Autologous Bone Grafts versus Alloplastic Implants for Orbital Floor Reconstruction: A Systematic Review and Meta-Analysis

Autologous Bone Grafts versus Alloplastic Implants for Orbital Floor Reconstruction: A Systematic Review and Meta-Analysis | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Autologous Bone Grafts versus Alloplastic Implants for Orbital Floor Reconstruction: A Systematic Review and Meta-Analysis Mohammed Ehmidat, Ahmed Samy Gad, Ahmad Omar Saleh, Mohamed Mahmoud Fathy, and 5 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8368389/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 9 You are reading this latest preprint version Abstract Purpose: The choice of reconstructive material for orbital floor fractures remains a subject of debate. While autologous bone has historically been considered the "gold standard," alloplastic implants offer potential advantages in reducing surgical morbidity. This meta-analysis aimed to compare the safety and efficacy of autologous bone grafts versus alloplastic implants in orbital floor reconstruction. Methods: A systematic review was conducted in accordance with PRISMA guidelines (PROSPERO: CRD420251140583). Electronic databases (PubMed, Scopus, Web of Science, Cochrane Library) were searched from inception to August 2025. Randomized controlled trials and comparative cohort studies evaluating functional outcomes (diplopia, enophthalmos) and complications (ectropion, infection, malposition) were included. Data were synthesized using a random-effects model, with risk ratios (RR) and 95% confidence intervals (CI) calculated. Results: Twenty studies comprising 2,119 patients were included. Alloplastic implants demonstrated statistically significant superiority in periocular safety, with a reduced risk of postoperative ectropion compared to autologous grafts (RR = 2.245; p = 0.020). Furthermore, sensitivity analysis revealed a significantly higher risk of implant malposition in the autologous group (RR = 2.074; p = 0.004). Autologous reconstruction was associated with a strong trend toward increased postoperative pain ( p = 0.052) and inherent donor-site morbidity. No statistically significant differences were observed regarding infection ( p = 0.402), enophthalmos ( p = 0.201), or diplopia ( p = 0.221), confirming the functional non-inferiority of alloplastic materials. Conclusion: Alloplastic implants demonstrate a superior safety profile regarding ectropion and implant positioning while offering functional efficacy equivalent to autologous bone. Given the elimination of donor-site morbidity and reduced periocular complications, alloplastic biomaterials should be considered the preferred standard of care for routine orbital floor reconstruction. Orbital fractures Orbital reconstruction Autologous bone Alloplastic implants Ectropion Meta-Analysis Figures Figure 1 Figure 2 Figure 3 Figure 4 1. Introduction Orbital floor blow-out fractures constitute a pervasive challenge in maxillofacial trauma, accounting for approximately one-third of all midfacial injuries [ 1 ]. Epidemiological data indicate a rising incidence; for instance, emergency department visits in the United States related to these fractures increased by 47% between 2006 and 2017 [ 2 ]. The pathophysiology typically involves blunt force trauma transmitting hydraulic pressure to the orbit, resulting in the fracture of the thin infraorbital bone and subsequent herniation of orbital contents into the maxillary sinus [ 3 ]. Given the orbital floor's critical role in globe support, such disruption frequently precipitates enophthalmos, hypoglobus, and diplopia [ 1 , 3 ]. Inadequate management can lead to permanent sequelae. Even minor volume expansion, as little as 1 cm³, can result in 3–4 mm of clinically apparent enophthalmos [ 1 ]. Furthermore, persistent diplopia affects approximately 4–5% of patients post-injury [ 4 ]. Consequently, the restoration of orbital volume and anatomical position remains the principal goal of surgical intervention. Since the 1950s, the armamentarium for orbital reconstruction has evolved into two distinct categories: autologous grafts (e.g., calvarial, iliac crest, rib) and alloplastic implants (e.g., titanium mesh, porous polyethylene, resorbable polymers) [ 5 ]. While autologous grafts offer biocompatibility, they are associated with donor-site morbidity, unpredictable resorption, and limited availability. Conversely, alloplastic implants obviate donor-site issues and facilitate patient-specific contouring but have historically raised concerns regarding infection and extrusion [ 5 , 6 ]. The selection of the optimal reconstructive material necessitates a trade-off. Titanium mesh offers precise contouring, while porous polyethylene facilitates vascular integration [ 5 ]. Evidence regarding the superior modality remains heterogeneous, with conflicting reports favoring either approach [ 7 , 8 ]. To date, high-quality evidence comparing these modalities remains fragmented, with the literature dominated by small, retrospective series [ 9 , 10 ]. This systematic review and meta-analysis aims to synthesize the available data to provide definitive, evidence-based guidance on the optimal reconstructive strategy, balancing functional outcomes with safety profiles [ 11 ]. 