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American Journal Of Biomedical Science & Pharmaceutical Innovation    
(ISSN – 2771-2753) 
VOLUME 03 ISSUE 05     Pages: 05-18 

SJIF IMPACT FACTOR (2021: 5. 705) (2022: 5. 705) (2023: 6.534) 
OCLC – 1121105677     

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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ABSTRACT 

The introduction of digital technologies and improvement of reconstruction methods, diagnostics of combined 

traumas of the maxillofacial region should be aimed at improving the quality of life and aesthetic parameters of 

patients, reducing traumatization, reconstructing anatomical areas, reducing the duration of the postoperative 

period. 

KEYWORDS 

Maxillofacial surgery, orbital floor, reconstruction, trauma, face. 

INTRODUCTION 

Orbital reconstruction is the first and most predictable 

step in the surgical treatment of orbital fractures. 

Orbital reconstruction is *keyhole* surgery performed 

in an enclosed space. The technology-supported 

workflow, called computer-assisted surgery (CAS), has 

become the standard for complex orbital trauma 

surgery in many hospitals. CAS technology has become 

the catalyst for the implementation of personalized 

medicine in orbital reconstruction. The complete 

workflow consists of diagnosis, planning, surgery, and 

  Research Article 

 

MODERN COMPREHENSIVE TREATMENT OF FACIAL INJURIES 
 

Submission Date: May 05, 2023, Accepted Date:  May 10, 2023,  

Published Date: May 15, 2023  

Crossref doi: https://doi.org/10.37547/ajbspi/Volume03Issue05-02 

 

 

Shamov Vladislav 
Students Dental Istitute Of Tashkent, Uzbekistan 

 

Kholikov Azizbek Alimurodovich 
Students Dental Istitute Of Tashkent, Uzbekistan 

 

Fattayeva Dilorom Rustamovna 
Students Dental Istitute Of Tashkent, Uzbekistan 

Journal Website: 

https://theusajournals.

com/index.php/ajbspi 

Copyright: Original 

content from this work 

may be used under the 

terms of the creative 

commons attributes 

4.0 licence. 

 

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Volume 03 Issue 05-2023 6 

                 

 
 

   
  
 

American Journal Of Biomedical Science & Pharmaceutical Innovation    
(ISSN – 2771-2753) 
VOLUME 03 ISSUE 05     Pages: 05-18 

SJIF IMPACT FACTOR (2021: 5. 705) (2022: 5. 705) (2023: 6.534) 
OCLC – 1121105677     

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Publisher: Oscar Publishing Services 

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evaluation. Advanced diagnostics and virtual surgical 

planning are methods used in the preoperative phase 

to optimally prepare for surgery and adapt treatment 

to the patient. Further personalization of treatment is 

possible if the reconstruction is performed using an 

implant that is customized for the patient, and several 

design options are available to adapt the implant to the 

individual needs. During surgery, visual assessment is 

used to evaluate the resulting position of the implant. 

Surgical navigation, intraoperative imaging, and 

special PSI design options can improve feedback in the 

CAS workflow. Assessment of surgical outcome can be 

done both qualitatively and quantitatively. The 

concepts of CAS and personalized medicine are 

intertwined throughout the workflow. A combination 

of methods can be used to achieve the most optimal 

clinical outcome. 

 

The position of the globe after trauma may be 

displaced, for example, with inward displacement 

(enophthalmos) or downward displacement 

(hypoglobus). The soft tissues of the orbit may also be 

affected by trauma. The structural integrity and 

functionality of the connective tissue or extraocular 

muscles may be compromised, resulting in impaired 

eye movement and double vision (diplopia). The 

location and type of impact, combined with the 

amount of energy delivered to the bony structures of 

the orbit and the soft tissues of the orbit, cause a 

heterogeneous clinical picture. 

There is an ongoing debate about the indications for 

surgical reconstruction, and systematic reviews have 

failed to provide evidence-based recommendations. 

Some advocate a radical approach to prevent clinical 

symptoms, others opt for a more conservative 

approach with delayed surgery if clinical symptoms 

develop. The indication for reconstruction in most 

cases remains a subjective decision, depending on the 

surgeon and the characteristics of the patient. Surgical 

treatment of orbital fractures focuses on repositioning 

the contents of the orbit and globe and restoring 

structural support to restore ocular function. Orbital 

reconstruction is the first and most predictable step in 

the surgical treatment of orbital fractures. 

