Accepted Manuscript Non-invasive three-dimensional evaluation of periorbital asymmetry in isolated unilateral orbital floor fractures Ali Modabber , M.D., D.M.D. Manuel Räsch , D.M.D. Mehrangiz Ghassemi , D.M.D. Mathias Knobe , M.D.,PhD Marcus Gerressen , M.D., D.M.D., Ph.D. Alireza Ghassemi , M.D., D.M.D. Majeed Rana , M.D., D.M.D. Frank Hölzle , M.D., D.M.D.., Ph.D. PII:

S2212-4403(14)00478-7

DOI:

10.1016/j.oooo.2014.05.010

Reference:

OOOO 924

To appear in:

Oral Surgery, Oral Medicine, Oral Pathology and Oral Radiology

Received Date: 12 December 2013 Revised Date:

28 April 2014

Accepted Date: 11 May 2014

Please cite this article as: Modabber A, Räsch M, Ghassemi M, Knobe M, Gerressen M, Ghassemi A, Rana M, Hölzle F, Non-invasive three-dimensional evaluation of periorbital asymmetry in isolated unilateral orbital floor fractures, Oral Surgery, Oral Medicine, Oral Pathology and Oral Radiology (2014), doi: 10.1016/j.oooo.2014.05.010. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

ACCEPTED MANUSCRIPT Non-invasive three-dimensional evaluation of periorbital asymmetry in isolated unilateral orbital floor fractures Short Title: Non-invasive three dimensional evaluation of periorbital asymmetry

1*

1

2

3

1

RI PT

Ali Modabber, M.D., D.M.D. ; Manuel Räsch, D.M.D. ; Mehrangiz Ghassemi, D.M.D. ; Mathias Knobe, 1

M.D.,PhD ; Marcus Gerressen, M.D., D.M.D., Ph.D. ; Alireza Ghassemi, M.D., D.M.D. ; Majeed Rana, M.D., 4

1

SC

D.M.D. ; Frank Hölzle, M.D., D.M.D.., Ph.D.

Department of Oral, Maxillofacial and Plastic Facial Surgery, RWTH Aachen University Hospital, Aachen, Germany.

2

Department of Orthodontics, RWTH Aachen University Hospital, Aachen, Germany.

3

Department of Orthopaedic Trauma, RWTH Aachen University Hospital, Aachen, Germany.

4

Department of Oral and Maxillofacial Surgery, Hannover Medical School, Hannover, Germany.

M AN U

1

Sources of support: none

TE D

*Corresponding author: Dr. Dr. Ali Modabber

Department of Oral, Maxillofacial and Plastic Facial Surgery, RWTH Aachen University Hospital

EP

Pauwelsstraße 30 52074 Aachen, Germany

AC C

Phone: 0049 - 241 - 8088231 Fax: 0049 - 241 - 8082430

E-Mail: [email protected]

Disclosure: The authors do not have any financial interests or commercial associations to disclose. word count of the abstract: 157, word count of the manuscript: 2587, number of tables: 2, number of figures: 5

ACCEPTED MANUSCRIPT Abstract Objective. The study was carried out to evaluate the degree of asymmetry between the injured and contralateral periorbital region in isolated orbital floor fractures after

RI PT

surgery. Study Design. The periorbital asymmetry of 35 patients with medium-sized orbital floor fractures that were surgically treated with alloplastic resorbable implants were evaluated and compared with a healthy control group using an optical three-

SC

dimensional facial scanner. Distance measurements between facial surface

M AN U

landmarks, as well as volume measurements between the original image and an automatically generated mirror image, were performed using special commercially available software.

Results. There were no statistically significant differences in the distance measurements (p > 0.05) and volume measurements (p > 0.05) in the groups or

TE D

when the study group and control group were compared using a Student’s t-test. Conclusions. Alloplastic resorbable implants can restore medium defects of the

EP

orbital floor without significant periorbital asymmetry. Automatically constructed

AC C

mirror images can be a helpful tool for detecting asymmetries in faces.