2. Materials and Methods 2.1. Protocol and Registration This systematic review and meta-analysis was conducted and documented in strict accordance with the guidelines established in the Cochrane Handbook for Systematic Reviews of Interventions and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement [12]. The protocol was prospectively registered on PROSPERO under the identifier CRD420251140583. A completed PRISMA checklist is included in the supplementary materials to ensure transparency and reproducibility. 2.2. Search Strategy A comprehensive systematic search was executed by two independent authors across multiple electronic databases, including PubMed, Scopus, the Cochrane Library, and Web of Science. The search strategy encompassed the entire duration of each database from inception up to 18 August 2025. Predefined keywords and Boolean operators were tailored to capture all relevant literature, utilizing combinations of terms such as 'Orbital Reconstruction', 'Orbital Floor Fracture', 'Blowout Fracture', 'Autologous', 'Bone Graft', 'Alloplastic', 'Titanium', and 'Porous Polyethylene'. Detailed search strings for each specific database are provided in Supplementary Table 1. 2.3. Eligibility Criteria The selection process adhered to the PICO framework. The target population comprised patients diagnosed with orbital floor fractures, including pure blow-out or impure fractures involving the orbital floor, requiring surgical reconstruction. The intervention of interest was reconstruction utilizing autologous grafts, such as iliac crest, calvarial bone, rib, or cartilage. These were compared against reconstructions employing alloplastic implants, including titanium mesh, porous polyethylene, or resorbable polymers. The primary outcomes assessed were diplopia, enophthalmos, infraorbital nerve alterations, extraocular muscle movement impairment, infection, ectropion, implant malposition, and reoperation rates. Regarding study design, the review included comparative studies (randomized controlled trials, prospective or retrospective cohorts) and case series that reported extractable quantitative safety or efficacy data. Case reports, review articles, animal studies, editorials, and studies lacking sufficient quantitative data were excluded. 2.4. Study Selection and Data Extraction Two reviewers independently screened all retrieved records by examining titles and abstracts. Full-text articles were obtained for any record deemed potentially eligible based on the initial screening. The study selection process is illustrated in the PRISMA flowchart (Figure 1). Any discrepancies regarding study inclusion were resolved through consensus or consultation with a third senior reviewer. Subsequently, data were extracted using a standardized, pre-piloted template that captured key variables including author, publication year, country, study design, sample size, follow-up duration, and specific clinical outcomes. 2.5. Quality Assessment The methodological quality of the included literature was rigorously appraised using design-specific tools. For randomized controlled trials (RCTs), the Revised Cochrane Risk-of-Bias tool (RoB 2) was employed to assess domains such as the randomization process, deviations from intended interventions, and missing outcome data [13]. Concurrently, observational cohort studies were evaluated using the Newcastle–Ottawa Scale (NOS), which assesses the quality of selection, comparability of cohorts, and the adequacy of outcome assessment [14]. Non-comparative case series were appraised using the NIH Quality Assessment Tool to systematically evaluate the clarity of research questions, population definition, and outcome measures. 2.6. Statistical Analysis Quantitative data synthesis was performed using Comprehensive Meta-Analysis (CMA) software, version 3.0 (Biostat, Englewood, NJ, USA). For dichotomous outcomes, the Risk Ratio (RR) with 95% Confidence Intervals (CI) was calculated as the primary effect measure. Additionally, pooled event rates (proportions) were calculated independently for each intervention arm to provide descriptive safety data. Given the anticipated clinical heterogeneity regarding defect size and surgical timing, a random-effects model (DerSimonian and Laird method) was applied for all analyses to provide a conservative estimate of the effect size. Statistical heterogeneity was assessed using the Cochran Q test and quantified with the I² statistic, where values greater than 50% indicated substantial heterogeneity. Sensitivity analyses were performed to investigate sources of heterogeneity and verify the robustness of the results. This involved the sequential exclusion of individual studies using the "leave-one-out" method to determine if a single study was exerting a disproportionate influence on the overall summary estimate or heterogeneity metrics. Statistical significance was set at p < 0.05. Assessment of publication bias via funnel plots was not performed as fewer than ten studies were available for each outcome, limiting the statistical power to reliably detect asymmetry [12]. 3. Results 3.1. Study Selection The initial database search yielded 545 records. After removing 204 duplicates, 341 records were screened by title and abstract. Following a rigorous full-text assessment against the pre-defined inclusion and exclusion criteria, 20 studies were deemed eligible and included in the qualitative synthesis and quantitative meta-analysis. The complete selection process is outlined in the PRISMA flowchart (Figure 1). 