Titanium mesh implants have now become the 

preferred biomaterial for surgical orbital 

reconstruction. Titanium implants can be divided into 

flat implants, pre-formed implants, and patient-specific 

implants (PSIs). Flat implants are shaped and trimmed 

by hand by the surgeon. A generic or custom (mirror) 

orbital model can assist in the shaping process. 

Prefabricated implants have a predetermined shape 

based on the mid orbital model . Patient Specific 

Implants (PSIs) are designed individually for the 

patient and are subsequently manufactured using 

additive manufacturing. 

The complex soft tissue architecture and proximity to 

vital structures create surgical challenges in orbital 

reconstruction. Orbital reconstruction is a keyhole 

surgery performed in a limited space. This contributes 

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Volume 03 Issue 05-2023 7 

                 

 
 

   
  
 

American Journal Of Biomedical Science & Pharmaceutical Innovation    
(ISSN – 2771-2753) 
VOLUME 03 ISSUE 05     Pages: 05-18 

SJIF IMPACT FACTOR (2021: 5. 705) (2022: 5. 705) (2023: 6.534) 
OCLC – 1121105677     

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Publisher: Oscar Publishing Services 

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to limited visualization, which is further enhanced by 

the protruding fat. The margin for error is small: an 

improperly placed implant can have significant 

implications for the clinical outcome and quality of life 

of the patient, and the literature considers this to be 

grounds for revision surgery. Medical technology has 

been incorporated into the clinical workflow of orbital 

reconstructions to reduce the risk of incorrect 

positioning of the implant . 

This technologically supported workflow, called 

computer-assisted surgery (CAS), has become the 

standard for complex orbital trauma surgery in many 

hospitals. The introduction of CAS has also allowed 

personalization of treatment: treatment planning is 

tailored to the capabilities and needs of the patient, 

and intraoperative management is adjusted to 

anatomical capabilities. The main goal of this article is 

to provide a comprehensive overview of the CAS 

workflow for orbital reconstruction, with an in-depth 

description of the methods built into the workflow and 

a particular focus on personalizing treatment with 

patient-specific implant design. 

The workflow of post-traumatic orbital 

reconstruction 

The normal workflow of post-traumatic orbital 

reconstruction and the possible CAS methods are 

shown in  

Figure 1. The individual steps are described in detail in 

the following paragraphs. 

Diagnosis 

A thorough clinical and radiographic evaluation of the 

patient is necessary to determine the optimal 

treatment. The clinical evaluation should at least assess 

the magnitude of ocular displacement and the degree 

of double vision. The Hertel exophthalmometer is the 

simplest instrument to quantify the relative 

ventrodorsal position of the globe. Despite known 

limitations such as asymmetry of the lateral edges of 

the orbit, soft tissue compression, and lack of uniform 

technique, it is currently the gold standard.  

Computed tomography (CT) is the method of choice 

for radiographic evaluation because of its superior 

visualization of bony structures. The size and extent of 

the fracture can be assessed or measured in the 

coronal, sagittal, or axial plane. Given that the bone is 

thin in some areas, a maximum slice thickness of 1.0 

mm is essential for 

 evaluation. In individual cases, evaluation of soft tissue 

changes may become important. It has been reported 

that shape changes in the inferior rectus muscle affect 

delayed or postoperative enophthalmos and may 

influence treatment decisions. In addition, orbital soft 

tissue herniation may be an indication for surgical 

reconstruction. Magnetic resonance imaging (MRI) 

provides better soft tissue contrast than CT and is more 

sensitive to detect extraocular muscle or periorbital fat 

entrapment . However, MRI is not part of the standard 

imaging protocol for orbital trauma . This may change 

in the future, given that all subsequent stages of 

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Volume 03 Issue 05-2023 8 

                 

 
 

   
  
 

American Journal Of Biomedical Science & Pharmaceutical Innovation    
(ISSN – 2771-2753) 
VOLUME 03 ISSUE 05     Pages: 05-18 

SJIF IMPACT FACTOR (2021: 5. 705) (2022: 5. 705) (2023: 6.534) 
OCLC – 1121105677     

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Publisher: Oscar Publishing Services 

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treatment benefit from optimized information 

gathering at the diagnostic stage. 

