CRANIOMAXILLOFACIAL TRAUMA

Does Integration of Technology and

Customization of Implants Produce
Better Outcomes in Post-Traumatic
Orbital Reconstruction? A Systematic
Review and Meta-Analysis
Varad Rajendra Saptarshi, MDS,* Srivalli Natarajan, MDS,y
Padmakar Sudhakar Baviskar, MDS,z
Suraj Arjun Ahuja, MDS,x and Aditya Dinesh Dhirawani, MDS*
Purpose: This review aims to compare and evaluate the outcomes achieved by integrating techno-
logical aids and the influence of different implant designs in the reconstruction of post-traumatic
orbital defects.
Methods: Electronic searches of the MEDLINE, Embase, Cochrane Library, and Google Scholar databases
until March 2023 were conducted. Clinical controlled trials, observational studies, cohort studies, and
retrospective studies were identified and included. The predictor variables were the integration of tech-
nological aids namely, computer-assisted surgical planning, mirror image overlay, and intraoperative nav-
igation with the utilization of different orbital implant designs (standard orbital meshes, preformed
implants, prebent implants, and patient-specific implant [PSI]) during post-traumatic orbital reconstruc-
tion. The primary outcome variables were orbital volume, diplopia, and enophthalmos. Weighted or
mean difference and risk ratios at 95% confidence intervals were calculated, where P ＜ .05 was consid-
ered significant and a random effects model was adopted.
Results: This review included 7 studies with 560 participants. The results indicate that the difference in
postoperative orbital volume between affected and nonaffected eye showed no statistically significant dif-
ference between PSI and prebent group (mean difference, 0.41 P = .28, I2 = 46%). PSI group resulted in
diplopia 0.71-fold less than that of the standard orbital mesh group but was not statistically significant
(P = .15). Standard orbital mesh group is 0.30 times at higher risk of developing enophthalmos as
compared to PSI group (P = .010). The literature suggests PSIs are preferred for patients with large defects
(Jaquiery’s III-IV), whereas prebent implants are equally effective as PSIs in patients with preserved infraor-
bital buttress and retrobulbar bulge.
Conclusion: PSIs are associated with improved outcomes, especially for correcting enophthalmos. The
data suggests the potential efficacy of prebent implants and PSIs in orbital volume corrections. There is a

*Resident, Department of Oral & Maxillofacial Surgery, MGM
Dental College & Hospital, Navi Mumbai, Maharashtra, India.
yDean, Professor and Head, Department of Oral & Maxillofacial
Surgery, MGM Dental College & Hospital, Navi Mumbai,
Maharashtra, India.
zAssistant Professor, Department of Oral & Maxillofacial Surgery,
MGM Dental College & Hospital, Navi Mumbai, Maharashtra, India.
xAssociate Professor, Department of Oral & Maxillofacial Surgery,
MGM Dental College & Hospital, Navi Mumbai, Maharashtra, India.
Conflict of Interest Disclosures: None of the authors have any
relevant financial relationship(s) with a commercial interest.
Address correspondence and reprint requests to Dr Natarajan:
Department of Oral & Maxillofacial Surgery, MGM Dental College
& Hospital, Sector – 1 Kamothe, Navi Mumbai, Maharashtra, India
410209; e-mail: srivalli.shrikanth@gmail.com
Received October 16 2023
Accepted March 26 2024
Ó 2024 American Association of Oral and Maxillofacial Surgeons
0278-2391/24/00213-1
https://doi.org/10.1016/j.joms.2024.03.031

