type consists of
the rupture of the orbital walls without fracture of the
orbital contour, possibly causing diplopia. One of the
probable causes of diplopia is muscular incarceration
at the site of the fracture 11, which must be treated in
order to eliminate the diplopia.
The major cause of orbital fractures are car accidents,
followed by physical aggression 4. In blow out fractures
the trauma increases internal pressure of the orbital
cavity, and in order to impede ocular explosion, there is a
rupture of fine bone on the orbital floor and/or of the
papyraceous lamina of the ethmoid bone.9,11
According to Panarello and collaborators 12,
diagnosis of the periorbital region is very complex
especially when there is swelling and laceration. In these
cases, imaging exams are of the utmost importance.
One complementary exam that could be used is the
Water’s postero-anterior radiograph 4, though only for
an initial evaluation, given its limitations. Fractures that
involve the orbital cavity demand more accurate exams,
such as computed tomography (CT), in order to visualize
the extension and localization of fractures in this
84 R. Ci. méd. biol. 2010; 9(1):83-86
Orbital floor reconstruction
complex region and to recommend the surgical procedure
that would involve the minimum sequelae 3,13.
Innovations in CT have enabled earlier surgeries for
the reconstruction of internal orbital walls. This
immediate diagnosis and early treatment has prevented
sequelae such as enophthalmia.14
Jank and collaborators 15 evaluated CT exams in 424
patients with orbital fracture, and observed that the
majority were fractures of the orbital floor (84.2%), followed
by the lateral wall (6.1%). They also observed combined
fractures in the orbital floor and lateral and medial walls
(1.2%) and isolated fractures of the medial (0.9%).
When surgery is indicated, autogenous bone grafts
provide excellent biological adaptation, but present
disadvantages such as donor site morbidity, limited
quantity and moldability as well as the possibility of
sub-correction reabsorption.16,17
The main applications for high density polyethylene
are restitution of cranial volume, bone defect filling, and
orbital reconstruction 16. According to Renò, Lombardi e
Cannas 18, alloplastic implants may cause minor
inflammatory reactions. However, this does not produce
complications such as the need to remove the implant.10
Zim 17 reported that high density polyethylene is inert,
with low tissue reaction and minimal reaction to foreign
bodies, and is insoluble to tissue fluids. Its microporous
nature (100 a 300ìm) allows for the growth of a fibrous
tissue that stabilizes the implant. In addition, it is easy
to use as it is malleable and can be shaped in an infinite
number of forms and sizes. Subperiosteal placement is
indicated and fixation with titanium screws is necessary.
CASE REPORT
Male patient, 22 years of age, single, soldier,
faioderma, who was punched. Clinical examination
showed the presence of periorbital ecchymosis, edema,
paresthesia of the infraorbital nerve, diploplia, as well
as respiratory difficulty. Palpation of the infraorbital
contour and the Waters radiographic exam revealed a
possible fracture of the orbital floor, hemosinus and
fracture of the nasal bones. CT in coronal (Figure 1) and
Figure 1. Tomography in coronal cut demonstrating herniation
of the left orbital content by rupture of the orbital floor.
Figure 2. Access to the fracture after incision and
separation of the infraorbital tissues.
Figure 3. Insertion and fixation of high density
polyethylene with titanium micro-screws.
Figure 4 . Waters radiograph at 15 days post-operative.
axial cuts confirmed orbital floor and nose fracture. The
patient was evaluated by ophthalmologists and
authorized for surgical treatment. The patient gave free
and informed consent of both the surgical procedure
and publication of the present case study. Subpalpebral
incision and tissue separation was carried out to allow
85R. Ci. méd. biol. 2010; 9(1):83-86
Daniel Humberto Pozza, et al.
DISCUSSION
In the clinical exam, the patient presented signs of
periorbital ecchymosis, edema and symptoms of
infraorbital paresthesia and diplopia, which are the
classical signs and symptoms of blow out fractures.