Key words: orbital floor fracture, three-dimensional facial scanning, main symmetry plane, orbital volume, facial asymmetry

ACCEPTED MANUSCRIPT Introduction The key objectives in orbital floor fracture treatment are the restoration of function, aesthetics, and relative symmetry.1,2 Fractures of the orbital floor may lead to an increase in orbital volume, resulting in signs and symptoms of ocular movement

RI PT

restriction, altered sensation, diplopia, and anterior, or posterior malposition of the globe.1,2,3,4,5,6,7,8 The reasons for visible periorbital asymmetry in clinical course of orbital floor fractures include scars, inaccurate restoration, and the development of

SC

ectropion, entropion, exophthalmos, or enophthalmos due to an increase in orbital volume or intraorbital fat resorption.

M AN U

Not all fractures of the orbit require surgical intervention. However, those that do may receive a wide range of treatments depending on defect size, symptoms, and operator-dependent preferences, which range from minimal exploration to surgical reconstruction with titanium mesh, porous polyethylene, PDS foils, Ethisorb patches,

TE D

teflon, silicone, periosteum, cartilage, and autogenous bone grafts.3,4,5,6,8 Even though the natural asymmetry of a face can obscure some inaccuracy in the surgical reconstruction to a certain degree,9 since perfect symmetry is often rated as

EP

unnatural, but facial attractiveness is highly correlated to facial symmetry,10 periorbital symmetry should be one of the main aims of orbital floor fracture surgery.

AC C

The advantages of three-dimensional stereophotogrammetry as a noncontact, nonionizing, inexpensive, fast, and highly accurate technique in exophthalmometry as an indicator for orbital asymmetry have been previously described, but its use has not become a part of the routine management of orbital fractures.2,3,10. The purpose of the study was to determine the degrees of postoperative plane and volumetric orbital asymmetries in patients suffering unilateral orbital floor fractures and compare them with the degrees of asymmetry occurring naturally in a non-trauma control group.

ACCEPTED MANUSCRIPT Patients and Methods Owing to the retrospective course of the study, no ethical approval was required. Written informed consent was obtained from each patient for three-dimensional facial scan. 35 patients with unilateral isolated orbital floor fractures who underwent surgery

RI PT

with alloplastic resorbable implants, which are routinely used for the restoration of small or medium sized orbital floor fractures at our department received threedimensional facial scans postoperatively and were compared with 35 age and gender

SC

matched controls for evaluation of periorbital asymmetry. All patients (eight women and 27 men; mean age: 40.60 years, range: 18–74 years) underwent ophthalmologic

M AN U

inspection before and after surgery and were treated with PDS foils (18 patients; Ethicon, Johnson & Johnson, Somerville, NJ, USA) or Ethisorb patches (17 patients; Ethicon, Johnson & Johnson, Somerville, NJ, USA) using an infraorbital approach. Patients who were treated with other materials were excluded. The time between

TE D

optical three-dimensional facial scan and surgery was at least one month (34–201 days, mean: 132 days). Additionally, fracture size was measured during the preoperative computed tomography (CT) scan.

EP

The age and gender matched control group consisted of seven women and 28 men, (mean age 38.03 years, range: 18–82 years). Patients who had already suffered a

AC C

previous midfacial fracture including the orbit were excluded, as were patients with syndromes, eye-disease, and obvious facial anomalies. The optical three-dimensional facial scanning device (FaceScan3D; 3D-Shape® GmbH, Erlangen, Germany) has also been used in previous studies.3,12,13 This scanner consists of an optical range sensor, two digital cameras, a mirror construction, and a commercial computer. The sensor is based on a phasemeasuring triangulation method.14 Since the scanner is nonionizing and contactless in data acquisition, there are no special safety precautions to comply with. Further

ACCEPTED MANUSCRIPT advantages include the high accuracy in the z-direction (within 200 µm) and the short measurement time (430 ms). The mirror construction enables the surgeon to capture more than 180° of the patients face in a single sho ot. The Slim3D software (3DShape® GmbH, Erlangen, Germany) automatically triangulates, merges, and post-

RI PT

processes the data.15 The final output for clinical use is a triangulated polygon mesh, which is visualized as a synthetically shaded or wire mesh representation.16 For volume calculation and linear distance measurement all patients were scanned with a

SC

standard technique for frontal views of the face.

