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Year : 2019  |  Volume : 7  |  Issue : 2  |  Page : 34-37

Intraoperative three-dimensional imaging in the management of orbital trauma

1 Department of Oral-Maxillofacial Surgery and Pathology, University of Mississippi Medical Center, Jackson, Mississippi, USA
2 Department of Care Planning and Restorative Sciences, University of Mississippi Medical Center, Jackson, Mississippi, USA

Date of Web Publication1-Oct-2019

Correspondence Address:
Pia Chatterjee Kirk
2500 N. State Street, Jackson, Mississippi 39216
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jomr.jomr_16_19

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Background: Intraoperative three-dimensional (3D) imaging can be utilized to detect bone malpositioning during facial fracture repair. Aim: This article exhibits a case of left Zygomatic maxillary complex fracture that was repaired with the aid of intraoperative 3D imaging technology. Methods: A critical size orbital floor defect was apparent on the imaging, necessitating an immediate repair avoiding a second-revision surgery. Results and Conclusion: The use of 3D imaging has historically been underutilized due to financial and time constraints. However, when comparing to costs and time utilized to undergo a second surgery, usage of 3D imaging intraoperatively is beneficial to the patient, team, and the institution.

Keywords: Orbital floor fractures, three-dimensional imaging, Facial trauma

How to cite this article:
Chandran R, Kirk PC, Moses W. Intraoperative three-dimensional imaging in the management of orbital trauma. J Oral Maxillofac Radiol 2019;7:34-7

How to cite this URL:
Chandran R, Kirk PC, Moses W. Intraoperative three-dimensional imaging in the management of orbital trauma. J Oral Maxillofac Radiol [serial online] 2019 [cited 2023 Mar 21];7:34-7. Available from: https://www.joomr.org/text.asp?2019/7/2/34/268236

  Introduction Top

Management and reconstruction of the facial skeleton in craniomaxillofacial trauma continues to be a challenge and requires accurate restoration of the three-dimensional (3D) anatomic relationships during surgery.[1],[2],[3] Visual assessment during surgery is difficult and inaccurate due to the presence of soft-tissue swelling, avulsive defects, and comminuted and displaced structures. Intraoperative computed tomography (CT) has gained popularity in craniomaxillofacial trauma surgery over the past decade and is now utilized by many centers. Computer-aided surgery was initially designed for neurosurgery, later being utilized in oral and maxillofacial surgery due to the level of accuracy.[4] Preoperatively, patient's CT and magnetic resonance imaging (MRI) can be taken and interpreted to see the surgical site and associated anatomical structures. Computer-assisted surgery can assist the surgical team preoperatively or navigation during surgery. Preoperatively, 3D models and images are used to help the surgeon to determine the placement of implants or degree of positioning of bones during orthognathic surgery. Navigation was developed as the next phase of computer-assisted surgery. Navigation systems allow the surgeon to use the surgery tools combined with data received from the 3D CT or MRI. The surgeon can maneuver into delicate anatomy with a minimally invasive approach, utilizing the sectional views from the imaging.[4] The navigation process is typically done in three steps. The first step is the diagnostic data gathering which includes the physical examination and imaging. Once these are evaluated, a surgical plan can be developed. The second step is a type of rehearsal of the surgery. Utilizing the 3D images model, software, splints, and guides, the preoperative surgical plan is designed at this state. The third step is to take the “virtual surgery planning” and use it to perform the surgery, after which surgical outcomes are assessed.[5] Here, we report some of the indications and usage of intraoperative O-arm™ [Figure 1] imaging system for acquisition of 3D images in facial trauma patients. This use was designed primarily for orthopedic and vascular surgery. It uses less radiation dosage and much less exposure for the technicians and surgeons who are present for the case. The O-shaped arm encircles the operating table allowing space for the surgical team.
Figure 1: The O-arm™ imaging system is a mobile X-ray system designed for two-dimensional fluoroscopic and three-dimensional imaging for adult and pediatric patients

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  Methods Top

In this report, we present a case of a 47-year-old male who sustained assault to his maxillofacial region. He was assessed by the University of Mississippi Oral and Maxillofacial Surgery Department and was determined to have sustained a left zygomaticomaxillary complex (ZMC) fracture involving the left zygomatic arch, left lateral orbital wall, and anterior and posterolateral aspect of the left maxillary sinus [Figure 2]. The patient's preoperatively visual assessment was fairly benign. He exhibited mild left subconjunctival hemorrhage, left periorbital edema and ecchymosis, and no diplopia, and his orbital rim was stable with only a minor step-off noted. Due to the amount of displacement of the fractures and the instability within the fractures, operative intervention was deemed necessary. The patient was taken to the operating room 1 week after initial injury for operative intervention.
Figure 2: Preoperative computed tomography image depicting facial fractures involving the left zygomaticomaxillary complex. Note the displacement at the left frontozygomatic, left infraorbital, and left zygomatic arch regions. The picture on the right depicts his initial presentation to our emergency department

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Multiple surgical approaches were utilized for reduction of this complex maxillofacial fracture. Initially, a lateral brow approach was utilized to achieve visualization of the left zygomaticofrontal suture region. After full exposure of this region, the orbital floor and the rim were exposed via a transconjunctival retroseptal approach until the rim and the floor were fully visualized. Finally, a maxillary vestibular incision was made and access to the ZMC buttress region was achieved. All fractures were mobilized. After verifying the proper reduction of the zygoma at the exposed fracture site, the initial plating was performed at the infraorbital rim. Next, the zygomaticofrontal suture was plated, followed by the ZMC buttress and piriform rim. All fractured segments were then visualized and deemed appropriately reduced and fixated. Traditionally, visual inspection is all the assessment performed intraoperatively to confirm satisfactory reduction.