4,5,6,7,8,9,10
Enophthalmia may occur in more extensive blow out
fractures, due to the herniation of orbital fat after the
dislocation of orbital cavity walls 6,8,9,10,16. The fracture
was relatively small and, consequently, significant
enophthalmia was not observed, though diplopia was
reported by the patient. Diplopia was probably caused
by the herniation of the orbital content to the inner
maxillary sinus and not because of muscle incarceration
8,10,11, since the patient did not present restriction of ocular
movement (ophthalmoplegia).
According to the patient, the fracture was caused by
physical aggression, which is in accordance with other
studies.4
Clinical and Waters radiographic examination
demonstrated orbital fracture, but were unable to verify
the extension of the fracture. CT in coronal and axial
cuts was necessary to quantify the length of the fracture,
in accordance with other authors7,14,19,20,21,22
In depth anatomic knowledge of the orbital region is
necessary due to the complexity of the structures such as
the ocular globe and the innervations of this area.1,2, 3
Alloplastic material was used for reconstruction of
the fracture in order to avoid of donor site morbidity
7,16,17. High density polyethylene was chosen as it is inert,
biocompatible, malleable, can not be reabsorbed and
can be shaped into an infinite number of forms and sizes,
allowing a prediction of the final result of surgical
reconstruction.17 The objectives of the surgery were to
reconstruct the orbital floor and consequently orbital
volume, reducing herniation; correct diplopia and avoid
enophthalmia, allowing correct muscular function;
relieve the compressed infraorbital nerve, allowing
paresthesia involution; create a barrier against
infections from the maxillary sinus. Taken together, these
aspects restore function and aesthetics, as has been
indicated by several authors 5,23,24,25,26. We agree with
Panarello and collaborators 12 that conservative
treatment is indicated in cases in which bone dislocation
is not visible and if there are no clinical manifestations
that would affect aesthetic and function after 14 days.
CONCLUSIONS
It can be concluded that CT is necessary for a correct
diagnosis and improved rehabilitative planning in blow
out fractures. In addition, in cases where there are
aesthetic-functional alterations, surgery is indicated.
When possible, alloplastic material should be used and
high density polyethylene is a good option due to its
adaptability, biocompatibility, lack of reabsorption and,
mainly, to the reduction in morbidity and the length of
the surgery.
REFERENCES
1 . COSTA, A.T.  Anatomia e acessos cirúrgicos em região
periorbitária para tratamento de traumatismos faciais.  2002.
(Trabalho de Conclusão de Curso) - Faculdade de Odontologia,
Pontifícia Universidade Católica do Rio Grande do Sul, Porto
Alegre, 2002.
2. GERHARDT DE OLIVEIRA, M.  Manual de anatomia da cabeça e
do pescoço.4.ed. rev. e ampliada.  Porto Alegre: EDIPUCRS,
2002.
3. SANTOS, R.S. et al.  Diagnóstico de traumatismos faciais
periorbitários por meio de tomografias computadorizadas.
RFO: R. Fac. Odontol., Passo Fundo, v.9, n.1, p.139-141, jan./
jun. 2004.
4. GERHARDT DE OLIVEIRA, M.; RAMOS, A.; OLIVEIRA, R.B.  Estudo
descritivo de sinais e sintomas das fraturas do complexo
orbital e avaliação radiográfica pela      incidência de Waters.
RFO: R. Fac. Odontol., Passo Fundo, v.4, n.2, p.53-56., jul./dez.
1999.
5. GUERRA, M.F. et al.  Reconstruction of orbital fractures with
dehydrated human dura   mater.  J. Oral Maxillofac. Surg.,
Philadelphia, v.58, n.12, p.1361-1366, Dec. 2000.
6. JIN, H.R. et al.  Endonasal endoscopic reduction of blowout
fractures of the medial orbital wall.  J. Oral Maxillofac. Surg.,
Philadelphia, v.58, n.8, p.847-851, Aug. 2000.