Advanced diagnostics 

Extended diagnostics seeks to maximize the 

information extracted from the available image data. 

For this purpose, CT scans are imported into a virtual 

surgical planning software. The CT scan is divided into 

voxels (three-dimensional pixels), each with a gray 

value corresponding to the absorption of X-rays in a 

given volume. These voxels can be segmented 

(grouped) based on the type of tissue or anatomical 

structure to which they belong. Anatomical structures 

of interest in orbital trauma are the orbit, the orbital 

cavity, and possibly the surrounding bony structures, 

such as the zygomatic complex. The segmentation is 

visualized as supra-. 

in a multiplanar view and as a 3D model. Additional 

information can be gathered Through quantification 

(e.g., volume measurement) or manipulation (e.g., 

mirror image) 

Segmented anatomy. The unaffected contralateral 

orbit and orbital cavity in unilateral fractures can serve 

as a reference for the affected orbit, giving an idea of 

the extent of the fracture and the displacement of the 

orbital walls or the surrounding bony structures. The 

volume of the affected orbit can be compared with the 

volume of the unaffected healthy side to determine 

the relative change in volume, because it has been 

proven that the orbits are very symmetrical. These 

volume changes can be incorporated into the 

treatment plan. Information can also be extracted 

from several sets of images. Image Image fusion allows 

multiple datasets of the same modality to be aligned 

over time or sets of images from different modalities. 

Image sets can be simultaneously visualized and 

evaluated after image fusion. The segmentation 

process can also be based on information from several 

merged modalities. 

 

 

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Volume 03 Issue 05-2023 9 

                 

 
 

   
  
 

American Journal Of Biomedical Science & Pharmaceutical Innovation    
(ISSN – 2771-2753) 
VOLUME 03 ISSUE 05     Pages: 05-18 

SJIF IMPACT FACTOR (2021: 5. 705) (2022: 5. 705) (2023: 6.534) 
OCLC – 1121105677     

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Publisher: Oscar Publishing Services 

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Figure 2: Extended diagnosis for two cases. I: Single orbital reconstruction (A-D). (A) Visualization of a three-

dimensional model of the bone surface. (B) Segmentation of the unaffected orbit. (C) Mirroring of the segmented 

orbit on the affected, contralateral side. (D) Visualization of additional structures such as the globe and ocular muscles. 

II Fracture of the zygomatic (F) Segmentation of the unaffected side. (G) Mirroring of the segmentation on the 

affected, contralateral side. (H) Visualization of displacement of the zygomatic complex. 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Design of a preformed titanium orbital implant. Size modifications can easily be performed by reducing the 

intersection bars. 

Intraoperative image fusion of the preoperative (blue 

outline) and intraoperative data set (orange) in coronal 

view. In addition, the preoperative planning 

(segmentation and mirroring) and the intra- operative 

acquired was merged. The white arrow represents the 

real implant position comparing with the virtual 

planning one in red.  

Virtual surgical planning (VSP) is a simulation of a real 

surgery based on imaging data. It is based on 

information gathered from previous treatment steps. 

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Volume 03 Issue 05-2023 10 

                 

 
 

   
  
 

American Journal Of Biomedical Science & Pharmaceutical Innovation    
(ISSN – 2771-2753) 
VOLUME 03 ISSUE 05     Pages: 05-18 

SJIF IMPACT FACTOR (2021: 5. 705) (2022: 5. 705) (2023: 6.534) 
OCLC – 1121105677     

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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The exact content of virtual surgical planning depends 

on the type of implant. If a flat mesh plate is used, 

virtual models of the mirror orbit and the affected orbit 

can be exported and printed on a 3D printer to serve as 

custom template(s) for bending when shaping the flat 

mesh. 

