Management of Complex Three-Wall Orbital Fractures with Digital Planning and Patient-Specific Two-Piece Implants

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 ± 0.107 mm (95% CI: 0.927-1.037 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 ± 0.176 cm³ (95% CI: 1.280-1.461 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.