M AN U

Distance measurements

The facial datasets were imported into the commercially available orthognathic planning software OnyxCeph3TM version 3.196 (Image Instruments, Chemnitz, Germany). The described analysis was integrated into this program as the Aachen

TE D

Analysis of the orbit (Figure 1). Distance measurements from four different landmarks of a constructed plane in the front of the face for each eye were calculated. These four

points

were

the

lateral

canthus

(Exocanthion,

Ex),

medial

canthus

EP

(Endocanthion, En), upper eyelid (i.e. the greatest concavity of the upper eyelid), and lower eyelid (i.e. the greatest concavity of the lower eyelid). The pupil landmark was

AC C

inserted for a better orientation when setting the other landmarks and for further measurements of angles constructible with the described landmarks. The first step of constructing the frontal plane of the face was the defining the first plane, which was constructed through the connecting line between the left and the right tragus (Trl, Trr) and the subnasale (Sn). A second plane was constructed perpendicular on the first through the Sn landmark and in front of the face. On its base through Sn, this second plane is parallel to the Trl-Trr connecting line. A distance measurement was performed between each of the four landmarks and the constructed frontal plane.

ACCEPTED MANUSCRIPT The orbital width between Ex and En landmarks on each side was measured, as was the orbital height between the upper eyelid and lower eyelid landmarks on each side. The distances were measured in mm.

RI PT

Volume measurements

The second step to detect a relative asymmetry was to perform a volume measurement by matching the two different halves of the face. The goal was to

SC

compare the injured and uninjured sides and the comparable sites in the control group. The volume measurement was accomplished by mirroring one side of the face

M AN U

so that a left-left respectively right-right image was constructed.

Detection of the symmetry plane is a tool in the OnyxCeph3TM software that is based on an adaption of the particle swarm algorithm and uses the planar reflective symmetry transform (PRST) first described by Podolak et al. as a normalized degree

TE D

of mirror symmetry.17,18 Within a marked area (the forehead and the nose in this study), which is used to define a certain part of the surface, the degree of asymmetry is rapidly calculated (Figure 2).

EP

The mirrored left-left and right-right images were imported into the Comparison software version 3.12 (3D-Shape® GmbH, Erlangen, Germany), which allows for

AC C

measurement of volume differences in selected facial regions by matching two threedimensional images. The region of interest was the eye and the periorbital soft tissue (Figure 3). The mirrored image fitted perfectly onto one half of the original image. On the other side, we found an increased or reduced volume when it was compared to the second image (Figure 4). There were two values to compare within each individual. The normal image was set as the standard, and in the control group, the volume was calculated between the standard and the image that showed two right

ACCEPTED MANUSCRIPT face halves. The image that showed two left face halves was used as the feedback control. The differential volume was stated in mm. To check for statistical significance of quantitative variables the Student’s t-test for unrelated samples was used for the left and right sides orbital widths, orbital heights,

RI PT

as well as the Exocanthion, Endocanthion, upper eyelid, lower eyelid – frontal plane distance differences and orbital volume differences. All data are expressed as mean values and SD, with a p-value of ≤ 0.05 being significant. To verify that the control

SC

group was homogenous, a χ²-test was utilized, and a p-value of ≤0.05 was defined as the level of significance. The statistical analysis was conducted using SPSS for

M AN U

Windows version 15.0 (SPSS Inc., Chicago, IL, USA).

Results

In the study group, the orbital floor fracture size was measured in the preoperative

TE D

CT scan and ranged from 2.3 cm2 to 5.8 cm2 (mean: 4.09 cm2, SD: 0.84 cm2). Of the fractures, 51.4% were treated with Ethisorb patch, while 48.6% were treated with PDS foil. Surgery was performed within 7 days after injury. Ophthalmic inspection

EP

before and after surgery were performed. The causes of injury as well as diplopia and eye-motility restriction rates are presented in Table 1.