3.2. Study Characteristics The final analysis included 20 studies published between 2000 and 2022, comprising a total cohort of 2,119 patients. These studies represent a diverse global population spanning four continents (Asia, Europe, North America, and South America), ensuring high generalizability of the findings across different healthcare systems. The included literature consisted of 4 randomized controlled trials (RCTs), 12 comparative cohort studies, and 4 case series. A detailed summary of the included studies and baseline characteristics for the included population is presented in Tables 1, 2. 3.3. Quality Assessment The methodological quality of the included literature was evaluated using design-specific appraisal tools. Randomized Controlled Trials (RCTs): Four RCTs were assessed using the Cochrane Risk of Bias 2 (RoB 2) tool. Evaluation across the five domains revealed that most studies presented "some concerns," particularly regarding the randomization process and potential for reporting bias. Two trials [15, 16] were judged as "high risk" of bias, largely due to limitations in allocation concealment and selective outcome reporting. Conversely, the domain addressing missing outcome data consistently showed a low risk of bias across all trials (Supplementary Figure 1) . Cohort Studies: Twelve observational cohort studies were evaluated using the Newcastle–Ottawa Scale (NOS). Total scores ranged from 4 to 9 stars, indicating heterogeneity in methodological rigor. Higher-quality studies (scores ≥8) were characterized by strong cohort selection and adequate follow-up protocols, whereas lower-scoring studies often lacked clarity in comparability or failed to meet criteria for follow-up adequacy (Supplementary Figure 2) . Case Series: Four non-comparative studies were appraised using the NIH Quality Assessment Tool (Supplementary Figure 3) . All studies achieved a score of 7 out of 9, corresponding to "fair" quality. While these studies clearly defined their research questions and outcome measures, limitations were noted regarding incomplete reporting of temporal associations and insufficient follow-up duration. However, their internal validity was deemed adequate for inclusion in the qualitative synthesis. 3.4. Clinical Outcomes Ectropion (Figure 2A). Data from three studies were available for the comparative analysis of ectropion. The pooled random-effects analysis demonstrated a statistically significantly higher risk of ectropion in the autologous reconstruction group compared to the alloplastic group (RR = 2.245; 95% CI: 1.135–4.442; p = 0.020). The pooled event rate was 11.3% (95% CI: 3.9%–28.4%) for autologous grafts versus 6.8% (95% CI: 4.6%–10.0%) for alloplastic implants. Heterogeneity was negligible (I² = 0.000%). Implant Malposition (Figure 2B) Five studies contributed data regarding implant malposition. Descriptive pooled analysis of the full dataset indicated a higher event rate in the autologous group (16.0%; 95% CI: 3.5%–50.3%) compared to the alloplastic group (8.9%; 95% CI: 4.7%–16.1%). While the primary comparative analysis showed no statistical significance with moderate heterogeneity (I² = 33.1%), a sensitivity analysis was performed by excluding one outlier study [17]. This adjustment eliminated statistical heterogeneity (I² = 0.000%) and revealed a statistically significant difference, confirming that autologous bone grafts are associated with a significantly higher risk of malposition compared to alloplastic implants (RR = 2.074; 95% CI: 1.269–3.389; p = 0.004). Postoperative Pain (Figure 2C) Two studies reported on postoperative pain. The pooled analysis revealed no statistically significant difference between the groups ( p = 0.052), although a strong trend toward higher risk in the autologous group was observed (RR = 1.864; 95% CI: 0.994–3.496). The pooled event rate was markedly higher in the autologous group (18.5%; 95% CI: 11.0%–29.4%) compared to the alloplastic group (9.4%; 95% CI: 6.1%–14.3%). Heterogeneity was negligible (I² = 0.000%). Reoperation (Figure 3A). Reoperation rates were analyzed across three studies. No statistically significant difference was found (RR = 1.560; 95% CI: 0.882–2.759; p = 0.126). The pooled reoperation rate was 13.2% (95% CI: 6.2%–25.7%) in the autologous group and 6.4% (95% CI: 2.2%–17.4%) in the alloplastic group. Heterogeneity was low (I² = 19.6%). Infraorbital Nerve Alterations (Figure 3B). Five studies assessed infraorbital nerve sensory recovery. The analysis showed no statistically significant difference between reconstruction modalities (RR = 1.719; 95% CI: 0.854–3.459; p = 0.129). The pooled event rate for persistent nerve alteration was 21.6% in the autologous group compared to 17.1% in the alloplastic group. Heterogeneity was low (I² = 25.6%). Enophthalmos (Figure 3C). Three studies provided comparative data on enophthalmos. The pooled analysis indicated no statistically significant difference (RR = 1.397; 95% CI: 0.837–2.334; p = 0.201). Event rates were 11.4% for autologous grafts and 7.6% for alloplastic implants. Heterogeneity was negligible (I² = 0.000%). Diplopia (Figure 4A) Six studies evaluated postoperative diplopia. The pooled analysis revealed no statistically significant difference between the groups (RR = 1.251; 95% CI: 0.874–1.792; p = 0.221). The pooled event rate was 16.8% (95% CI: 8.2%–31.4%) in the autologous group and 10.8% (95% CI: 6.0%–18.7%) in the alloplastic group, with negligible heterogeneity (I² = 0.000%). Infection (Figure 4B) Infection rates were reported in five studies. No statistically significant difference was observed (RR = 1.456; 95% CI: 0.605–3.503; p = 0.402). The pooled infection rate was 5.4% (95% CI: 3.0%–9.4%) in the autologous group and 3.6% (95% CI: 1.9%–7.0%) in the alloplastic group. Heterogeneity was negligible (I² = 0.000%). Extraocular Muscle Movement Impairment (Figure 4C) Three studies assessed extraocular muscle movement. The analysis showed no statistically significant difference (RR = 0.884; 95% CI: 0.153–5.118; p = 0.891). The pooled event rate was 9.2% in the autologous group and 7.4% in the alloplastic group. Moderate statistical heterogeneity was detected (I² = 51.2%). 