1
2 DO TECHNOLOGICAL AIDS PRODUCE BETTER OUTCOMES IN ORBITAL RECONSTRUCTION?
lack of randomized studies. This review should serve as a recommendation for further studies to contribute
to the existing literature.
Ó 2024 American Association of Oral and Maxillofacial Surgeons
J Oral Maxillofac Surg -:1-14, 2024
The orbit is one of the most complex and intricate
structures in the human skeleton. Orbital fractures
occur due to a sudden rise in intraorbital pressure,
causing fractures of these frail and delicate orbital
walls.1 The normal position of the globe within the
orbit is maintained by a balance between the orbital
volume and intraorbital soft tissue.2 Reconstructing
post-traumatic orbital defects is complex and requires
precise techniques and sound knowledge. Due to the
narrow operating field, the surgery is heavily reliant on
skill, knowledge, and experience of the surgeon.1
Complex cases involving the orbit still pose a signifi-
cant challenge due to the complex anatomy and diffi-
culty in replicating the geometry, dimensions, and
volume, which have a very narrow margin for error
from an esthetic and functional stand point.3
Conventional reconstruction methods afford the ad-
vantages of availability and ease of intraoperative
manipulation while also being cost-effective.4 Howev-
er, these lack the personalized approach that is desired
while reconstructing an anatomically challenging area
like the orbit. This particular lacuna is filled by the
incorporation of various technological aids in the sur-
gical management of orbital fractures.
The advent and widespread use of computer-assisted
surgical planning (CASP) and computer-aided design
and computer-aided manufacturing (CAD-CAM) has
paved the way for personalized solutions for orbital
reconstruction.4 This may include either of the two:
1. Computed tomography (CT) scan-derived mirror im-
age overlay (MIO) from the contralateral, uninjured
orbit to obtain a stereolithographic three-dimensional
model serving as a template onto which an orbital
implant can be prebent preoperatively. 2. Fabrication
of a patient-specific implant (PSI), which involves a
CT scan-derived MIO followed by virtual design and is
usually manufactured externally, thus not requiring
the step of precontouring.5-8 One of the first orbital
reconstructions with a PSI was reported in 2010.9 Addi-
tionally, intraoperative imaging techniques such as in-
traoperative CT and intraoperative navigation (ION)
can provide real-time visualization and guidance during
surgery, enabling the surgeon to make informed deci-
sions and adjustments as needed. Finally, the use of
augmented reality and virtual reality technologies may
have potential for intraoperative visualization and guid-
ance in the future.10,11
This systematic review aims to compare and evaluate
the outcomes of different technological aids, namely,
CASP, MIO, and ION, in the reconstruction of post-
traumatic orbital defects. Additionally, the review also
assesses the outcomes associated with various orbital
implant designs, such as standard orbital mesh, pre-
formed implants, prebent implants, and PSIs.
Materials and Methods
Protocol and Registration: The protocol was regis-
tered in the International Prospective Register of Sys-
tematic Reviews under registration number
CRD42023415564. The systematic review was con-
ducted in accordance with the Preferred Reporting
Items for Systematic Reviews and Meta-Analyses
statement.12
Focus Question and Population,
Intervention, Comparison, and Outcome
Criteria
The focus question was developed according to the
population, intervention, comparison, and outcome
study design: ‘‘In patients requiring post-traumatic
orbital reconstruction, does the integration of techno-
logical aids (CASP, MIO, ION) and different orbital
implant designs (prebent, PSI) contribute to improved
outcomes in terms of orbital volume, diplopia, and
enophthalmos?’’
Population (P): Patients requiring post-traumatic
orbital reconstruction. Intervention (I): Open reduc-
tion and internal fixation with integration of techno-
logical aids (CASP, MIO, ION) and different orbital
implant designs (prebent, PSI). Comparison (C):
Open reduction and internal fixation without integra-
tion of technological aids and use of standard orbital
mesh/preformed implant. Outcomes (O): Primary out-
comes (orbital volume, enophthalmos, diplopia) and
secondary outcomes (intraoperative time, postopera-
tive implant position, restricted ocular motility).
Search Strategy: Electronic searches of MEDLINE,
Embase, Cochrane Library, and Google Scholar data-
bases until March 2023 were conducted using key
words such as orbital floor fracture, blowout fracture,
orbital injury, orbital trauma, orbital reconstruction,
PSI, prebent, computer-assisted surgery planning,
ION, and orbital implants.
Selection Criteria: The inclusion criteria were: 1)
randomized controlled trials (RCTs), controlled clin-
ical trials (CCTs), clinical studies, case-control studies,
cohort studies, and retrospective studies; 2) studies
integrating technological aids for post-traumatic
SAPTARSHI ET AL
reconstruction; and 3) at least one of the following
outcome measures was assessed and recorded: orbital
volume, diplopia, and enophthalmos. The exclusion
criteria were: 1) Studies with # 10 patients; 2) no out-
comes of interest; 3) published in a language other
than English; and 4) inappropriate study design (ie, re-
view, protocol, animal trial, and conference article).
Screening and Data Extraction
Two reviewers (V.R.S. and S.N.) independently re-
viewed the titles and abstracts, excluding those that
did not meet inclusion criteria. In case of any doubt,
the study was included for further screening in the
next stage. The abstracts were then independently
screened. Disagreements were resolved by discussion.
A third reviewer (P.S.B.) was involved in the final deci-
sion if any disagreement persisted. The following data
were extracted from the included studies: author, year
of publication, study design, country, demographics of
participants (age range, site of fracture), sample size,
mechanism of injury, technology employed and type
of implants used, outcomes (orbital volume, diplopia,
enophthalmos, intraoperative time, postoperative
implant position, restricted ocular motility.)
Variables
Predictor variables: integration of technological aids
namely, CASP, MIO, ION, and utilization of different
orbital implant designs (standard orbital meshes, pre-
formed implants, prebent implants, PSI) during open
reduction and internal fixation of orbital fractures.
Primary outcome variables: orbital volume, enoph-
thalmos, diplopia.
Secondary outcome variables: intraoperative time,
postoperative implant position, restricted ocular motility.
Standardization of Terms
It became apparent to the authors that the nonuni-
form utilization of terminology to describe implant
types introduced a state of ambiguity, making it chal-
lenging to discern interstudy associations. Therefore,
with the aim of simplifying and standardizing, this sys-
tematic review categorizes implant types into four cat-
egories, namely:
STANDARD (CONVENTIONAL) ORBITAL MESHES
Standard, noncustomized implants require freehand
intraoperative shaping and bending.
PREFORMED (STOCK) IMPLANTS
Standardized implants are manufactured with pre-
determined shapes that closely resemble generic
anatomical features.
3
PREBENT IMPLANTS
Implants that are bent preoperatively to the desired
contour on a three-dimensional printed model of the
ideal orbit form by using MIO and CAD-CAM.
PATIENT-SPECIFIC IMPLANTS (PSIs)
Customized implants, manufactured to fit a specific
orbit using CAD-CAM technology.
After thoroughly reviewing the included studies, an
understanding was reached as to which of the four
above-mentioned categories of implants were used in
the respective study. Table 1 summarizes the technol-
ogy employed and the type of implants used in the
included studies.
Risk of Bias
Two independent reviewers appraised the risk of
bias in the studies included in the review using the
Risk Of Bias In Non-randomised Studies - of Interven-
tion (ROBINS-I) tool.13 Every domain was assessed
for the risk of bias. The categories for risk of bias judg-
ments are low risk, moderate risk, and high risk of bias.
For quality assessment of observational studies, the
Newcastle-Ottawa Scale (NOS) tool14 was used. The
NOS evaluates three quality parameters (selection,
comparability, and outcome) divided across eight spe-
cific items, which slightly differ when scoring cross-
sectional and cohort studies. Each item on the scale
was scored at one point, except for comparability,
which was adapted to the specific topic of interest
to score up to two points. Thus, the maximum for
each study was 9, with studies having less than 5
points being identified as having a high risk of bias.
Data Synthesis
Review Manager (RevMan) 5.3 was applied for sta-
tistical analysis. Mean difference (MD) and relative
risks were adopted as effect size measures for contin-
uous variables and dichotomous variables, respec-
tively. 95% confidence intervals (CIs) were used, and
P < .05 was considered to indicate statistical signifi-
cance. c2 and Tau-square were used to assess whether
the observed difference was homogeneous or hetero-
geneous among the studies. Statistical heterogeneity
was assessed by the I2 test at a = 0.10. For I2>50%,
the random effects model was applied. Also, the statis-
tical significance was set at P value (two-tailed) <.05.
Summary Measures: The primary objective of this
systematic review was twofold. First, to evaluate the
impact of integrating technological aids (CASP, MIO,
and ION) in the reconstruction of post-traumatic
orbital defects. Second, to assess the outcomes
achieved with the use of different implant designs
(standard orbital meshes, preformed implants,
4 DO TECHNOLOGICAL AIDS PRODUCE BETTER OUTCOMES IN ORBITAL RECONSTRUCTION?