7. BOURGUIGNON FILHO, A.M. et al.  Fraturas orbitárias blowout:
tratamento com telas de titânio.  R. Cir. Traumatol. Buco-Maxilo-
Fac., Recife, v.5, n.3, p.35-42,  jul./set. 2005.
8. MAZOCK, J.B.; SCHOW, S.R.; TRIPLETT, R.G.  Evaluation of ocular
changes secondary to blowout fractures.  J. Oral Maxillofac.
Surg., Philadelphia, v.62, n.10,  p.1298-1302, Oct. 2004.
9. CUNNINGHAM, L.L.; PETERSON, G.P.; HAUG, R.H.  The
relationship between enophthalmos, linear displacement,
and volume change in experimentally recreated orbital
fractures.  J. Oral Maxillofac. Surg., Philadelphia, v.63, n.8,
p.1169-1173, Aug. 2005.
10. AL-SUKHUN, J.; LINDQVIST, C.  A comparative study of 2 implants
used to repair inferior orbital wall bony defects: autogenous
Figure 5. Clinical aspect of the patient at 6 months post-
operative.
access to the fracture (Figure 2). Correction of the
remaining orbital floor was carried out using MEDPOR®
(Porex Surgical, Inc, College Park, GA) high density
polyethylene fixed with two 4mm titanium microscrews
(Figure 3). The cut was sutured in planes with 4-0 vicryl
and 5-0 mononylon. In the immediate post operative
period, the patient presented paresthesia, but not
diplopia. At 15 days (Figure 4) and 6 months (Figure 5)
post-operative, the patient showed no sequelae.
86 R. Ci. méd. biol. 2010; 9(1):83-86
Orbital floor reconstruction
bone graft versus bioresorbable poly-L/DL-Lactide [P(L/
DL)LA70/30] plate.  J. Oral Maxillofac. Surg., Philadelphia, v.64,
n.7, p.1038-1048, July 2006.
11. ILIFF, N. et al.  Mechanism of extraocular muscle injury in orbital
fractures.  Plastic Reconstr. Surg., Hagerstown, v.103, n.3, p.787-
799, Mar. 1999.
12. PANARELLO, A.F. et al.  Fraturas orbitárias: diagnostico e
indicações para cirurgia:  revisão de literatura.  R. Int. Cir.
Traumatol. Bucomaxilofac., Curitiba, v.2, n.8, p.245-251, 2004.
13. KOLK, A. et al.  A novel high-resolution magnetic resonance
imaging microscopy coil  as an alternative to the multislice
computed tomography in postoperative imaging of  orbital
fractures and computer-based volume measurement.  J. Oral
Maxillofac. Surg.,Philadelphia, v.63, n.4, p.492-498, Apr. 2005.
14. ELLIS 3rd, E.; TAN, Y.  Assessment of internal orbital
reconstruction for pure blow  out fractures: cranial bone grafts
versus titanium mesh.  J. Oral Maxillofac. Surg., Philadelphia,
v.61, n.4, p.442-453, Apr. 2003.
15. JANK, S. et al.  Clinical signs of orbital wall fractures as a function
of anatomic location.  Oral Surg. Oral Med. Oral Pathol. Oral
Radiol. Endod., St. Louis, v.96, n.2, p.149-153, Aug. 2003.
16. KONTIO, R.  Treatment of orbital fractures: the case for
reconstruction with autogenous bone.  J. Oral Maxillofac. Surg.,
Philadelphia, v.62, n.7, p.863-868, July 2004.
17. ZIM, S.  Skeletal volume enhancement: implants and
osteotomies.  Curr. Opin. Otolaryngol. Head Neck Surg.,
Philadelphia, v.12, n.4, p.349-356, Aug. 2004.
18. RENÒ, F.; LOMBARDI, F.; CANNAS, M.  Oxidation increases
granulocytes activation: a role in tissue response after prosthesis
implant.  Biomaterials, Oxford, v.24, n.17, p.2895-2900, Aug 2003.