Next, the intraoperative O-arm™ system was brought into the operating room to achieve 3D imaging after reduction and fixation. After obtaining the 3D images, a significant orbital floor defect was noticed that was not fully appreciated preoperatively [Figure 3]. The decision was then made to fully explore the inferior orbital floor, reduce the fracture, and reconstruct the defect with a pre-shaped titanium orbital floor implant. Surgical closure was then completed, and the patient was awakened from general anesthesia.
Figure 3: Intraoperative scans showing good reduction of left zygomaticomaxillary fracture, with unappreciated large orbital blowout fracture still needing repair

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  Results Top

Postoperatively, the patient was followed by the Oral and Maxillofacial Surgery Department under standard guidelines and exhibited a normal healing course. His visual examination remained benign, and the patient exhibited no functional or cosmetic defects. A postoperative in-office CT scan was obtained to fully visualize the fractured segments and was deemed satisfactory [Figure 4].
Figure 4: Postoperative scans showing proper reduction of all fracture segments including the left orbital floor reconstruction. The fractures are typically fixated at the zygomatic buttress, infraorbital, and frontozygomatic regions. Note the postoperative photo showing adequate facial projection

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  Discussion Top

The zygoma is a quadrangular-shaped bone that provides a lateral and anterior projection of the central part of the face. It articulates with the frontal, temporal, maxillary, and sphenoid bone at the zygomaticofrontal, zygomaticotemporal, ZMC, and zygomaticosphenoid sutures. The ZygomaticoSphenoid suture and Zygomatic arch are the key landmarks for the verification of anatomic reduction. Clinicians should understand that the zygoma forms major portions of the orbital floor and lateral wall, and therefore, all fractures of the ZMC involve the orbit. Treatment goals of ZMC fracture are restoration of facial projection and facial symmetry as well as restoration of orbital volume, globe position, and shape of the palpebral fissure. Intraoperatively, it is difficult to fully visualize all key areas of reduction in a complex ZMC fracture. The intraoperative O-arm™ provides a sense of security in managing complex craniomaxillofacial trauma cases; in that it provides valuable imaging intraoperatively that may prevent the need for “take-back revision surgery.”

Historically, utilizing CT scanners intraoperatively is very cost-prohibitive, time consuming, too large for the operating room utilization, and produced large radiation dosages. Newer intraoperative imaging modalities, such as the O-arm™, are mobile, efficient, and customizable to the surgical site, limits radiation dosage, and limits the need to send the patient to radiology. The additional time added to operative time is under 20 min that involves sterile draping of the patient, obtaining the images, and viewing the results. The O-arm™ is highly mobile and requires minimal positional changes with the operating room table. Utilizing 3D technology for craniofacial surgeries allows more precision to be used from the planning phases to the execution of treatment.[6]

In this example of oral and maxillofacial surgery, the navigation system was primary in the zygomatic or midfacial region. This is typically an immobile region, unlike the mandible which would be more difficult to match up with the presurgical imaging.[4]

  Conclusion Top

The result of our study is consistent with other reports that state intraoperative CT can detect implant or bone malposition which allows for correction at the time of initial repair and prevents the need for a secondary procedure.[7] Given the cost of re-operating and the complexity of a revision surgery, very few revision procedures would need to be performed to justify the use of intraoperative 3D imaging. Added benefits include less time in the operating room under general anesthesia due to preplanned surgeries, keeping surgeries minimally invasive, better healing, and allowing the patient to return to their normal lifestyles in a reasonable time frame.[8] To summarize, intraoperative CT scan is a critical armamentarium for surgeons operating in the maxillofacial region. They provide invaluable intraoperative information that lowers the chances of necessitating secondary revision surgery and improves clinical outcomes.

Declaration of patient consent

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

Financial support and sponsorship


Conflicts for interest

There are no conflicts for interest.

  References Top

Kellman RM, Tatum SA. Pediatric craniomaxillofacial trauma. Facial Plast Surg Clin North Am 2014;22:559-72.  Back to cited text no. 1
Bitonti DA. Craniomaxillofacial trauma. Atlas Oral Maxillofac Surg Clin North Am 2013;21:7-8.  Back to cited text no. 2
Ellis E 3rd. Update on craniomaxillofacial trauma. J Oral Maxillofac Surg 2017;75:888-9.  Back to cited text no. 3
Sukegawa S, Kanno T, Furuki Y. Application of computer-assisted navigation systems in oral and maxillofacial surgery. Jpn Dent Sci Rev 2018;54:139-49.  Back to cited text no. 4
Lin HH, Lo LJ. Three-dimensional computer-assisted surgical simulation and intraoperative navigation in orthognathic surgery: A literature review. J Formos Med Assoc 2015;114:300-7.  Back to cited text no. 5
Cevidanes LH, Tucker S, Styner M, Kim H, Chapuis J, Reyes M, et al. Three-dimensional surgical simulation. Am J Orthod Dentofacial Orthop 2010;138:361-71.  Back to cited text no. 6
Bagheri SC, Bell RB, Khan HA. Current Therapy in Oral and Maxillofacial Surgery. Philadelphia: Elsevier Saunders; 2012. p. 324-33.  Back to cited text no. 7
Hegab A. The cutting Edge in oral and maxillofacial surgery. J Oral Hyg Health 2015;3:184.  Back to cited text no. 8


  [Figure 1], [Figure 2], [Figure 3], [Figure 4]


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