Table 1. SUMMARY OF TECHNOLOGY EMPLOYED AND TYPES OF IMPLANTS USED

Study Technology Employed Types of Implants Used

Without Navigation Fan et al1 2017
Chepurnyi et al17 2020
Beder et al16 2022
With Navigation Rana et al10 2015 MIO + 3D Printing vs ION + PSI
3D planning software: iPlan CMF
Zimmerer et al15 2016
3D planning software: iPlan CMF
Cai et al3 2012
Zavattero et al18 2017
MIO + 3D Printing Prebent vs Standard orbital
3D planning software: MIMICS mesh
software (V17, Materialize,
China), 3D model: RL200 A,
Myriwell, China
MIO + 3D Printing vs PSI PSI vs Standard orbital mesh
3D planning software: Disior
Bonelogic CMF Orbital
Analysis Software (Helsinki,
Finland), 3D model: N/A*, PSI:
N/A*
MIO + 3D Printing vs PSI PSI vs Prebent implants
Orbital volume analysis:
BONELOGIC CMF ORBITAL
version 2.1.18-research
software, 3D planning
software: 3Diagnosys, version
4.1; 3diemme, Como, Italy), 3D
model: (Upbox, Tiertime,
Korea) PEEK PSI milling:
Mimics 10.01 (Materialise,
Leuven, Belgium)
PSI vs Prebent implants
3.0.5 (Brainlab, Feldkirchen,
Germany), 3D model: Phacon
(Lepizig, Germany), PSI:
Freeform Plus (Geomagic,
Morrisville, NC), Navigation
system: Kick, Brainlab
MIO + 3D Printing + ION vs PSI (n = 3) vs Prebent (n = 47)
PSI + ION vs Preformed implants
(n = 100)y
(Version 3.0.5, Brainlab,
Feldkirchen, Germany), 3D
model: Phacon GmbH, Leipzig,
Germany, Navigation system:
N/A*
MIO + ION N/A*,z
3D planning software: iPlan
Cranial version 2.6; Brainlab,
Feldkirchen, Germany,
Navigation system: Kolibri
(BrainLab, Munich, Germany)
MIO + ION a. Isolated single-wall and Floor
Navigation system: Brainlab, fractures: standard orbital
Munich, Germany, 3D mesh (n = 43)
planning software: N/A*, 3D b. Fractures involving medial wall
model: N/A* and orbital floor: preformed
implants (n = 12)