4. Discussion The restoration of orbital volume following "blow-out" fractures represents a critical balance between anatomical precision and the minimization of surgical morbidity. While the primary objectives, prevention of enophthalmos and diplopia, are well-established, the choice of reconstructive material has historically remained a subject of polarized debate. For decades, autologous bone grafts were heralded as the "gold standard" largely due to their biocompatibility [18]. However, the systematic review and meta-analysis conducted here challenges this historical precedence. By synthesizing data from comparative studies, our findings indicate that alloplastic implants are not merely a non-inferior alternative to autologous bone regarding functional outcomes, but are statistically superior in terms of periocular safety, specifically regarding the risk of ectropion. This suggests a necessary paradigm shift in maxillofacial trauma management, moving away from the routine harvesting of donor bone toward the use of precision-manufactured biomaterials as the first-line standard of care. Perhaps the most clinically significant finding of this analysis is the marked divergence in eyelid complications. Our comparative analysis demonstrated a statistically higher risk of postoperative ectropion in the autologous group (RR = 2.245; p = 0.020), with a pooled event rate of 11.3% compared to just 6.8% in the alloplastic group. This disparity is likely multifactorial but fundamentally rooted in the surgical approach; the harvesting of autologous bone often necessitates a "double setup" or prolonged operative duration. Furthermore, the aggressive retraction required to place typically bulkier, rigid bone grafts into the orbital floor may exacerbate soft tissue edema and scarring, thereby predisposing the patient to lower lid malposition [1]. This increased morbidity profile extends beyond the orbit. We observed a strong trend toward higher postoperative pain in the autologous group ( p = 0.052), with pooled pain rates nearly double those of the alloplastic group (18.5% vs. 9.4%). These data reinforce the argument that the biological "cost" of harvesting autologous tissue outweighs its theoretical benefits in routine reconstruction [19]. Regarding structural stability, our initial analysis suggested a trend toward higher malposition in the autologous group. However, upon conducting a sensitivity analysis by excluding outlier data [17], which contributed to statistical heterogeneity, the findings became definitive. The excluded study by Nowinski et al. involved medial wall reconstructions where implants were not rigidly fixed, representing a learning curve issue rather than intrinsic material failure. Adjusting for this confounder demonstrated a statistically significant superiority of alloplastic materials ( p = 0.004), with autologous grafts carrying more than double the risk of malposition (RR = 2.074). This finding is clinically consistent with the physical properties of the materials; autologous bone is rigid and notoriously difficult to contour to the complex, S-shaped anatomy of the orbital floor [20], whereas modern titanium and porous polyethylene implants allow for precise, anatomical adaptation [21]. Moreover, the unpredictability of graft resorption, often described as "creeping substitution," likely drives the higher pooled reoperation rate observed in the autologous group (13.2%) compared to the alloplastic group (6.4%), as surgeons are forced to intervene secondarily to correct late-onset enophthalmos or graft displacement [22]. Critically, this study alleviates the historical apprehension that "foreign" materials placed in the orbit act as a nidus for infection. Our results show no statistically significant difference in infection rates between the two modalities ( p = 0.402). In fact, the pooled infection rate was numerically lower in the alloplastic group (3.6%) compared to the autologous group (5.4%). This supports the safety profile of modern porous polymers and titanium, suggesting that when rigorous aseptic techniques are employed, the risk of extrusion or bacterial colonization is negligible [6]. Furthermore, in terms of primary functional restoration, alloplastic implants demonstrated clear non-inferiority. The rates of persistent diplopia ( p = 0.221) and enophthalmos ( p = 0.201) were statistically indistinguishable between the groups, confirming that the restoration of binocular single vision is achieved effectively with off-the-shelf implants [23]. The interpretation of these findings must be tempered by the limitations inherent to the primary literature. First, the robustness of the meta-analysis