19. HARRIS, G.J. et al.  Correlation of preoperative computed
tomography and postoperative ocular motility in orbital
blowout fractures.  Ophthal. Plast. Reconstr. Surg., Hagerstown,
v.16, n.3, p.179-187, May 2000.
20. BRADY, S.M. et al.  The diagnosis and management of orbital
blow out fractures: update 2001.  Am. J. Emerg. Med.,
Philadelphia, v.19, n.2, p.147-154, Mar. 2001.
21. TANRIKULU, R.; EROL, B.  Comparison of computed tomography
with conventional radiography for midfacial fractures.
Dentomaxillofac. Radiol., Houndsmills, v.30, n.3, p.141-146,
May 2001.
22. SOARES, L.P. et al.  Indicações da tomografia computadorizada
no diagnóstico das fraturas naso-órbito-etimoidais.  R. Clin.
Pesq. Odontol., Curitiba, v.1, n.1, p.29-33, 2004.
23. BANSAGI, Z.C.; MEYER, D.R.  Internal orbital fractures in
the pediatr ic  age group:  character izat ion and
management.   Ophthalmology,  New York,  v.107,  n.5,
p.829-836, May 2000.
24. EGBERT, J.E. et al.  Pediatric orbital floor fracture: direct
extraocular muscle involvement.  Ophthalmology, New York,
v.107, n.10, p.1875-1879, Oct. 2000.
25. SIDDIQUE, S.A.; MATHOG, R.H.  A comparison of parietal and iliac
crest bone grafts for orbital reconstruction.  J. Oral Maxillofac.
Surg., Philadelphia, v.60, n.1, p.44-50,  Jan. 2002.
26. GRANT 3rd, J.H. et al.  Trapdoor fracture of the orbit in a pediatric
population.  Plastic Reconstr. Surg., Hagerstown, v.109, n.2,
p.482-489, Feb. 2002.


English

Orbital floor reconstruction with high density polyethylene

Repositório Aberto da Universidade do Porto

83R. Ci. méd. biol. 2010; 9(1):83-86Daniel Humberto Pozza, et al.Orbital floor reconstruction with high density polyethyleneReconstrução de assoalho orbital com polietileno de alta densidadeDaniel Humberto Pozza1, Diego Segatto Blaya2, Marcos André Matos de Oliveira3, Nelson Ribeiro Neto4,MaríliaGerhardt de Oliveira51Doctor of Laser - Universidade Federal da Bahia/Universidade Federal de Paraíba; Specialist in Oral and Maxillofacial Surgery(OMS) - Centro Baiano de Estudos Odontológicos, Salvador, BA; 2Master in OMS - Pontifícia Universidade Católica do RioGrande do Sul; Specialist in OMS - PUCRS; 3Doctor of Immunology - UFBA; 4Doctor of Laser - UFBA/UFPB; Specialist in OMS -Universidade Federal do Ceará; Specialist in Implantodonty - Escola de Aperfeiçoamento Profissional - Associação Brasileira deOdontologia/BA; 5PhD Associate Professor Post-graduate Program in OMS - School of Dentistry – PUCRS; CNPq fellowAbstractSurgical interventions in blow out fractures are generally indicated in cases of alterations in orbital function (e.g. diplopia)and for aesthetic reasons (e.g. enophthalmos). In assessing the severity of the injury, the clinician often uses parameterssuch as changes in visual acuity, patient-reported diplopia, changes in globe position and evaluation of the extraocularmuscles in association with imaging exams. Computed tomography has been the modality of choice for detailed imagingdiagnosis and surgical planning of orbital trauma. High density polyethylene may be successfully used in orbital floorreconstruction to restore function and esthetics. Taking into account the follow up of six months, the availability and theadvantages of high density polyethylene implants, it can be concluded that their use in reconstruction of orbital floordefects is a good choice.Keywords: Orbital fractures – Surgery – High density polyethylene.ResumoJustifica-se intervir cirurgicamente em fraturas do tipo blow out naqueles casos em que haja alterações da função orbital,como a diplopia, ou mesmo por razões