Abbreviations: 3D, three-dimensional; ION, intraoperative navigation; MIO, mirror image overlay; PSI, patient-specific implants.
* Not available.
y Non-CAD (n = 45)-based orbital implants were used in addition to the above-mentioned implants in the study group.
z Assisted and control groups were matched for implants used.
Saptarshi et al. Do Technological Aids Produce Better Outcomes in Orbital Reconstruction? J Oral Maxillofac Surg 2024.
SAPTARSHI ET AL
prebent implants, and PSIs) for post-traumatic orbital
reconstruction.
Results
Results of Literature Screening: A pool of 702 arti-
cles was initially retrieved. 551 remained after
removing duplicates. After screening the titles and ab-
stracts, the full texts of 32 articles were left. These 32
articles underwent a comprehensive full-text assess-
ment, resulting in a final set of 7 articles included in
the review. A descriptive summary of data selection
is presented in Figure 1 as a Preferred Reporting Items
for Systematic Reviews and Meta-Analyses flowchart.
Characteristics of the Included Studies: Four studies
were demarcated as CCTs,3,15-17 1 cohort study18 and
2 retrospective studies.1,10 No RCTs were identified.
One of these studies was a multicentric study.
Table 2 summarizes the demographics of the included
studies. Table 3 summarizes outcomes of the included
studies. The review comprised a total of 560 patients
across 7 studies. From an epidemiological perspective,
the demographic domain of age (mean age 43.19 years)
was found to be consistent with the data found in the
literature.19 In relation to the etiology of orbital frac-
tures, assault was found to be the most prevalent
cause, followed by road traffic accidents and sports-
related incidents. Assault and road traffic accidents ac-
counted for more of all etiologies, aligning with the
existing body of scientific literature.20 The fracture
site most commonly observed was the floor of the
orbit, followed by fractures involving both the floor
(one of the weakest parts of the orbit) and medial
wall. This anatomical relationship can be explained
by the inherent vulnerability of these regions to frac-
ture, which can be attributed to their thin bony
structure.21
Risk of Bias
All four included CCTs (nonrandomized studies)
showed a low risk of bias (Table 4). All the retrospec-
tive and cohort studies evaluated by the NOS tool
showed high study quality, ie, low risk of bias
(Table 5,6). Because quality assessment was,
however, an ordered variable, a weighted kappa was
also carried out to establish relative concordance
between reviewers. It was assumed that the
differences between individual quality scores were
equal. The inter-rater agreement (kappa with linear
weighting) was 0.89 (95% CI, 0.76 to 0.94) indicating
substantial to perfect agreement.
Synthesis of Results
A total of 4 studies10,15-17 fulfilled the inclusion
criteria for quantitative analysis. Subsequently, 3
5
meta-analyses were conducted, out of which 2 forest
plots compared the results of enophthalmos and
diplopia at 3 months between the PSI and standard
orbital mesh and one forest plot compared the results
of difference in orbital volume between affected and
nonaffected eyes between the PSI and prebent group.
Orbital Volume
Orbital volume, a key factor in orbital reconstruc-
tion, was assessed in five of the seven studies. Table 7
summarizes comparative orbital volume data. The
meta-analysis of two studies10,16 (Fig 2) assessing the
MD for difference in orbital volume between affected
and nonaffected eyes comparing PSI and prebent
groups was carried out using a random effects model.
The MD for difference in orbital volume between
affected and nonaffected eyes PSI group showed no sta-
tistically significant difference between PSI and preb-
ent group (MD, 0.41, 95% CI = 1.16 to 0.34,
P = .28, I2 = 46%). The orbital volume data reported
by Zimmerer et al15 included only the range of orbital
volume differences and variances with no mention of
central tendency. However, it is worth noting that
this study reported statistically significant results with
the use of PSI in correcting orbital volume (P < .001).
The results reported by Chepurnyi et al17 indicate
that PSI group (0.137  0.8 cm3) exhibited a lower
mean orbital shape difference between damaged and
intact orbits when compared with the standard orbital
mesh (1.05  1.9 cm3) group, indicating that the orbits
reconstructed with PSI were more similar to unaf-
fected orbits. Zavattero et al18 analyzed the influence
of ION. Volume reductions were 3.066 cm3
(1.304 cm3) in the navigation group and 2.064 cm3
(1.372 cm3) in the non-navigation group.
Enophthalmos
Four studies evaluated enophthalmos as one of the
parameters. The pooled outcomes from 2 studies15,17
using a random effects model for assessing the risk of
developing enophthalmos in PSI group as compared
to the standard orbital mesh group was conducted.
As in the study conducted by Zimmerer et al,15 there
were 0 reported cases of enophthalmos in both the
PSI and standard orbital mesh group, the risk ratio
for that study was not estimated. In the study conduct-
ed by Chepurnyi et al,17 it was observed that the stan-
dard orbital mesh group is 0.30 times at higher risk of
developing enophthalmos as compared to PSI group.
The test of overall effect was z = 2.58 and P value = .010
(Fig 3), but the overall heterogeneity was not esti-
mated. Fan et al1 reported a statistically significant dif-
ference between the affected and unaffected orbits
with the use of prebent implants compared to
6 DO TECHNOLOGICAL AIDS PRODUCE BETTER OUTCOMES IN ORBITAL RECONSTRUCTION?