AC C

There was no significant diefference in age or gender between the study sample and control group. Within both groups, no significant differences could be detected when we calculated the right-left difference of each distance-measurement parameter, orbital height, and orbital width (Table 2). The volume measurements for the control group showed a mean volume for the right mirrored face half of -0.11ml (SD: 0.40 ml) and 0.04 ml (SD: 0.47 ml) for the left mirrored face half both matched and compared with the original image. In the study group, the mean volume measurement matching the original image and the image

ACCEPTED MANUSCRIPT with two fracture-side face halves was -0.06 (SD: 0.70 ml). The volume was 0.14 ml (SD: 0.63 ml) when we matched the original image and the image with two healthyside face halves. There were no significant differences for the study group image

RI PT

arrangements matched with both healthy-group image arrangements (Figure 5).

Discussion

Indications for orbital floor fracture surgery include retrobulbar hematoma in

SC

combination with impaired vision, muscle entrapment and ischemia, aesthetically disturbing enophthalmos, infraorbital anesthesia, enophthalmos, limitation of motility,

M AN U

and diplopia.4,7 While the diplopia rate and eye restriction motility rate before and after surgery (43% to 3%, respectively) in this study are smaller than those in some studies (57.14% to 5.8%, respectively), they are comparable to the results reported by Jank et al.3,4,6 This can be explained by both the larger fractured area (mean: >

TE D

4.09 cm2) reported in other publications, since the presence of diplopia may increase with larger fractured area, and by the larger number of patients, including those with zygomatic fractures and complex midfacial fractures.3,4,5,7 Infraorbital anesthesia was

EP

the second major indication for surgery in the presented study. The postoperative enophthalmos values correlate significantly with fracture size and are reported as 1%

AC C

to 3.8%, and 1% for exophthalmos.4,5,6,7 PDS foil and Ethisorb patches are indicated in the surgical treatment of defects up to 4 cm2. However, according to the literature, they are compatible with even larger defects (≤ 9cm2) and, therefore, the presented fracture sizes ranging from 2.3 cm2 to 5.8 cm2 were within the limitations, and their use led to satisfactory long-term results.3,6,8 In our department titanium meshes are usually used for sufficient stabilization of large sized orbital floor defects.

ACCEPTED MANUSCRIPT The aim of this study was to evaluate the symmetry of the periorbital region in unilateral orbital floor fractures using an optical three-dimensional device. In the first step, a landmark-dependent analysis for the detection of asymmetry in facial threedimensional scans was used. In the second step, a surface-dependent and primarily

RI PT

landmark-independent volume was calculated to determine the degree of asymmetry. Techniques for rating asymmetries by exophthalmometry using optical threedimensional facial scanning, including the distance measurements introduced in this

SC

study, share the problem of intra- and inter-observer differences that occur when facial landmarks are set. According to previous reports, intra- and inter-observer

M AN U

landmark identification differences for the tragus, superior palpebral fissure, and inferior palpebral fissure have poor reliability (1.5 mm > SD > 1 mm), while medial canthus, lateral canthus, and subnasale show high (SD < 0.5mm) to moderate (SD < 1mm) reliability.19,20

TE D

Since computed tomography was available, checking three-dimensional symmetry was widely performed to compare the volume for both orbits as a digital threedimensional kind of exophthalmometry.1,3,7,21 Even volume measurements and

EP

comparisons of fractured and unfractured orbits in orbital floor fractures was performed.3 The main volume difference between right and left healthy orbits was

AC C

about 0.16–2.22 cm3. A volume increase of 1 cm3 was associated with an enophthalmos of 0.8–0.9 mm, which can lead to visible asymmetry when 2–3 mm enophthalmos are exceeded.1,3,21 Similar values could be proven by MRI studies on complex orbital fractures.1 Nkenke et al. investigated unilateral zygomatic fractures and first described exophthalmometry using three-dimensional facial images.11 Their technique has been proven to be practicable for use during repositioning of malpositioned, asymmetric globes.2 Corneal apices were rectangular projected on the symmetry

ACCEPTED MANUSCRIPT plane to allow for relative distance measurements as an indicator for exophthalmos or enophthalmos and asymmetric positioning of the globe. While their symmetry plane was detected by a manually performed coarse registration and an automatic fine registration method, the symmetry plane in this study was detected