estéticas, como a enoftalmia. Clinicamente, as fraturas do tipo blow out revelamalterações estéticas e funcionais que, associadas aos exames complementares por imagem, como a tomografiacomputadorizada, indicam o procedimento cirúrgico reparador. A utilização do polietileno de alta densidade (PAD) nareconstrução do assoalho orbital reduz a morbidade do enxerto autógeno, apresentando estabilidade e biocompatibilidade.Este artigo discute um caso cirúrgico de evolução favorável após seis meses de reconstrução do assoalho orbital com PAD.Palavras-chave: Fraturas orbitárias – Tratamento cirúrgico – Polietileno de alta densidade.RELATO DE CASOISSN 1677-5090© 2010 Revista de Ciências Médicas e BiológicasRecebido em 08 de setembro de 2009; revisado em 10 de fevereiro de2010 Correspondência / Correspondence: Dr. Marília Gerhardt deOliveira. Rua Lucas de Oliveira, 1841/203. CEP: 90.460-001 – PortoAlegre – RS - Brazil. Phone: +55 (51) 3330-9545. E-mail:mogerhardt@yahoo.com.brINTRODUCTIONThe orbital cavity is comprised of the frontal,sphenoid, and ethmoid bones do neurocranium, and themaxillary, palatine, zygomatic and lacrimal bones of thevisceral cranium. These bilateral cavities house theocular globes, muscles, cranial nerves (II, III, IV, V andVI), vascular and connective tissue and fat 1,2. Knowledgeof orbital anatomy is fundamental in making a betterdiagnosis of periorbital fractures and a correct imagingassessment in traumatized patients.3Signs associated with orbital fractures includeperiorbital ecchymosis, edema and subconjunctivalecchymosis, ophthalmoplegia, enophthalmia, hemosinusand bone rupture, revealed by imaging exams; and thesymptoms are infraorbital paresthesia anddiplopia.4,5,6,7,8,9,10Bourguignon Filho and collaborators 7 reported thatamong orbital fractures, the blow out type consists ofthe rupture of the orbital walls without fracture of theorbital contour, possibly causing diplopia. One of theprobable causes of diplopia is muscular incarcerationat the site of the fracture 11, which must be treated inorder to eliminate the diplopia.The major cause of orbital fractures are car accidents,followed by physical aggression 4. In blow out fracturesthe trauma increases internal pressure of the orbitalcavity, and in order to impede ocular explosion, there is arupture of fine bone on the orbital floor and/or of thepapyraceous lamina of the ethmoid bone.9,11According to Panarello and collaborators 12,diagnosis of the periorbital region is very complexespecially when there is swelling and laceration. In thesecases, imaging exams are of the utmost importance.One complementary exam that could be used is theWater’s postero-anterior radiograph 4, though only foran initial evaluation, given its limitations. Fractures thatinvolve the orbital cavity demand more accurate exams,such as computed tomography (CT), in order to visualizethe extension and localization of fractures in this84 R. Ci. méd. biol. 2010; 9(1):83-86Orbital floor reconstructioncomplex region and to recommend the surgical procedurethat would involve the minimum sequelae 3,13.Innovations in CT have enabled earlier surgeries forthe reconstruction of internal orbital walls. Thisimmediate diagnosis and early treatment has preventedsequelae such as enophthalmia.14Jank and collaborators 15 evaluated CT exams in 424patients with orbital fracture, and observed that themajority were fractures of the orbital floor (84.2%), followedby the lateral wall (6.1%). They also observed combinedfractures in the orbital floor and lateral and medial walls(1.2%) and isolated fractures of