{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,20]],"date-time":"2026-09-20T07:21:06Z","timestamp":1789888866003,"version":"4.0.1"},"reference-count":23,"publisher":"MDPI AG","issue":"6","license":[{"start":{"date-parts":[[2026,5,28]],"date-time":"2026-05-28T00:00:00Z","timestamp":1779926400000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Medicina"],"abstract":"<jats:p>Background and Objectives: The surgical management of three-wall orbital fractures remains a significant challenge due to complex anatomy, limited exposure, and the absence of clear landmarks. These extensive reconstructions are rare and traditionally burdened by high complication rates and inconsistent outcomes. This study presents a standardized surgical protocol for complex three-wall orbital reconstruction, highlighting the role of digital planning and a novel two-piece interlocking patient-specific implant (PSI). Materials and Methods: Between 2018 and 2024, 17 patients with unilateral three-wall orbital fractures underwent reconstruction using digitally planned, patient-specific two-piece titanium implants designed to restore the orbital floor, medial, and lateral walls. Implant positioning was assessed through qualitative evaluation of postoperative CT scans and quantitative comparison between planned and actual implant positions, as well as orbital volume analysis between reconstructed and unaffected orbits. Clinical outcomes were evaluated pre- and postoperatively. Results: Reconstruction was classified as ideal in 16 cases (94.1%) and satisfactory in one case (5.9%). Quantitative analysis demonstrated a high level of concordance between the planned and postoperative implant positions, with a mean deviation of 0.982 \u00b1 0.107 mm (95% CI: 0.927\u20131.037 mm). All implants were positioned within 1.5 mm of the planned location. Postoperative orbital volumes closely approximated those of the contralateral side, with a mean volume difference of 1.371 \u00b1 0.176 cm3 (95% CI: 1.280\u20131.461 cm3). Diplopia resolved in all patients, and enophthalmos was fully corrected in 15 cases (88.2%). No major complications or revision surgeries were observed. Conclusions: The proposed two-piece interlocking PSI enabled precise and reproducible reconstruction of complex three-wall orbital fractures. This approach demonstrates that even technically demanding orbital reconstructions can be performed with greater reliability, leading to favorable functional and aesthetic outcomes.<\/jats:p>","DOI":"10.3390\/medicina62061043","type":"journal-article","created":{"date-parts":[[2026,5,28]],"date-time":"2026-05-28T08:00:36Z","timestamp":1779955236000},"page":"1043","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":2,"title":["Management of Complex Three-Wall Orbital Fractures with Digital Planning and Patient-Specific Two-Piece Implants"],"prefix":"10.3390","volume":"62","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-5028-891X","authenticated-orcid":false,"given":"Lisa","family":"Catarzi","sequence":"first","affiliation":[{"name":"Maxillo-Facial Surgery Unit, Department of Medicine, University of Siena, Viale Bracci, 53100 Siena, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-6830-9309","authenticated-orcid":false,"given":"Giulio","family":"Cirignaco","sequence":"additional","affiliation":[{"name":"Maxillo-Facial Surgery Unit, Department of Medicine, University of Siena, Viale Bracci, 53100 Siena, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-5407-0862","authenticated-orcid":false,"given":"Massimiliano","family":"Gilli","sequence":"additional","affiliation":[{"name":"Department of Maxillo-Facial Surgery, Santa Maria Della Misericordia Hospital, 06132 Perugia, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-3529-709X","authenticated-orcid":false,"given":"Roberto","family":"Lo Giudice","sequence":"additional","affiliation":[{"name":"Department of Human Pathology of Adults and Developmental Age, Messina University, 98100 Messina, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Maurizio","family":"Gladi","sequence":"additional","affiliation":[{"name":"Neurosurgical Department, Marche Polytechnic University, Azienda Ospedaliero Universitaria delle Marche, 60126 Ancona, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-9454-9464","authenticated-orcid":false,"given":"Carlos M.","family":"Chiesa-Estomba","sequence":"additional","affiliation":[{"name":"Department