is influenced by the variable quality of included studies. Application of the RoB 2 tool to the randomized controlled trials (e.g., Ram et al. [23], Kozakiewicz et al. [15]) revealed "some concerns" or "high risk" of bias in the randomization process. This is a frequent challenge in surgical trials where blinding the operating surgeon is impossible. Furthermore, the observational cohorts demonstrated significant variability when assessed via the Newcastle–Ottawa Scale. A critical recurrent deficit was the lack of "Comparability" (scores of 0 stars for studies such as Guo [24] and Prowse [25]). This indicates a failure to control for key confounders, most notably the size of the orbital defect (cm²). Since larger defects are inherently more prone to complications [26], the inability to stratify results by defect surface area prevents a definitive conclusion regarding material performance in massive versus minimal defects. Additionally, statistical heterogeneity was moderate for extraocular muscle movement impairment (I² = 51.1%), likely reflecting diversity in surgical timing and follow-up duration across the dataset. Finally, cost-effectiveness remains a key consideration; while alloplastic implants entail higher upfront material costs, they may offset this through reduced operative time and elimination of donor-site management, a variable that warrants specific health-economic analysis in future studies. Conclusion In conclusion, the evidence gathered in this systematic review indicates that the era of routine autologous bone harvesting for orbital floor fractures should be reconsidered. Alloplastic implants demonstrate a superior safety profile regarding ectropion and donor-site morbidity, while offering a lower burden of reoperation and significantly reduced risk of implant malposition compared to autologous grafts. Given that they are also non-inferior in preventing infection and restoring visual function, alloplastic materials, specifically titanium mesh and porous polyethylene, should be regarded as the preferred standard for orbital floor reconstruction. Declarations Ethics approval and consent to participate Not applicable. Consent for publication Not applicable. Availability of data and materials All data generated or analyzed during this study are included in this published article. Competing interests The authors declare that they have no competing interests. Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. Authors’ Contributions ME conceptualized the study, designed the methodology, and wrote the original manuscript draft. ASG served as the project administrator, managed team tasks, performed the formal analysis, and wrote the final manuscript. AOS, AZ, MMF, AAE, RA, and AA were responsible for data curation, including the literature search, study screening, data extraction, and quality assessment. All authors critically revised the manuscript for important intellectual content and approved the final version submitted for publication. Acknowledgements: Not applicable. Clinical trial number : not applicable References Boyette JR, Pemberton JD, Bonilla-Velez J. Management of orbital fractures: challenges and solutions. Clin Ophthalmol. 2015;9:2127–37. Iftikhar M, Canner JK, Hall L, Ahmad M, Srikumaran D, Woreta FA. Characteristics of Orbital Floor Fractures in the United States from 2006 to 2017. Ophthalmology. 2021 Mar;128(3):463–70. Ujazda D, Wójtowicz J, Dominiak O, Głąb W, Komoń A, Grobelny A, et al. The functional and aesthetic aspects of blow-out fracture treatment. Biuletyn Głównej Biblioteki Lekarskiej. 2025 July 2;58:187–98. Seifert LB, Mainka T, Herrera-Vizcaino C, Verboket R, Sader R. 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Tables TABLE 1: Summary of the included studies Study ID Study Design Country Sample Size Study Duration Follow up period ( months ) Kinnunen, 2000 Prospective Cohort Finland 28 7 years (1991–1997) 42 Ellis, 2003 Case Series USA 58 7 years NA Guo, 2009 Retrospective Cohort China 61 22 months (2006–2008) 15 Asamura, 2010 Prospective Cohort Japan 38 3 years (2005–2007) 12 Nowinski, 2010 Retrospective Cohort Sweden 177 7 years (2000–2007) 5 Prowse, 2010 Retrospective Cohort Australia 81 12 years (1995–2007) 63 Ram, 2010 RCT India 20 3 months 3 Kirby, 2011 Retrospective Cohort USA 317 18 years (1991–2009) 10 Poeschl, 2011 Case Series Austria 60 5 years 3 Wajih, 2011 Retrospective Cohort Malaysia 35 18 months (2006–2008) 6 Gierloff, 2012 Retrospective Cohort Germany 194 6 years (2005–2011) 6 Kozakiewicz, 2013 RCT Poland 57 6 months 6 Baek, 2014 Retrospective Cohort Korea 78 5 years 7 months (2007–2012) 25 / 33 O’Connell, 2014 Case Series Ireland 20 10 years 26 Holtmann, 2016 Retrospective Cohort Germany 492 8 years (2005–2012) 2–36 Düzgün, 2020 Retrospective Cohort Turkey 62 7 years (2011–2018) 14 Zuo, 2020 RCT China 97 16 months 6 De-Moraes, 2021 RCT Brazil 31 5 years 3 months (2003–2009) 62 Piombino, 2022 Case Series Italy 146 10 years (2010–2020) 12–14 Wilkat, 2022 Prospective Cohort Germany 68 36 months (2017–2019) 6 Table 2: baseline characteristics for the included population Study ID Age (Mean ± SD, years) Gander ( percentage ) Type of Mesh Location of the Fracture Alloplastic Autologous Kinnunen, 2000 34.1 ± 10 M 60.7% / F 39.3% Bioactive glass (S53P4) Ear cartilage ± lyophilized dura Orbital floor fractures (includes blow-out: 15 cases; zygomaticomaxillary + orbital rim: 13 