the medial (0.9%).When surgery is indicated, autogenous bone graftsprovide excellent biological adaptation, but presentdisadvantages such as donor site morbidity, limitedquantity and moldability as well as the possibility ofsub-correction reabsorption.16,17The main applications for high density polyethyleneare restitution of cranial volume, bone defect filling, andorbital reconstruction 16. According to Renò, Lombardi eCannas 18, alloplastic implants may cause minorinflammatory reactions. However, this does not producecomplications such as the need to remove the implant.10Zim 17 reported that high density polyethylene is inert,with low tissue reaction and minimal reaction to foreignbodies, and is insoluble to tissue fluids. Its microporousnature (100 a 300ìm) allows for the growth of a fibroustissue that stabilizes the implant. In addition, it is easyto use as it is malleable and can be shaped in an infinitenumber of forms and sizes. Subperiosteal placement isindicated and fixation with titanium screws is necessary.CASE REPORTMale patient, 22 years of age, single, soldier,faioderma, who was punched. Clinical examinationshowed the presence of periorbital ecchymosis, edema,paresthesia of the infraorbital nerve, diploplia, as wellas respiratory difficulty. Palpation of the infraorbitalcontour and the Waters radiographic exam revealed apossible fracture of the orbital floor, hemosinus andfracture of the nasal bones. CT in coronal (Figure 1) andFigure 1. Tomography in coronal cut demonstrating herniationof the left orbital content by rupture of the orbital floor.Figure 2. Access to the fracture after incision andseparation of the infraorbital tissues.Figure 3. Insertion and fixation of high densitypolyethylene with titanium micro-screws.Figure 4 . Waters radiograph at 15 days post-operative.axial cuts confirmed orbital floor and nose fracture. Thepatient was evaluated by ophthalmologists andauthorized for surgical treatment. The patient gave freeand informed consent of both the surgical procedureand publication of the present case study. Subpalpebralincision and tissue separation was carried out to allow85R. Ci. méd. biol. 2010; 9(1):83-86Daniel Humberto Pozza, et al.DISCUSSIONIn the clinical exam, the patient presented signs ofperiorbital ecchymosis, edema and symptoms ofinfraorbital paresthesia and diplopia, which are theclassical signs and symptoms of blow out fractures.4,5,6,7,8,9,10Enophthalmia may occur in more extensive blow outfractures, due to the herniation of orbital fat after thedislocation of orbital cavity walls 6,8,9,10,16. The fracturewas relatively small and, consequently, significantenophthalmia was not observed, though diplopia wasreported by the patient. Diplopia was probably causedby the herniation of the orbital content to the innermaxillary sinus and not because of muscle incarceration8,10,11, since the patient did not present restriction of ocularmovement (ophthalmoplegia).According to the patient, the fracture was caused byphysical aggression, which is in accordance with otherstudies.4Clinical and Waters radiographic examinationdemonstrated orbital fracture, but were unable to verifythe extension of the fracture. CT in coronal and axialcuts was necessary to quantify the length of the fracture,in accordance with other authors7,14,19,20,21,22In depth anatomic knowledge of the orbital region isnecessary due to the complexity of the structures such asthe ocular globe and the innervations of this area.1,2, 3Alloplastic material was used for reconstruction ofthe fracture in order to avoid of donor site