FIGURE 1. PRISMA flowchart of the search process. PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses.
Saptarshi et al. Do Technological Aids Produce Better Outcomes in Orbital Reconstruction? J Oral Maxillofac Surg 2024.

standard orbital mesh (P < .05). Beder et al16 reported
results in favor of PSI group compared to prebent
group. Cai et al3 reported no statistically significant dif-
ferences in enophthalmos in the ION group at
different time points.
Diplopia
Assessed by five studies. The pooled outcomes from
2 studies15,17 with a total sample size of 108 and 129 in
PSI and standard orbital mesh groups, respectively,
using a random effects model showed that PSI group
resulted in diplopia 0.71-fold less than that of the stan-
dard orbital mesh group with 0% heterogeneity (I2)
(risk ratio, 0.71; 95% CI: 0.45 to 1.13; P = .15), but
the difference was not statistically significant (Fig 4).
The results reported by Cai et al,3 favor the use of
ION. The ION group consistently had a lower percent-
age of patients with diplopia at different time points,
which were statistically significant (0 = 0.039). These
 SAPTARSHI ET AL
Table 2. SUMMARY OF DEMOGRAPHICS

Author and Country Age Range Sample

Year of Study Study Design of Study in Years Site of Fracture Size Mechanism of Injury

Cai et al3 2012 Controlled Singapore 19 - 61 Site Non-navigation Navigation 58 Mechanism Non-navigation Navigation
Clinical group group group group
Trial
Floor 29 29 RTA 14 11
Roof 04 05 Fall 04 06
Medial Wall 13 16 Assault 09 06
Lateral Wall 13 16 Others 02 06
Rana et al10 Retrospective Germany 17 - 70 Not mentioned 92 Not mentioned
2015 study
Zimmerer Controlled Germany, 18 - 80 Orbital floor and/or medial wall 195 RTA, assault, sports injury, fall, other
et al15 2016 Clinical Spain,
Trial United
States of
America,
Singapore,
Austria
Zavattero Prospective Italy 26 - 62 Isolated orbital floor: 39 55 Assault: 26, RTA: 04, fall: 14, sports: 11
et al18 2017 Cohort Isolated medial wall: 04
with Medial and orbital floor: 12
Historical
Controls
Fan et al1 Retrospective China Mean age: Medial wall: 22 56 Assault: 32, sport injury: 10, fall: 09, RTA: 03,
2017 study Standard orbital Inferior wall: 13 others: 02
mesh group: Medial and inferior wall: 21
34.07
Prebent
implant
group: 39.03
Chepurnyi Controlled Ukraine 17 - 70 Orbital floor and/or medial wall 92 Not mentioned
et al17 2020 Clinical
Trial
Beder et al16 Controlled Egypt 14 - 55 Orbital floor 11 RTA: 58.3%, fall 25.3%, assault 16.7%
2022 Clinical
Trial

Abbreviation: RTA, road traffic accident.

Saptarshi et al. Do Technological Aids Produce Better Outcomes in Orbital Reconstruction? J Oral Maxillofac Surg 2024.

7
 8
Table 3. SUMMARY OF OUTCOMES OF INCLUDED STUDIES
Postoperative Postoperative
Postoperative Postoperative Position of Restricted
Study CT Scan Postoperative Diplopia Enophthalmos Intraoperative Time Implant Ocular Motility

Cai et al3 2012 Performed 1 mo 3 mo 6 mo 12 mo Navigation group 3 vs 10% in non- Not available Vertical distance measured from the boundaries of the floor defects 1 mo 3 mo 6 mo 12 mo
navigation group over for patients in the navigation group was 3.24 m
12 months. lower than the vertical distance measured for patients i
n the non-navigation group.
Navigation 24% 14% 14% 02% Navigation 14% 10% 07% 03%
Non-navigation 59% 55% 45% 10% Non- 17% 07% 03% 03%
Navigation
Rana et al10 Performed Not available Not available Not available Postoperative mean angular deviation from unaffected Not available

DO TECHNOLOGICAL AIDS PRODUCE BETTER OUTCOMES IN ORBITAL RECONSTRUCTION?