of Otorhinolaryngology-Head and Neck Surgery, Hospital Universitario Donostia, 20003 San Sebastian, Spain"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-7789-145X","authenticated-orcid":false,"given":"Luigi Angelo","family":"Vaira","sequence":"additional","affiliation":[{"name":"Maxillofacial Surgery Operative Unit, Department of Medicine, Surgery and Pharmacy, University of Sassari, 07100 Sassari, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-3508-5847","authenticated-orcid":false,"given":"Giuseppe","family":"Consorti","sequence":"additional","affiliation":[{"name":"Division of Maxillofacial Surgery, Department of Neurological Sciences, Marche University Hospitals-Umberto I, 60126 Ancona, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2026,5,28]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1016\/j.fjs.2015.06.002","article-title":"Evolving concepts in the management of orbital fractures with enophthalmos: A retrospective comparative analysis","volume":"49","author":"Chen","year":"2016","journal-title":"Formos. J. Surg."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"532","DOI":"10.1016\/j.jcms.2024.02.012","article-title":"Customized orbital implant versus 3D preformed titanium mesh for orbital fracture repair: A retrospective comparative analysis of orbital reconstruction accuracy","volume":"52","author":"Consorti","year":"2024","journal-title":"J. Craniomaxillofac. Surg."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"e80","DOI":"10.1016\/j.bjoms.2020.06.038","article-title":"Limitations of non-patient-specific titanium implants in orbital reconstruction","volume":"58","author":"Schlittler","year":"2020","journal-title":"Br. J. Oral Maxillofac. Surg."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"1074","DOI":"10.1016\/j.bjoms.2021.03.017","article-title":"Going beyond the limitations of non-patient-specific titanium implants in orbital reconstruction","volume":"59","author":"Holmes","year":"2021","journal-title":"Br. J. Oral Maxillofac. Surg."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"547","DOI":"10.1007\/s12070-022-03127-9","article-title":"Management of orbital floor fractures: Our experience in 10 years","volume":"74","author":"Piombino","year":"2022","journal-title":"Indian J. Otolaryngol. Head Neck Surg."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"1236","DOI":"10.1097\/SCS.0000000000008461","article-title":"Customized and navigated primary orbital fracture reconstruction: The CONSORT protocol","volume":"33","author":"Consorti","year":"2022","journal-title":"J. Craniofac. Surg."},{"key":"ref_7","doi-asserted-by":"crossref","unstructured":"Helgers, L., Prikule, I., Salms, G., and Bagante, I. (2025). Emerging technologies in the treatment of orbital floor fractures: A systematic review. Medicina, 61.","DOI":"10.3390\/medicina61081330"},{"key":"ref_8","doi-asserted-by":"crossref","unstructured":"Ebeling, M., Pietzka, S., Sakkas, A., Kist, S., Scheurer, M., Schramm, A., and Wilde, F. (2025). Advances in the treatment of midface fractures: Innovative CAD\/CAM drill guides and implants for simultaneous primary management of zygomatic\u2013maxillary\u2013orbital complex fractures. Appl. Sci., 15.","DOI":"10.3390\/app151810194"},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"213","DOI":"10.1007\/s10006-022-01074-x","article-title":"Orbital reconstruction: A systematic review and meta-analysis evaluating the role of patient-specific implants","volume":"27","author":"Kotecha","year":"2023","journal-title":"Oral Maxillofac. Surg."},{"key":"ref_10","doi-asserted-by":"crossref","unstructured":"G\u0105siorowski, K., Gontarz, M., Bargiel, J., Marecik, T., and Wyszy\u0144ska-Pawelec, G. (2025). An exceptional case of blow-out fracture with complete globe dislocation into the maxillary sinus: Diagnostic imaging and surgical reconstruction. Diagnostics, 15.","DOI":"10.3390\/diagnostics15212705"},{"key":"ref_11","doi-asserted-by":"crossref","unstructured":"Dinu, C., Tamas, T., Agrigoroaei, G., Stoia, S., Opris, H., Bran, S., Armencea, G., and Manea, A. (2022). Prospective evaluation of intraorbital soft tissue atrophy after post-traumatic bone reconstruction as a risk factor for enophthalmos. J. Pers. Med., 12.","DOI":"10.20944\/preprints202207.0017.v1"},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"e341","DOI":"10.1016\/j.bjoms.2020.08.082","article-title":"Custom three-dimensional printed orbital plate composed of two joined parts with variable thickness for large orbital floor reconstruction following post-traumatic zygomatic fixation","volume":"58","author":"Ananth","year":"2020","journal-title":"Br. J. Oral Maxillofac. Surg."