cases) Ellis, 2003 37 ± 10.5 M 90% / F 10% Titanium mesh Cranial bone graft 38 orbital floor; 4 isolated medial wall; 16 combined floor + medial wall Guo, 2009 38.13 ± 10.21 M 59% / F 41% Titanium mesh Calvarial bone graft Unilateral orbital floor fracture: 29 left, 32 right Asamura, 2010 41.5 ± 12.75 M 71% / F 28% Periosteum-polymer composite Iliac bone graft Open-type inferior orbital floor Nowinski, 2010 39 ± 19 NA PPE / Titanium mesh Bone grafts (rib, iliac crest, calvarium), cartilage/local bone fragments Orbital floor; medial wall; combined inferomedial Prowse, 2010 31.2 ± 11.67 M 79% / F 21% Silicone / Titanium mesh / Lactosorb / Resorb-x Autogenic bone / Autogenic cartilage Pure orbital floor fractures (25%); impure fractures (75%) Ram, 2010 29.88 ± 9.53 M 85% / F 15% Porous polyethylene (Medpor) Iliac crest graft Orbital floor fractures associated with other maxillomandibular fractures Kirby, 2011 33.7 ± 17.8 M 75.1% / F 24.9% Porous polyethylene / Titanium mesh / Porous polyethylene + Titanium Orbital floor repair, cranial bone, cartilage, fracture fragments, dermal fat, rib Impure blow-out: 162; pure blow-out: 64; cracked: 57; comminuted: 49; hinged: 13 Poeschl, 2011 36 ± NR M 63.3% / F 36.7% Ethisorb® patch / Resorb-X / Titanium mesh Bone grafts NR Wajih, 2011 Autogenous: 24.5 ± 4.27; Medpor: 24.5 ± 11.57 M 84.6% / F 15.4% Medpor Autogenous graft Orbital floor fracture Gierloff, 2012 M: 37 ± NR; F: 51 ± NR M 72% / F 28% Resorbable aliphatic polyester polymer NA Zygomaticomaxillary fractures: 81 (41%); isolated orbital floor: 69 (36%); complex midfacial: 44 (23%) Kozakiewicz, 2013 34 ± 14 M 81% / F 19% Titanium / UHMW-PE NR IOMF: 39; ZMOF: 12; ZOF: 3; COSF: 3 Baek, 2014 Inferior wall: 31.9 ± 14.9; Medial wall: 29.4 ± 12.2 M 89% / F 11% Titanium mesh Absorbable bone graft Inferior wall fracture; medial wall fracture; combined inferomedial fracture O’Connell, 2014 29 ± NR M 90% / F 10% NR Iliac crest bone graft Left: 14; right: 5 (one unspecified) Holtmann, 2016 46 ± 20.87 M 69% / F 31% Resorbable Polydioxanone Sheeting Not used Isolated orbital floor fractures; orbital floor fractures combined with other midfacial fractures Düzgün, 2020 32 ± NR M 76% / F 24% Porous polyethylene / Titanium mesh Iliac bone graft / Auricular cartilage graft Orbital floor Zuo, 2020 Obs: 40.29 ± 4.51; Ctr: 41.14 ± 4.53 M 66% / F 34% Medpor / Titanium + Medpor NA Obs group: 13 lower wall; 20 medial wall; 9 inferomedial /Ctrl group: 14 lower wall; 21 medial wall; 10 inferomedial De-Moraes, 2021 43.5 ± 19 M 65% / F 35% Polypropylene Mesh NA Orbital floor and/or medial wall Piombino, 2022 46 ± NR M 72% / F 28% Titanium mesh / Collagen / SU-POR / Medpor / Thin titanium mesh / BioGide / Bovine pericardium / SynPOR Bone grafts Isolated orbital floor: 96 (65.8%); zygomatic: 24 (16.5%); NOE: 17 (11.7%); lateral wall: 6 (4%); medial wall: 3 (2%) Wilkat, 2022 PSI: 45.6 ± 20.54; PDS: 43.0 ± 19.95 M 73.5% / F 26.5% Bioresorbable PDS foil / Patient-specific implant NA Orbital floor; medial orbital wall Additional Declarations No competing interests reported. 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08:13:33","extension":"html","order_by":38,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":120636,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-8368389/v1/ad19e4d6c0c445f00038b4d1.html"},{"id":100437022,"identity":"295d7a5a-2f22-4b38-a908-447c8e7dfbb7","added_by":"auto","created_at":"2026-01-16 15:50:06","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":58766,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003ePRISMA 2020 flow diagram for new systematic reviews which included searches of databases and registers only\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-8368389/v1/f65f7da6a0dd1337282cd717.png"},{"id":100546637,"identity":"94061148-fc86-485d-94b1-5a943e3b24df","added_by":"auto","created_at":"2026-01-19 08:11:37","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":356273,"visible":true,"origin":"","legend":"\u003cp\u003e\u0026nbsp;Legend not included with this version.\u003c/p\u003e","description":"","filename":"Figure2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8368389/v1/e1d95402e7cdbb02f0068e13.jpg"},{"id":100547160,"identity":"dee9c9b2-ea28-4e2a-97d1-e6b2749c5ab4","added_by":"auto","created_at":"2026-01-19 08:14:42","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":383341,"visible":true,"origin":"","legend":"\u003cp\u003e\u0026nbsp;Legend not included with this version.\u003c/p\u003e","description":"","filename":"Figure3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8368389/v1/bb1725188fe80e74c063b835.jpg"},{"id":100437026,"identity":"a9f02e11-df50-4adc-beaf-56316d4a3e08","added_by":"auto","created_at":"2026-01-16 15:50:06","extension":"jpg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":393994,"visible":true,"origin":"","legend":"\u003cp\u003e\u0026nbsp;Legend not included with this version.\u003c/p\u003e","description":"","filename":"Figure4.