When the finished implant is placed, a 

stereolithographic model (STL) of the finished implant 

is imported into the planning environment to perform 

a virtual reconstruction of the affected orbit. The 

potential for implant placement is assessed and its 

optimal position is simulated to accurately reconstruct 

the pre-injured anatomy. Thus, the potential for VSP in 

the pre-formed implant environment is highly 

dependent on the willingness of implant 

manufacturers to provide STL files of their pre-formed 

implants. In modern planning software, the implant 

can be automatically aligned to another virtual model, 

such as a mirrored orbit. Manual correction may be 

necessary to prevent bone interference and provide 

coverage of the orbital defect with adequate support 

of the implant on the dorsal protrusion and the 

possibility of fixation on the infraorbital rim. 

The implant can be virtually trimmed to simulate a 

medial or posterior implant cut. The surgery can be 

simulated several times in virtual surgical planning, 

with different implant types and sizes . This allows you 

to compare pre-prepared implant options and make an 

informed decision before surgery. The number of 

attempts during virtual planning is unlimited without 

consequences for the patient, unlike attempts during 

actual surgery. Determining the optimal position in 

virtual planning provides the surgeon with 

intraoperative feedback, which can reduce surgical 

time and the amount of intra-orbital manipulation 

during surgery. 

 

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Volume 03 Issue 05-2023 11 

                 

 
 

   
  
 

American Journal Of Biomedical Science & Pharmaceutical Innovation    
(ISSN – 2771-2753) 
VOLUME 03 ISSUE 05     Pages: 05-18 

SJIF IMPACT FACTOR (2021: 5. 705) (2022: 5. 705) (2023: 6.534) 
OCLC – 1121105677     

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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Figure 3: Virtual placement of various pre-formed implants for a single orbital fracture.  

 Three-dimensional models of the KLS Martin (A), Synthes (B) and Stryker (C) pre-formed implants are visualized with 

potential incision lines (black lines) in the first column. Implants are virtually positioned (red outline) and the fit is 

evaluated on the coronal, sagittal, and axial slices.  

Adequate support (on the posterior prominence, on the medial wall, and on the 

infraorbital rim) and no interference with the bone. 

 

Patient-specific implant design 

Orbital reconstruction with PSI is the final step in 

individualizing orbital reconstruction. The PSI is 

virtually modeled from scratch using information from 

the (advanced) diagnostic stage and exported virtual 

models. A prototype of the implant is created in special 

design software. The prototype is imported into virtual 

surgical planning and its fit is evaluated. The prototype 

position is not adjusted in virtual surgical planning to 

improve the fit, but the prototype design is adjusted 

and the new prototype is re-imported. Although the 

PSI design is not fixed in the protocols, various design 

variants have been described in the literature. An 

overview of the variants is given in Table 1. This 

overview is not exhaustive, and new design variants 

regularly appear in the literature. Structural 

considerations can be categorized according to their 

intended effect: stability, ease of positioning, accuracy 

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Volume 03 Issue 05-2023 12 

                 

 
 

   
  
 

American Journal Of Biomedical Science & Pharmaceutical Innovation    
(ISSN – 2771-2753) 
VOLUME 03 ISSUE 05     Pages: 05-18 

SJIF IMPACT FACTOR (2021: 5. 705) (2022: 5. 705) (2023: 6.534) 
OCLC – 1121105677     

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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of implant placement, or relief of clinical symptoms. 

The size and shape of the implant depend on the 

extent of the defect. The defect must be covered by 

the implant, and its shape should reflect the intended 

reconstruction of the affected orbital walls. Reliance 

on existing bone structures is taken into account to 

ensure stability of the reconstruction. Similar to pre-

formed implants, support is most often at three points 

in the orbit. Fixation is recommended to ensure the 

stability of the PSI. Possible screw positions can be 

evaluated in virtual planning, considering the patient's 

anatomy and local bone quality. Implant thickness and 

the presence of an atraumatic cord around the edge 

are factors that affect both implant stability and ease 

of positioning during surgery. Thanks to the rigidity of 

additively manufactured titanium, the implant 

thickness of 0.3 mm combined with the atraumatic 

cord provides a good balance between rigidity and 

ease of positioning. 