RI PT

automatically.11,17,22 The search for the plane with the highest PRST is lead back on an optimization problem. Of the many optimization algorithms, we chose the particle swarm optimization (PSO) for this study, which allowed for a fast and robust method

In

a

recent

study,

the

SC

for finding the main symmetry plane in objects or faces.23,24

supraorbitale-pupil-infraorbitale

(SPI)

angle

for

M AN U

exophthalmometry and periorbital asymmetry measurements of the orbital floor fractures did not show statistical significance between a post-surgical scanned group and a control group.3 In contradiction to previous publications, no matted, grey, opaque contact lenses were used to reduce reflections from the light source of the

TE D

optical sensor.2,3,11 Although this may lead to incorrect positioning of the pupillandmark, the results seem to be meaningful.2,3,11 The absence of statistical significance for CT-measured orbital volume differences between the control group

EP

and surgery group (treated with PDS foil or Ethisorb patches in previous publications) supports the symmetry results in the presented study.3

AC C

Ideal symmetry of the facial surface, which is well known to be identified as unnatural, is associated with the absence of volume differences between both facial halves. To a certain degree, the natural asymmetry of human faces obscures some inaccuracy in surgical reconstructions.9 When compared to the control group, the volume and mean distance differences after surgery failed to show statistical significance, which confirms that the goal of the surgery (e.g. orbital symmetry) has been achieved.1,2 Assuming that facial symmetry is an essential goal of facial surgical treatments, the presented technique could be transferred to other fields of

ACCEPTED MANUSCRIPT craniomaxillofacial surgery, such as unilateral mandible fractures, zygomatic fractures, or forehead fractures, as postsurgical course control.

Conclusion

RI PT

Periorbital facial asymmetry a well-known complication of orbital floor fractures. In agreement with previous reports, this study shows that PDS foils and Ethisorb patches could be used for medium-size orbital floor fractures with satisfactory results

SC

in terms of functional and aesthetic outcomes. Optical three-dimensional facial scanning and distance or volume measurements using automatically constructed

M AN U

mirror images are useful tools for detecting periorbital asymmetries during the postsurgical course and could be helpful in other fields of craniomaxillofacial surgery. Further studies are needed to investigate the clinical benefits of software-aided

EP

TE D

asymmetry detection using non-invasive three-dimensional facial scanning.

study.

AC C

Disclosure: Neither Ethicon nor Johnson and Johnson had a role in funding this

ACCEPTED MANUSCRIPT References 1. Kolk A, Pautke C, Schott V, Ventrella E, Wiener E, Ploder O, et al. Secondary post-traumatic enophthalmos: high-resolution magnetic resonance imaging compared with multislice computed tomography in postoperative orbital volume measurement. J

RI PT

Oral Maxillofac Surg 2007;65:1926-34.

2. Kramer M, Maier T, Benz M, Holbach LM, Hausler G, Neukam FW, et al. Intraoperative

noncontact, nonionizing,

optical 3D exophthalmometry during

SC

repositioning of dislocated globes: first results. J Oral Maxillofac Surg 2006;64:902-9. 3. Gerressen M, Gillessen S, Riediger D, Hölzle F, Modabber A, Ghassemi A.

M AN U

Radiologic and facial morphologic long-term results in treatment of orbital floor fracture with flexible absorbable alloplastic material. J Oral Maxillofac Surg 2012;70:2375-85.

4. Gosau M, Schoneich M, Draenert FG, Ettl T, Driemel O, Reichert TE.

TE D

Retrospective analysis of orbital floor fractures--complications, outcome, and review of literature. Clinical oral investigations 2011;15:305-13. 5. Rosado P, de Vicente JC. Retrospective analysis of 314 orbital fractures. Oral

EP

Surg Oral Med Oral Pathol Oral Radiol 2012;113:168-71. 6. Jank S, Emshoff R, Schuchter B, Strobl H, Brandlmaier I, Norer B. Orbital floor

AC C

reconstruction with flexible Ethisorb patches: a retrospective long-term follow-up study. Oral surgery, oral medicine, oral pathology, oral radiology, and endodontics 2003;95:16-22.