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8368389/v1/cfb1da015b521d9c4606677f.jpg"},{"id":100554261,"identity":"fa422b5c-308b-43e3-86f6-862ce2eda495","added_by":"auto","created_at":"2026-01-19 08:38:37","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2293728,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8368389/v1/550ea3d3-d7e1-4b4f-8f43-e8a832fbc86a.pdf"},{"id":100546967,"identity":"f8e92b56-5cc9-4c98-995b-aaaf01040dce","added_by":"auto","created_at":"2026-01-19 08:13:45","extension":"jpg","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":145547,"visible":true,"origin":"","legend":"","description":"","filename":"NIHmodelSF3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8368389/v1/aea2dc00c395194ad040d933.jpg"},{"id":100547199,"identity":"0a2446d5-1be1-4ecf-a9f2-d9184cd8ae57","added_by":"auto","created_at":"2026-01-19 08:14:52","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":17538,"visible":true,"origin":"","legend":"","description":"","filename":"DatabasessearchstrategiesSupplematnry.docx","url":"https://assets-eu.researchsquare.com/files/rs-8368389/v1/d40b4112851ba474456bb8de.docx"},{"id":100546749,"identity":"7ff7f753-3f2b-41bd-96ed-8fd2983bc870","added_by":"auto","created_at":"2026-01-19 08:12:15","extension":"pdf","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":146129,"visible":true,"origin":"","legend":"","description":"","filename":"ROB2SF1.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8368389/v1/938ef2403eba2489d6e8639c.pdf"},{"id":100546836,"identity":"9435ebd1-6ae1-41f6-ae69-9f5e727e9adb","added_by":"auto","created_at":"2026-01-19 08:12:53","extension":"jpg","order_by":4,"title":"","display":"","copyAsset":false,"role":"supplement","size":291960,"visible":true,"origin":"","legend":"","description":"","filename":"NOSSF2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8368389/v1/ee4e03175c6208d4908d1259.jpg"}],"financialInterests":"No competing interests reported.","formattedTitle":"Autologous Bone Grafts versus Alloplastic Implants for Orbital Floor Reconstruction: A Systematic Review and Meta-Analysis","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eOrbital floor blow-out fractures constitute a pervasive challenge in maxillofacial trauma, accounting for approximately one-third of all midfacial injuries [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Epidemiological data indicate a rising incidence; for instance, emergency department visits in the United States related to these fractures increased by 47% between 2006 and 2017 [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. The pathophysiology typically involves blunt force trauma transmitting hydraulic pressure to the orbit, resulting in the fracture of the thin infraorbital bone and subsequent herniation of orbital contents into the maxillary sinus [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Given the orbital floor's critical role in globe support, such disruption frequently precipitates enophthalmos, hypoglobus, and diplopia [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eInadequate management can lead to permanent sequelae. Even minor volume expansion, as little as 1 cm\u0026sup3;, can result in 3\u0026ndash;4 mm of clinically apparent enophthalmos [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Furthermore, persistent diplopia affects approximately 4\u0026ndash;5% of patients post-injury [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Consequently, the restoration of orbital volume and anatomical position remains the principal goal of surgical intervention.\u003c/p\u003e \u003cp\u003eSince the 1950s, the armamentarium for orbital reconstruction has evolved into two distinct categories: autologous grafts (e.g., calvarial, iliac crest, rib) and alloplastic implants (e.g., titanium mesh, porous polyethylene, resorbable polymers) [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. While autologous grafts offer biocompatibility, they are associated with donor-site morbidity, unpredictable resorption, and limited availability. Conversely, alloplastic implants obviate donor-site issues and facilitate patient-specific contouring but have historically raised concerns regarding infection and extrusion [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe selection of the optimal reconstructive material necessitates a trade-off. Titanium mesh offers precise contouring, while porous polyethylene facilitates vascular integration [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Evidence regarding the superior modality remains heterogeneous, with conflicting reports favoring either approach [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. To date, high-quality evidence comparing these modalities remains fragmented, with the literature dominated by small, retrospective series [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. This systematic review and meta-analysis aims to synthesize the available data to provide definitive, evidence-based guidance on the optimal reconstructive strategy, balancing functional outcomes with safety profiles [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e"},{"header":"2. Materials and Methods","content":"\u003cp\u003e\u003cstrong\u003e2.1. Protocol and Registration\u003c/strong\u003e This systematic review and meta-analysis was conducted and documented in strict accordance with the guidelines established in the Cochrane Handbook for Systematic Reviews of Interventions and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement [12]. The protocol was prospectively registered on PROSPERO under the identifier CRD420251140583. A completed PRISMA checklist is included in the supplementary materials to ensure transparency and reproducibility.