morbidity7,16,17. High density polyethylene was chosen as it is inert,biocompatible, malleable, can not be reabsorbed andcan be shaped into an infinite number of forms and sizes,allowing a prediction of the final result of surgicalreconstruction.17 The objectives of the surgery were toreconstruct the orbital floor and consequently orbitalvolume, reducing herniation; correct diplopia and avoidenophthalmia, allowing correct muscular function;relieve the compressed infraorbital nerve, allowingparesthesia involution; create a barrier againstinfections from the maxillary sinus. Taken together, theseaspects restore function and aesthetics, as has beenindicated by several authors 5,23,24,25,26. We agree withPanarello and collaborators 12 that conservativetreatment is indicated in cases in which bone dislocationis not visible and if there are no clinical manifestationsthat would affect aesthetic and function after 14 days.CONCLUSIONSIt can be concluded that CT is necessary for a correctdiagnosis and improved rehabilitative planning in blowout fractures. In addition, in cases where there areaesthetic-functional alterations, surgery is indicated.When possible, alloplastic material should be used andhigh density polyethylene is a good option due to itsadaptability, biocompatibility, lack of reabsorption and,mainly, to the reduction in morbidity and the length ofthe surgery.REFERENCES1 . COSTA, A.T.  Anatomia e acessos cirúrgicos em regiãoperiorbitária para tratamento de traumatismos faciais.  2002.(Trabalho de Conclusão de Curso) - Faculdade de Odontologia,Pontifícia Universidade Católica do Rio Grande do Sul, PortoAlegre, 2002.2. GERHARDT DE OLIVEIRA, M.  Manual de anatomia da cabeça edo pescoço.4.ed. rev. e ampliada.  Porto Alegre: EDIPUCRS,2002.3. SANTOS, R.S. et al.  Diagnóstico de traumatismos faciaisperiorbitários por meio de tomografias computadorizadas.RFO: R. Fac. Odontol., Passo Fundo, v.9, n.1, p.139-141, jan./jun. 2004.4. GERHARDT DE OLIVEIRA, M.; RAMOS, A.; OLIVEIRA, R.B.  Estudodescritivo de sinais e sintomas das fraturas do complexoorbital e avaliação radiográfica pela      incidência de Waters.RFO: R. Fac. Odontol., Passo Fundo, v.4, n.2, p.53-56., jul./dez.1999.5. GUERRA, M.F. et al.  Reconstruction of orbital fractures withdehydrated human dura   mater.  J. Oral Maxillofac. Surg.,Philadelphia, v.58, n.12, p.1361-1366, Dec. 2000.6. JIN, H.R. et al.  Endonasal endoscopic reduction of blowoutfractures of the medial orbital wall.  J. Oral Maxillofac. Surg.,Philadelphia, v.58, n.8, p.847-851, Aug. 2000.7. BOURGUIGNON FILHO, A.M. et al.  Fraturas orbitárias blowout:tratamento com telas de titânio.  R. Cir. Traumatol. Buco-Maxilo-Fac., Recife, v.5, n.3, p.35-42,  jul./set. 2005.8. MAZOCK, J.B.; SCHOW, S.R.; TRIPLETT, R.G.  Evaluation of ocularchanges secondary to blowout fractures.  J. Oral Maxillofac.Surg., Philadelphia, v.62, n.10,  p.1298-1302, Oct. 2004.9. CUNNINGHAM, L.L.; PETERSON, G.P.; HAUG, R.H.  Therelationship between enophthalmos, linear displacement,and volume change in experimentally recreated orbitalfractures.  J. Oral Maxillofac. Surg., Philadelphia, v.63, n.8,p.1169-1173, Aug. 2005.10. AL-SUKHUN, J.; LINDQVIST, C.  A comparative study of 2 implantsused to repair inferior orbital wall bony defects: autogenousFigure 5. Clinical aspect of the patient at 6 months post-operative.access to the fracture (Figure 2). Correction of theremaining orbital floor was carried out using MEDPOR®(Porex Surgical, Inc, College Park, GA) high densitypolyethylene fixed with two 4mm titanium microscrews(Figure 3). The cut was sutured in planes with 4-0 vicryland 5-0 mononylon. In the immediate post operativeperiod, the patient presented paresthesia, but notdiplopia. At 15 days (Figure 4) and 6 months (Figure 5)post-operative, the patient showed no sequelae.86 R. Ci. méd. biol. 2010; 9(1):83-86Orbital floor reconstructionbone graft versus bioresorbable poly-L/DL-Lactide [P(L/DL)LA70/30] plate.  