The accuracy of positioning of the implant can be 

controlled by extending over the unaffected bone 

supports. Extension of the implant over the bony 

structures creates a secure fixation. Extension of the 

infraorbital rim limits rotation and translation in the 

anteroposterior direction. Additional flaps may be 

placed on the posterior lateral wall to prevent 

unwanted movement of the implant. The screw 

positions from the fixation material of the previous 

reconstruction can be reused in the secondary 

reconstruction to provide guidance and thus increase 

the accuracy of the implant positioning . Another 

design option is the inclusion of navigation markers 

and vectors that can improve the interpretation of 

feedback from the intraoperative navigation system. 

The last category, clinical symptoms, is related to the 

correction of globe displacement. 

overcorrection to counteract fat atrophy and 

anticipated iatrogenic soft tissue loss. 

The amount of overcorrection can be subjectively 

determined at the time of surgery, by introducing 

Orbital volume is corrected to reduce globe 

displacement, but the volume can be after the equator 

of the bulbus . On the other hand, hypoglobus are 

additional struts, or it can be fully integrated into the 

PSI structure, the posterior portion of which is the 

result of caudal displacement of the infraorbital rim. 

The anterior elevation, corresponding to the equator 

of the bulbus . On the other hand, the hypoglobe is the 

result of a caudal downward displacement of the 

orbital rim, which can facilitate the hypoglobe. 

Displacement of the infraorbital rim. The anterior 

elevation corresponding to the amount of (Figure 4). 

The PSI grid can be developed using a variety of 

techniques: the use of a large downward displacement 

of the orbital rim can facilitate the hypoglobe (Figure 

4). A horizontal grid pattern for maximum drainage, or 

a more porous arrangement of PSIs can be developed 

using a variety of techniques: the use of a large 

horizontal pattern for The multitude of design and 

hand-design options results in a wide range of 

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Volume 03 Issue 05-2023 13 

                 

 
 

   
  
 

American Journal Of Biomedical Science & Pharmaceutical Innovation    
(ISSN – 2771-2753) 
VOLUME 03 ISSUE 05     Pages: 05-18 

SJIF IMPACT FACTOR (2021: 5. 705) (2022: 5. 705) (2023: 6.534) 
OCLC – 1121105677     

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Publisher: Oscar Publishing Services 

Servi 

maximizing drainage, or a more porous arrangement. 

The many possible forms of PSI 

Design options and manual design result in a wide 

range of possible PSI shapes 

Figure 4: Examples of two patient-specific implant designs with overcorrection (red outline) in 

mirrored orbital volume (yellow outline). 

The first patient-specific implant is designed with an 

anterior elevation on the infraorbital rim to 

compensate for globe position asymmetry (A,B). The 

second patient-specific implant is designed with a large 

overcorrection to reconstruct the anophthalmic eye 

socket (C,D). 

 

Figure 5. Shows the different shapes of available prefabricated implants and patient-specific implants 

There is a wide variety of shapes of patient-specific 

implants. From left to right the rim extension 

increases. From top to bottom medial wall support 

increases 

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Volume 03 Issue 05-2023 14 

                 

 
 

   
  
 

American Journal Of Biomedical Science & Pharmaceutical Innovation    
(ISSN – 2771-2753) 
VOLUME 03 ISSUE 05     Pages: 05-18 

SJIF IMPACT FACTOR (2021: 5. 705) (2022: 5. 705) (2023: 6.534) 
OCLC – 1121105677     

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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The PSI design can be adapted to facilitate 

reconstruction of multi-walled defects, for example, by 

using multiple PSIs (Figure 6). This allows a 

reconstruction that covers the entire defect, while 

limiting the size of the PSI and, in turn, the required 

incision [46,55]. Depending on the connection used, it 

also provides an opportunity to create artificial support 

and relative feedback. In cases with concomitant 

fractures of the surrounding bony structures, orbital 

reconstruction with PSI alone is not sufficient. In 

addition to orbital reconstruction, repositioning of the 

surrounding bone may be necessary. Additional design 

options are available to provide PSI feedback on the 

subsequent steps of reconstruction in these more 

complex cases. Examples include incorporating the 

desired position of the zygomatic complex into the PSI 

design to facilitate proper repositioning   

Figure 6. Patient-specific implant design for multivessel 

cases. (A) The ridges on the orbital floor implant 

provide relative feedback for positioning the lateral 

wall implant. (B) Matrix-matrix connection to connect 

the medial wall implant and the orbital floor. (C) The 

orbital floor implant with medial wall extension is 

connected to the lateral wall implant dorsally with 

ridges and anteroposteriorly with a jigsaw joint. (D) 

Quadruple wall reconstruction with hook-and-loop 

connection for additional support of the orbital floor 

implant. 