2015 orbit (in degrees):
Angle anterior Angle medial Angle posterior
Prebent 11.3 11.6 10.8
PSI 4.1 8.2 8.2
Zimmerer et al15 Performed  Preformed implants: 25 (29.8%)  Preformed implants: 0 Mean Duration of Standard: Not available  Preformed implants: 1 (1.2%)
2016  PSI/Prebent implants: 15 (24.6%)  PSI/Prebent implants: 0  PSI/Prebent implants:  PSI/Prebent implants: 2 (3.3%)
60 minutes
 Preformed implants:
71 minutes
Zavattero et al18 Performed Navigation Non- Not available Not available Not available Not available
2017 navig
ation
Grade III 05 03
Grade II 15 13
Grade I 07 03
Fan et al1 2017 Performed Not available Absolute difference of  Prebent: Standard orbital mesh Prebent Not available
postoperative enophthalmos: 75.34  15.68 minutes
 Prebent: 1.0  0.5 mm  Standard orbital mesh:
 Standard orbital mesh: 95.37  22.19 minutes
2.5  1.0 mm
DMW 5.60  0.90 mm 2.51  0.53 mm
DMD 4.61  0.89 mm 2.58  0.46 mm
DAR 84.05  20.89 mm2 43.59  9.53 mm2
DAG 12.58  5.04o 2.82  0.44o
Chepurnyi Performed  PSI: 7  PSI: 5 Not available Implant malposition: Not available
et al17 2020  Standard orbital mesh: 13  Standard orbital mesh: 16  PSI: 3
 Standard orbital mesh: 10
Beder et al16 Performed  PSI: 0 2 wk 1 mo 3 mo 6 mo Not available Not available 2 wk 1 mo 3 mo 6 mo
2022  Prebent: 1
PSI 3 3 3 3 PSI 1 1 1 1
Prebent 4 4 4 4 Prebent 2 2 2 2

Abbreviations: DAG, difference in the angle of the medial and inferior wall corner in the same coronal plane between the surgical eye and the healthy eye; DAR, difference in the area
between the fracture zone and implant; DMD, difference in the maximum depth between the fracture zone and implant; DMW, difference in the maximum width between the fracture
zone and implant; PSI, patient-specific implants.
Saptarshi et al. Do Technological Aids Produce Better Outcomes in Orbital Reconstruction? J Oral Maxillofac Surg 2024.
SAPTARSHI ET AL 9

findings suggest a positive impact of the ION. Zavat-

Risk of Bias
tero et al18 also reported similar results in favor of

Low
Low
Low
Low
ION. Diplopia was assessed using the diplopia severity
scoring described by Bly et al22 Beder et al16 reported
improvement in diplopia with the use of PSI, but these
results were not statistically significant.
Bias Due to Selective
Reporting of Results

Moderate risk
No risk Intraoperative Time
No risk
No risk Assessed by two studies. Zimmerer et al,15 reported
a median intraoperative time of 71 minutes in pre-
formed group versus 60 minutes in PSI/prebent group
(P = .017). The study also shows that 90% of pre-
formed implants require intraoperative adjustments
and take more time to implant than PSI/Prebent
Bias in Measurement

implants. Fan et al,1 reported a statistically significant

Moderate risk
of Outcomes

difference with the use of prebent implants

No risk

No risk
No risk

(75.34  15.68 minutes) compared to standard orbital

meshes (95.37  22.19 minutes) (P < .05).

Postoperative Implant Position

Saptarshi et al. Do Technological Aids Produce Better Outcomes in Orbital Reconstruction? J Oral Maxillofac Surg 2024.

Assessed by four studies. Cai et al3 reported that the

Missing Data
Bias Due to

No risk
No risk
No risk
No risk

vertical distance measured from the boundaries of the

floor defects for patients in the navigation group was
3.24 mm lower in the non-navigation group, this was
highly significant P = .001. Rana et al10 showed a signif-
icant difference for the anterior angle favoring PSI
Interventions
Bias Due to
Deviation

(mean 4.1) over prebent implants (11.3), P = .001.

Intended

No risk
No risk
No risk
No risk
From

Fan et al1 reported that the reconstructed angle of

the medial and inferior wall corners was more similar
between the affected and unaffected eyes in the preb-
ent group compared to standard orbital mesh group,
P < .05. Chepurnyi et al17 reported that implant malpo-
Misclassification

sition occurred in 3 cases with PSI (6.4%) and 10 cases

No risk
No risk
No risk
No risk

with standard orbital mesh (22.2%) (P = .033).

Bias
Table 4. RISK OF BIAS OF CCTS (NONRANDOMIZED TRIALS)

Restricted Ocular Motility

Assessed by three studies. No statistical differences
Selection

were found in restricted ocular motility in navigation

No risk
No risk
No risk
No risk
Bias

and non-navigation groups at different time points,

as reported by Cai et al.3 A similar finding was reported
Abbreviation: CCTs, controlled clinical trials.

by Zimmerer et al.15 Results reported by Beder et al,16

showed improvement in the limitation of ocular
Confounding

No risk
No risk
No risk
No risk

motility of the affected eye in comparison to preoper-

Bias

ative status favoring the use of PSI. These results were

not statistically significant.