7. Ploder O, Klug C, Voracek M, Burggasser G, Czerny C. Evaluation of computerbased area and volume measurement from coronal computed tomography scans in isolated blowout fractures of the orbital floor. J Oral Maxillofac Surg 2002;60:1267-72.

ACCEPTED MANUSCRIPT 8. Gierloff M, Seeck NG, Springer I, Becker S, Kandzia C, Wiltfang J. Orbital floor reconstruction

with

resorbable

polydioxanone

implants.

J

Craniofac

Surg

2012;23:161-4. 9. Metzger MC, Hohlweg-Majert B, Schon R, Teschner M, Gellrich NC, Schmelzeisen

RI PT

R, et al. Verification of clinical precision after computer-aided reconstruction in craniomaxillofacial surgery. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2007;104:e1-10.

SC

10. Thornhill R, Gangestad SW. Facial attractiveness. Trends in cognitive sciences 1999;3:452-60.

M AN U

11. Nkenke E, Benz M, Maier T, Wiltfang J, Holbach LM, Kramer M, et al. Relative en- and exophthalmometry in zygomatic fractures comparing optical non-contact, non-ionizing 3D imaging to the Hertel instrument and computed tomography. J Craniomaxillofac Surg 2003;31:362-8.

TE D

12. Rana M, Gellrich NC, Ghassemi A, Gerressen M, Riediger D, Modabber A. Three-dimensional evaluation of postoperative swelling after third molar surgery using 2 different cooling therapy methods: a randomized observer-blind prospective

EP

study. J Oral Maxillofac Surg 2011;69:2092-8. 13. Rana M, Gellrich NC, von See C, Weiskopf C, Gerressen M, Ghassemi A,

AC C

Modabber, A. 3D evaluation of postoperative swelling in treatment of bilateral mandibular fractures using 2 different cooling therapy methods: A randomized observer blind prospective study. J Craniomaxillofac Surg 2013;41:e17-23. 14. Gruber M, Häusler G. Simple, robust and accurate phase-measuring triangulation. Optik 1992;89:188-122 1992. 15. Laboureux X, Hausler G. Localization and Registration of Three-Dimensional Objects in Space-Where are the Limits? Applied optics 2001;40:5206-16.

ACCEPTED MANUSCRIPT 16. Hartmann J, Meyer-Marcotty P, Benz M, Hausler G, Stellzig-Eisenhauer A. Reliability of a Method for Computing Facial Symmetry Plane and Degree of Asymmetry Based on 3D-data. J Orofac Orthop 2007;68:477-90. 17. Wagner S. Bestimmung und Evaluierung der Hauptspiegelebene eines 3DUnpublished

observation

2010.

Available

chemnitz.de/~wags/about/hauptspiegelebene.pdf

at:

http://www-user.tu-

RI PT

Modells.

18. Podolak J, Shilane P, Golovinskiy A, Rusinkiewicz S, Funkhouser T. A planar-

SC

reflective symmetry transform for 3D shapes. ACM Trans Graph 2006;25:549-59. 19. Hajeer MY, Ayoub AF, Millett DT, Bock M, Siebert JP. Three-dimensional imaging

M AN U

in orthognathic surgery: the clinical application of a new method. The International journal of adult orthodontics and orthognathic surgery 2002;17:318-30. 20. Toma AM, Zhurov A, Playle R, Ong E, Richmond S. Reproducibility of facial soft tissue landmarks on 3D laser-scanned facial images. Orthodontics & craniofacial

TE D

research 2009;12:33-42.

21. Whitehouse RW, Batterbury M, Jackson A, Noble JL. Prediction of enophthalmos

1994;78:618-20.

EP

by computed tomography after 'blow out' orbital fracture. Br J Ophthalmol

22. Benz M, Laboureux X, Maier T, et al. The symmetry of faces. In Greiner G,

AC C

Niemann H, Ertl T, et al. (eds). Vision, Modeling and Visualization. Amsterdam: IOS Press, 2002:332-9.