Intraoperative feedback 

During surgery, the surgeon strives to position the 

implant as close as possible to the ideal position that 

was established in the HSP. The presence of the VSP 

provides intraoperative feedback, which improves the 

outcome of the reconstruction [35]. There are 

additional types of feedback that help with accurate 

positioning of the implant (summarized in Table 2). 

Design options related to implant positioning provide 

static feedback through a unique and convincing PSI fit 

(Figure 7). In secondary cases, reuse of screw positions 

from the primary reconstruction will also help to find 

the planned position. 

 

 

Figure 7: Illustration of the different feedback 

methods.). Markers and vectors are visualized in (A) 

and (B). The convincing match of the patient-specific 

implant design is indicated by red arrows (A-C) 

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Volume 03 Issue 05-2023 15 

                 

 
 

   
  
 

American Journal Of Biomedical Science & Pharmaceutical Innovation    
(ISSN – 2771-2753) 
VOLUME 03 ISSUE 05     Pages: 05-18 

SJIF IMPACT FACTOR (2021: 5. 705) (2022: 5. 705) (2023: 6.534) 
OCLC – 1121105677     

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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Segmentation of the screw holes of the previous 

reconstruction is shown in red (D) and the previous 

implant is shown in dark gray. 

Surgical navigation can be used to provide dynamic 

feedback of the implant position. During registration 

for surgical navigation, the patient's position in the 

operating room is linked to preoperative imaging data 

in virtual surgical planning. There are several methods 

of registration: soft-tissue registration, bone-fixed 

fiducials, and surgical splints. Splint registration 

methods used to require repeated radiographs with a 

fiducial splint in place, but combining intraoral 

scanning data during the in-depth diagnostic phase 

allows a registration splint to be fabricated without 

additional radiological imaging [59]. The splint is 

designed taking into account the individual features of 

the patient's dentition and contains fiducials that can 

be specified virtually in the planning software and 

physically in the operating room. 

After registration, the position of the navigation 

pointer in the patient is visualized in the virtual surgical 

planning on the screen of the navigation system. 

Once registered, the position of the navigation pointer 

in the patient is visualized in the virtual surgical 

planning on the navigation system screen. This 

provides the surgeon with feedback on the position of 

the pointer, representing the position of the specified 

location (a specific point on the implant surface). The 

quality and interpretability of the feedback can be 

improved with navigation markers embedded in the 

design [39,52]. 

The markers are indicated in the EP as navigational 

landmarks and are used in the operating room as a 

reference point. If the surgeon places a pointer in the 

navigational marker on the implant, visual and 

quantitative feedback about the position of the 

pointer in relation to the landmark is provided. 

 

Figure 8: Illustration of the evaluation. (A) Three-dimensional model of the planned patient-specific implant (red) 

and the realized patient-specific implant (green) from different perspectives. 

(B-D) Axial, sagittal, and coronal views of the 

postoperative CT scan with the planned contour of the 

patient-specific implant highlighted in red. 

An optimally positioned orbital implant is no guarantee 

for a perfect clinical result. Restoration of the globe 

position can be achieved relatively well with PSI, even 

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American Journal Of Biomedical Science & Pharmaceutical Innovation    
(ISSN – 2771-2753) 
VOLUME 03 ISSUE 05     Pages: 05-18 

SJIF IMPACT FACTOR (2021: 5. 705) (2022: 5. 705) (2023: 6.534) 
OCLC – 1121105677     

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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in secondary reconstructions [22]. The treatment of 

diplopia is more difficult because it involves mechanical 

eye movement, combined visual perception and 

processing in the visual cortex. Visual processing can 

(partially) adapt over time. On discharge, the patient is 

informed that double vision will be present for the first 

10-14 days, possibly longer. 