Discussion
Chepurnyi et al 2020

Zimmerer et al 2016

By identifying gaps in the literature, this review aims

Beder et al 2022
Cai et al 2012

to improve clinical decision-making and patient out-

comes in post-traumatic orbital reconstruction. All
studies necessitated the inclusion of preoperative
Study

and postoperative CT scans. Operative planning of

complex fractures depends on optimal imaging.23 A
 10
Table 5. RISK OF BIAS OF RETROSPECTIVE STUDIES

Selection Comparability Outcome Total

Score Quality
Representativeness Sample Ascertainment Main Additional Assessment Statistical
Study of Sample Size Nonresponders of Exposure Factor Factor of Outcome Test

Fan et al 2017 * - * * * - * * 6 High

Rana et al * - * * * - * * 6 High
2015

DO TECHNOLOGICAL AIDS PRODUCE BETTER OUTCOMES IN ORBITAL RECONSTRUCTION?

No score assigned.
* Score assigned.
Saptarshi et al. Do Technological Aids Produce Better Outcomes in Orbital Reconstruction? J Oral Maxillofac Surg 2024.

Table 6. RISK OF BIAS OF COHORT STUDY

Selection Comparability Outcome Total

Score Quality
Outcome of
interest Was
Selection of present follow- Loss to
Representativeness nonexposed Ascertainment at start of Main Additional Assessment up follow-
Study of cohort cohort of exposure study factor factor of outcome enough up

Zavattero et al * * * * * - * * - 7 High
2017

No score assigned.
* Score assigned.
Saptarshi et al. Do Technological Aids Produce Better Outcomes in Orbital Reconstruction? J Oral Maxillofac Surg 2024.
 SAPTARSHI ET AL
Table 7. COMPARATIVE ORBITAL VOLUME DATA

Study Mean Orbital Shape Difference Preoperative Orbital Volume Postoperative Orbital Volume Volume Difference

Chepurnyi et al17 PSI: Not mentioned Not mentioned Not mentioned

0.137  0.8 cm3 (1.7 cm3 to
2.3 cm3)
Standard orbital mesh:
1.05  1.9 cm3 (1.8 cm3 to
8.3 cm3)
Beder et al16 2022 Not mentioned PSI: PSI: PSI: 0.50  0.72 cm3
Affected eye: 28.89  3.28 cm3 Affected: 25.82  3.44 cm3 Prebent: 1.35  0.86 cm3
Nonaffected eye: 24.98  2.34 cm3 Nonaffected: 25.32  2.72 cm3
Prebent: Prebent:
Affected eye: 28.87  3.42 cm3 Affected: 26.91  3.3 cm3
Nonaffected eye: 25.23  2.13 cm3 Nonaffected: 25.56  2.44 cm3
Rana et al10 Not mentioned Not mentioned Not mentioned Volume between unaffected and
affected eye:
PSI: 0.4 cm3
Prebent: 0.6 cm3
Zimmerer et al15 Not mentioned Not mentioned Not mentioned Differences in volume between the
reconstructed and the unaffected
orbit:
PSI/Prebent + Navigation:
3.5 to 1.4 ml Variance: 0.6 ml2
Standard preformed + Navigation:
4.3 to 2.7 ml Variance: 1.8 ml2
Zavattero et al18 Not mentioned Volumes of affected orbits: Not mentioned Navigation group:
Navigation group: 3.066 cm3 (1.304 cm3)
31.945 cm3 (2.035 cm3), Non-navigation group:
Non-navigation group: 2.064 cm3 (1.372 cm3)
31.415 cm3 (3.520 cm3).

Abbreviation: PSI, patient-specific implants.

Saptarshi et al. Do Technological Aids Produce Better Outcomes in Orbital Reconstruction? J Oral Maxillofac Surg 2024.

11
12 DO TECHNOLOGICAL AIDS PRODUCE BETTER OUTCOMES IN ORBITAL RECONSTRUCTION?

FIGURE 2. Forest plot of comparative orbital volume data.

Saptarshi et al. Do Technological Aids Produce Better Outcomes in Orbital Reconstruction? J Oral Maxillofac Surg 2024.