J. Oral Maxillofac. Surg., Philadelphia, v.64,n.7, p.1038-1048, July 2006.11. ILIFF, N. et al.  Mechanism of extraocular muscle injury in orbitalfractures.  Plastic Reconstr. Surg., Hagerstown, v.103, n.3, p.787-799, Mar. 1999.12. PANARELLO, A.F. et al.  Fraturas orbitárias: diagnostico eindicações para cirurgia:  revisão de literatura.  R. Int. Cir.Traumatol. Bucomaxilofac., Curitiba, v.2, n.8, p.245-251, 2004.13. KOLK, A. et al.  A novel high-resolution magnetic resonanceimaging microscopy coil  as an alternative to the multislicecomputed tomography in postoperative imaging of  orbitalfractures and computer-based volume measurement.  J. OralMaxillofac. Surg.,Philadelphia, v.63, n.4, p.492-498, Apr. 2005.14. ELLIS 3rd, E.; TAN, Y.  Assessment of internal orbitalreconstruction for pure blow  out fractures: cranial bone graftsversus titanium mesh.  J. Oral Maxillofac. Surg., Philadelphia,v.61, n.4, p.442-453, Apr. 2003.15. JANK, S. et al.  Clinical signs of orbital wall fractures as a functionof anatomic location.  Oral Surg. Oral Med. Oral Pathol. OralRadiol. Endod., St. Louis, v.96, n.2, p.149-153, Aug. 2003.16. KONTIO, R.  Treatment of orbital fractures: the case forreconstruction with autogenous bone.  J. Oral Maxillofac. Surg.,Philadelphia, v.62, n.7, p.863-868, July 2004.17. ZIM, S.  Skeletal volume enhancement: implants andosteotomies.  Curr. Opin. Otolaryngol. Head Neck Surg.,Philadelphia, v.12, n.4, p.349-356, Aug. 2004.18. RENÒ, F.; LOMBARDI, F.; CANNAS, M.  Oxidation increasesgranulocytes activation: a role in tissue response after prosthesisimplant.  Biomaterials, Oxford, v.24, n.17, p.2895-2900, Aug 2003.19. HARRIS, G.J. et al.  Correlation of preoperative computedtomography and postoperative ocular motility in orbitalblowout fractures.  Ophthal. Plast. Reconstr. Surg., Hagerstown,v.16, n.3, p.179-187, May 2000.20. BRADY, S.M. et al.  The diagnosis and management of orbitalblow out fractures: update 2001.  Am. J. Emerg. Med.,Philadelphia, v.19, n.2, p.147-154, Mar. 2001.21. TANRIKULU, R.; EROL, B.  Comparison of computed tomographywith conventional radiography for midfacial fractures.Dentomaxillofac. Radiol., Houndsmills, v.30, n.3, p.141-146,May 2001.22. SOARES, L.P. et al.  Indicações da tomografia computadorizadano diagnóstico das fraturas naso-órbito-etimoidais.  R. Clin.Pesq. Odontol., Curitiba, v.1, n.1, p.29-33, 2004.23. BANSAGI, Z.C.; MEYER, D.R.  Internal orbital fractures inthe pediatr ic  age group:  character izat ion andmanagement.   Ophthalmology,  New York,  v.107,  n.5,p.829-836, May 2000.24. EGBERT, J.E. et al.  Pediatric orbital floor fracture: directextraocular muscle involvement.  Ophthalmology, New York,v.107, n.10, p.1875-1879, Oct. 2000.25. SIDDIQUE, S.A.; MATHOG, R.H.  A comparison of parietal and iliaccrest bone grafts for orbital reconstruction.  J. Oral Maxillofac.Surg., Philadelphia, v.60, n.1, p.44-50,  Jan. 2002.26. GRANT 3rd, J.H. et al.  Trapdoor fracture of the orbit in a pediatricpopulation.  Plastic Reconstr. Surg., Hagerstown, v.109, n.2,p.482-489, Feb. 2002.

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Orbital floor reconstruction with high density polyethylene

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