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"991","DOI":"10.1097\/SCS.0000000000008303","article-title":"Technical note on three- and four-wall orbital reconstructions with patient-specific implants","volume":"33","author":"Sabelis","year":"2022","journal-title":"J. Craniofac. Surg."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"334","DOI":"10.1016\/j.jcms.2023.10.007","article-title":"Epidemiological analysis of isolated orbital floor blowout fractures: Correlation between demographic characteristics and fracture area","volume":"52","author":"Troise","year":"2024","journal-title":"J. Craniomaxillofac. Surg."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"2332","DOI":"10.1097\/SCS.0000000000009668","article-title":"Orbital fractures: A new CT-based protocol to guide surgical approach and reconstruction material selection","volume":"34","author":"Consorti","year":"2023","journal-title":"J. Craniofac. Surg."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"678","DOI":"10.1016\/j.ijom.2019.09.009","article-title":"Implant-oriented navigation in orbital reconstruction part II: Preclinical cadaver study","volume":"49","author":"Schreurs","year":"2020","journal-title":"Int. J. Oral Maxillofac. Surg."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"326","DOI":"10.4103\/njms.njms_85_22","article-title":"Late patient-fitted total orbital reconstruction for facial gunshot wound sequelae","volume":"14","author":"Pinto","year":"2023","journal-title":"Natl. J. Maxillofac. Surg."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"424","DOI":"10.5999\/aps.2015.42.4.424","article-title":"Combined orbital fractures: Surgical strategy of sequential repair","volume":"42","author":"Hur","year":"2015","journal-title":"Arch. Plast. Surg."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"2539.e1","DOI":"10.1016\/j.joms.2021.07.025","article-title":"Custom interlocking implants for primary and secondary reconstruction of large orbital floor defects: Case series and workflow description","volume":"79","author":"Hajibandeh","year":"2021","journal-title":"J. Oral Maxillofac. Surg."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"55","DOI":"10.1055\/s-0035-1563392","article-title":"Orbital wall reconstruction with two-piece puzzle 3D-printed implants: Technical note","volume":"9","author":"Mommaerts","year":"2016","journal-title":"Craniomaxillofac. Trauma Reconstr."},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"496","DOI":"10.1016\/j.bjps.2017.11.016","article-title":"Patient-specific puzzle implant preformed with a 3D-printed rapid prototype model for combined orbital floor and medial wall fractures","volume":"71","author":"Kim","year":"2018","journal-title":"J. Plast. Reconstr. Aesthet. Surg."},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"112","DOI":"10.1016\/j.bjoms.2019.08.012","article-title":"Patient-specific two-piece screwless implant for reconstruction of a large orbital fracture","volume":"58","author":"Tikkanen","year":"2020","journal-title":"Br. J. Oral Maxillofac. Surg."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"333","DOI":"10.1007\/s10006-022-01065-y","article-title":"Primary reconstruction of extensive orbital fractures using two-piece patient-specific implants: The Helsinki protocol","volume":"27","author":"Salli","year":"2023","journal-title":"Oral Maxillofac. Surg."}],"container-title":["Medicina"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/1648-9144\/62\/6\/1043\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,5,28]],"date-time":"2026-05-28T08:46:50Z","timestamp":1779958010000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/1648-9144\/62\/6\/1043"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,5,28]]},"references-count":23,"journal-issue":{"issue":"6","published-online":{"date-parts":[[2026,6]]}},"alternative-id":["medicina62061043"],"URL":"https:\/\/doi.org\/10.3390\/medicina62061043","relation":{},"ISSN":["1648-9144"],"issn-type":[{"value":"1648-9144","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,5,28]]}}}