Ocular mobility can be improved by training the 

extraocular muscles to prevent scarring and anticipate 

fibrosis [61]. Instructions are given to mobilize the eye 

as much as possible: monocular orthoptical exercises 

six times a day for 6-12 weeks to prevent adhesions and 

to stimulate the reduction of orbital soft tissue edema, 

especially for the extraocular muscles. This protocol 

has a positive effect on clinical improvement in both 

primary and secondary cases. 

Several larger comparative studies have demonstrated 

a positive effect of (components of) CAS on the 

accuracy of volumetric reconstruction [62], clinical 

outcomes [36], and the need for revision surgery [63]. 

In practice, a combination of several CAS components 

is often used. This leads to heterogeneity of surgical 

approaches, which makes it difficult to compare results 

between studies. Differences in indications, patient 

and fracture characteristics, and implant materials 

used further complicate the comparison [64]. 

Determining the effect of individual CAS techniques on 

patient outcomes is difficult because of the overlap 

between the techniques in the groups studied. 

Individual effects of CAS techniques have been 

evaluated in a one-to-one comparison on a series of 

cadavers [65]. Despite the limitations of the cadaveric 

model and the inability to estimate clinical outcome 

parameters, a positive effect of virtual planning, 

intraoperative imaging, and surgical navigation on 

reconstruction accuracy was found. 

The best solution to achieve an optimal result [78] and 

in the future can be accurately adapted to the 

individual patient, provided the above knowledge gaps 

are filled. Cost, turnaround time, and logistical 

requirements are disadvantages of using PSI. Pricing. 

can vary depending on geography, but typically the 

process costs between 1,500 and 6,000 euros. Making 

the implant takes about 3-5 business days; this amount 

does not include sterilization or the time required for 

virtual surgery planning and design. Korn et al. 

described the average communication time between 

the surgeon and the PSI technician during virtual 

surgical planning, which was nearly nine days for 

isolated wall fractures and 16 days for multi-wall 

fractures [82]. Adjustments to the original design 

proposed by the technician were required in nearly 

three-quarters of cases, but implants placed by 

technicians trained by the company required fewer 

adjustments. Improved communication and 

understanding are believed to be the reasons for the 

increased efficiency. Complete in-house planning and 

design by a dedicated technician on site can improve 

planning efficiency and ultimately significantly reduce 

preparation time (assuming the surgeon and 

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Volume 03 Issue 05-2023 17 

                 

 
 

   
  
 

American Journal Of Biomedical Science & Pharmaceutical Innovation    
(ISSN – 2771-2753) 
VOLUME 03 ISSUE 05     Pages: 05-18 

SJIF IMPACT FACTOR (2021: 5. 705) (2022: 5. 705) (2023: 6.534) 
OCLC – 1121105677     

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Publisher: Oscar Publishing Services 

Servi 

technician are experienced and have collaborated on 

previous cases). In-house design is supposed to reduce 

costs because the commercial partners rely only on 

production. These advantages of in-house design may 

be why surgeons using in-house planning feel less of 

the disadvantages of using PSI . 

Although this paper focuses on posttraumatic orbital 

reconstruction, other orbital-related applications of 

PSI have also been described. In cheekbone 

reconstruction after trauma, ablative surgery or 

congenital deformity, PSI has been found to accurately 

restore anatomy without the need for additional bone 

grafts. In secondary posttraumatic reconstruction of 

the orbit and zygomatic bone, PSIs allow for a one-

stage surgical procedure in which the order of 

operations is reversed: if the orbit is operated on first, 

the functional result of orbital reconstruction does not 

depend on repositioning of the zygomatic complex 

[54]. PSIs can also be used to create an artificial rim and 

orbital floor to support the globe after maxillectomy 

[84,85]. The most extensive orbital reconstructions 

using PSI have been described after resection of a 

spheno-orbital meningioma or neurofibroma . In these 

cases, reconstruction of all four orbital walls with 

multiple PSIs allowed predictable reconstruction of the 

internal orbital structure under the same surgical 

conditions as the resection. The design of PSI in the 

aforementioned cases may differ significantly from 

that of posttraumatic reconstruction of single orbital 

fractures. Nevertheless, the point of using PSI is the 

same: freedom of design to adapt PSI to the patient's 

anatomy and a predictable and accurate end result. 

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