preoperative CT scan is necessary for accurate diag-
nosis and CASP, whereas a postoperative CT scan is
necessary to assess the effectiveness of the interven-
tions, volume measurement, and implant positioning,
thereby reiterating it as a need in orbital fractures
where there is minimal margin of error.24
Five studies employed the transconjunctival/trans-
caruncular approach when dealing with orbital
fractures. Despite the potential complications of
developing entropion with transconjunctival
approach,25 it indicates a gradual yet conscious shift
toward utilizing the hidden scar approach in the man-
agement of orbital fractures.
Orbital volume correction is one of the primary aims
of performing orbital reconstruction in traumatic
cases. The results of this review indicate that integra-
tion of technological aids has a positive impact on
orbital volume correction. Although the meta-
analysis yielded nonsignificant results while equating
PSI with prebent implant, it is clear that some element
of customization (PSI/prebent implants) is associated
with improved orbital volume results. Results by
Zimmerer et al15 and Zavattero et al underscore
advantages of combining two different technologies
(MIO-PSI + ION) for superior outcomes. This has
found support in the literature as well.26,27
Post-traumatic enophthalmos is caused by orbital
volume expansion rather than changes in the fat con-
tent;2,28,29 hence, correcting the orbital volume is
paramount. Globe position is the result of a complex
interplay between the bony orbital anatomy and the
soft tissue envelope.30 A key restoration landmark is
the retrobulbar bulge. As one moves from the orbital
rim posteromedially, the orbital floor inclines superi-
orly to meet the medial wall, creating a distinct bony
convergence profile. This bulge is an important struc-
ture supporting the globe in an anteroposterior posi-
tion, making the reconstruction of this anatomic
landmark along with the medial wall critical for cor-
recting enophthalmos.31,32 The meta-analysis suggests
the effectiveness of PSIs in correcting enophthalmos
and diplopia.
Two of the included studies3,18 reported results in
favor of ION while assessing diplopia; however, due
to missing data, they were not amenable to a meta-
analysis. ION is thought to be beneficial as it provides
a real-time feedback on implant position, minimizes
the necessity of extensive dissection, and helps trans-
fer the virtually planned surgery into patient
outcomes.33,34
The study by Schreurs et al35 confirms the findings
of this review, reiterating that PSIs are suitable for pa-
tients with large orbital defects. Chepurnyi et al17
through their study concluded that prebent implants
are equally effective as PSIs in patients with preserved
infraorbital buttress and retrobulbar bulge; however,
they are not the choice when reconstructing large de-
fects. The existing literature suggests that the primary
problem with using standard orbital meshes is restora-
tion of the deep areas of the inferior and medial orbital
walls. Standard orbital meshes have demonstrated a
weakness in cases that require cantilevered recon-
struction (Jaquiery’s category36 III and IV).17 This is
where the customized approaches in the form of
either prebent implants or PSIs have yielded bet-
ter results.

FIGURE 3. Forest plot of the risk of developing enophthalmos.

Saptarshi et al. Do Technological Aids Produce Better Outcomes in Orbital Reconstruction? J Oral Maxillofac Surg 2024.
SAPTARSHI ET AL
FIGURE 4. Forest plot of the risk of developing diplopia at 3 months.
Saptarshi et al. Do Technological Aids Produce Better Outcomes in Orbital Reconstruction? J Oral Maxillofac Surg 2024.
A statistically significant reduction in intraoperative
time was reported by Zimmerer et al15 when different
technological aids (MIO + PSI + ION) were combined.
In the context of maxillofacial surgery, a reduced intra-
operative time contributes to reduced hospitalization
time and also lowers cost of hospitalization.37 As high-
lighted by Zimmerer et al,15 even in the hands of highly
experienced surgeons, the overall precision of recon-
struction tends to be inferior with preformed implants
compared to either prebent implants or PSIs, thus con-
tradicting the intended purpose of preformed implants.
Utilization of PSI with ION produced fewer instances
of implant malpositioning.10 The improved fit and
reduced instances of malpositioning seen with PSI
can be attributed to the fact that these implants are
custom-made and ION provides real-time feedback.
None of the studies included in this review utilized
autogenous materials for orbital reconstruction. Beder
et al,16 mentioned that the decision to use titanium
mesh was influenced by the results of Ellis and Tan,38
who reported that titanium meshes showed better re-
sults than bone grafts for orbital reconstruction. Tita-
nium mesh is preferred because of its malleability and
adaptability to the shape of the defect, excellent
biocompatibility, and the ability for connective tissue
to grow around and through the implant, preventing
migration. This is seconded in the study by Gor-
don et al.32
Although there is some encouraging data to support
improved outcomes with the use of prebent implants,
mainly due to their ease of use and being a cost-
effective reconstructive option, the current data set
cannot objectively equate them with PSIs.
A notable gap emerges from this review: the lack of
standardized reporting guidelines or consensus, espe-
cially for orbital reconstructive surgeries leading to
variations in preferences and practices among
different surgeons. Each surgeon’s approach is
supported by varying degrees of research. The find-
ings within the literature exhibit inconsistency, pri-
marily relying on retrospective case series with a
limited number of subjects, resulting in inconclusive
data. Furthermore, individual surgeon preferences
diverge concerning the choice of orbital implant.39,40
13
This is evidenced by only one study17 utilizing
Jaquiery’s categories to describe the orbital defect.
This systematic review has several limitations. The
absence of RCTs, while not uncommon, stands out
as a significant limitation. Diverse case presentations
make standardization of treatment options and
obtaining ethical clearances challenging, creating an
inherent limitation at the selection and inclusion stage.
There is a paucity of literature in the field, nonstandar-
dized reporting, and the fact that most studies looked
at very few outcomes, and patient-reported outcome
measures were rarely reported. This review does not
comment on outcomes achieved by using different
implant materials.
The outcomes of this review offer valuable insights
into the available evidence for the integration and uti-
lization of technological aids and various implant de-
signs for post-traumatic orbital reconstruction.
Nevertheless, the reliability of these findings is con-
strained by the nature of the included studies. To
affirm the conclusions derived from this review, it is
imperative to undertake well-designed randomized
studies. These studies should incorporate objective as-
sessments and comprehensive reporting of vital pa-
rameters to establish a foundation for quantifiable
and robust conclusions.
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