23. Kennedy J, Eberhart R. Particle swarm optimization in Proceedings of IEEE International Conference on Neural Networks (ICNN '95) 1995;4:1942–8. 24. Eberhart R, Kennedy J. A new optimizer using particle swarm theory. Proceedings of the Sixth International Symposium on Micro Machine and Human Science 1995.

ACCEPTED MANUSCRIPT Figure Legends

Figure 1: Detected facial surface landmarks and distance measurement values

RI PT

illustrated using OnyxCeph3TM.

Figure 2: Three-dimensional view on the final mirror plane constructed using

SC

OnyxCeph3TM.

Figure 3: Region of interest and volume of interest calculated using the software

M AN U

Comparison.

Figure 4: Surface matching of the standard image and the left face half mirrored

TE D

image with perfect fitting on the mirrored face half by the software Comparison.

Figure 5: Boxplot for the comparison of the orbital volume differences (in ml) between standard images and their constructed mirror images (CG: control group;

EP

SG: surgery group) and the calculated p-values. The indicated orbit was mirrored

AC C

and the volume difference of the standard image was measured.

ACCEPTED MANUSCRIPT

Table 1. Baseline characteristics of patients (n/total (%))

Preoperative Postoperativ day 5 Postoperative day 7 Postoperative day 30

15/35 (43) 11/35 (31) 5/35 (14) 1/35 (3)

RI PT

Diplopia and eye-motility restriction

Causes of injury

12/35 10/35 8/35 5/35

AC C

EP

TE D

M AN U

SC

Assaults Vehicle accidents Falls Sport accidents

(34) (29) (23) (14)

ACCEPTED MANUSCRIPT Table 2. Statistical Data

N

Mean

Standard Deviation

PValue

95% Convidence Interval lower

Sex Surgery Group Control Group

35 35

Age Surgery Group Control Group

35 35

40.60 38.03

18.337 19.209

0.569

Difference of orbital width Surgery Group Control Group

35 35

1.069 1.494

0.7977 1.5035

0.145

Difference of orbital height Surgery Group Control Group

35 35

0.934 0.729

0.7475 0.4618

Difference Exocanthion – Frontal plane Surgery Group Control Group

35 35

2.303 1.889

Difference Endocanthion – Frontal plane Surgery Group Control Group

35 35

Difference Lower eyelid – Frontal plane Surgery Group Control Group

AC C

RI PT

0.771

11.529

-1.0031

0.1517

0.171

-0.0917

0.5032

1.9497 1.2897

0.299

-0.3764

1.2050

1.131 1.014

0.9576 0.7167

0.564

-0.2863

0.5206

35 35

1.663 1.434

1.5385 1.2916

0.503

-0.4490

0.9061

35 35

1.726 1.711

1.3876 1.2755

0.964

-0.6214

0.6500

M AN U

SC

-6.386

TE D

EP

Difference Upper eyelid – Frontal plane Surgery Group Control Group

upper

AC C

EP

TE D

M AN U

SC

RI PT

ACCEPTED MANUSCRIPT

AC C

EP

TE D

M AN U

SC

RI PT

ACCEPTED MANUSCRIPT

AC C

EP

TE D

M AN U

SC

RI PT

ACCEPTED MANUSCRIPT

AC C

EP

TE D

M AN U

SC

RI PT

ACCEPTED MANUSCRIPT

AC C

EP

TE D

M AN U

SC

RI PT

ACCEPTED MANUSCRIPT

ACCEPTED MANUSCRIPT Clinical Relevance:

Alloplastic resorbable implants could be used for medium-size orbital floor fractures with satisfactory surgical outcome. Optical three-dimensional facial scanning and

RI PT

distance or volume measurements using automatically constructed mirror images are

AC C

EP

TE D

M AN U

SC

useful tools for detecting periorbital asymmetries during the postsurgical course.

Noninvasive 3-dimensional evaluation of periorbital asymmetry in isolated unilateral orbital floor fractures.

The study was carried out to evaluate the degree of asymmetry between the injured and contralateral periorbital region in isolated orbital floor fract...
357KB Sizes 4 Downloads 4 Views