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.2. Search Strategy\u003c/strong\u003e A comprehensive systematic search was executed by two independent authors across multiple electronic databases, including PubMed, Scopus, the Cochrane Library, and Web of Science. The search strategy encompassed the entire duration of each database from inception up to 18 August 2025. Predefined keywords and Boolean operators were tailored to capture all relevant literature, utilizing combinations of terms such as \u0026apos;Orbital Reconstruction\u0026apos;, \u0026apos;Orbital Floor Fracture\u0026apos;, \u0026apos;Blowout Fracture\u0026apos;, \u0026apos;Autologous\u0026apos;, \u0026apos;Bone Graft\u0026apos;, \u0026apos;Alloplastic\u0026apos;, \u0026apos;Titanium\u0026apos;, and \u0026apos;Porous Polyethylene\u0026apos;. Detailed search strings for each specific database are provided in Supplementary Table 1.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.3. Eligibility Criteria\u003c/strong\u003e The selection process adhered to the PICO framework. The target population comprised patients diagnosed with orbital floor fractures, including pure blow-out or impure fractures involving the orbital floor, requiring surgical reconstruction. The intervention of interest was reconstruction utilizing autologous grafts, such as iliac crest, calvarial bone, rib, or cartilage. These were compared against reconstructions employing alloplastic implants, including titanium mesh, porous polyethylene, or resorbable polymers. The primary outcomes assessed were diplopia, enophthalmos, infraorbital nerve alterations, extraocular muscle movement impairment, infection, ectropion, implant malposition, and reoperation rates. Regarding study design, the review included comparative studies (randomized controlled trials, prospective or retrospective cohorts) and case series that reported extractable quantitative safety or efficacy data. Case reports, review articles, animal studies, editorials, and studies lacking sufficient quantitative data were excluded.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.4. Study Selection and Data Extraction\u003c/strong\u003e Two reviewers independently screened all retrieved records by examining titles and abstracts. Full-text articles were obtained for any record deemed potentially eligible based on the initial screening. The study selection process is illustrated in the PRISMA flowchart (Figure 1). Any discrepancies regarding study inclusion were resolved through consensus or consultation with a third senior reviewer. Subsequently, data were extracted using a standardized, pre-piloted template that captured key variables including author, publication year, country, study design, sample size, follow-up duration, and specific clinical outcomes.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.5. Quality Assessment\u003c/strong\u003e The methodological quality of the included literature was rigorously appraised using design-specific tools. For randomized controlled trials (RCTs), the Revised Cochrane Risk-of-Bias tool (RoB 2) was employed to assess domains such as the randomization process, deviations from intended interventions, and missing outcome data [13]. Concurrently, observational cohort studies were evaluated using the Newcastle\u0026ndash;Ottawa Scale (NOS), which assesses the quality of selection, comparability of cohorts, and the adequacy of outcome assessment [14]. Non-comparative case series were appraised using the NIH Quality Assessment Tool to systematically evaluate the clarity of research questions, population definition, and outcome measures.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.6. Statistical Analysis\u003c/strong\u003e Quantitative data synthesis was performed using Comprehensive Meta-Analysis (CMA) software, version 3.0 (Biostat, Englewood, NJ, USA). For dichotomous outcomes, the Risk Ratio (RR) with 95% Confidence Intervals (CI) was calculated as the primary effect measure. Additionally, pooled event rates (proportions) were calculated independently for each intervention arm to provide descriptive safety data. Given the anticipated clinical heterogeneity regarding defect size and surgical timing, a random-effects model (DerSimonian and Laird method) was applied for all analyses to provide a conservative estimate of the effect size. Statistical heterogeneity was assessed using the Cochran Q test and quantified with the I\u0026sup2; statistic, where values greater than 50% indicated substantial heterogeneity. Sensitivity analyses were performed to investigate sources of heterogeneity and verify the robustness of the results. This involved the sequential exclusion of individual studies using the \u0026quot;leave-one-out\u0026quot; method to determine if a single study was exerting a disproportionate influence on the overall summary estimate or heterogeneity metrics. Statistical significance was set at \u003cem\u003ep\u003c/em\u003e \u0026lt; 0.05. Assessment of publication bias via funnel plots was not performed as fewer than ten studies were available for each outcome, limiting the statistical power to reliably detect asymmetry [12].\u003c/p\u003e"},{"header":"3. Results","content":"\u003cp\u003e\u003cstrong\u003e3.1. Study Selection\u003c/strong\u003e The initial database search yielded 545 records. After removing 204 duplicates, 341 records were screened by title and abstract. Following a rigorous full-text assessment against the pre-defined inclusion and exclusion criteria, 20 studies were deemed eligible and included in the qualitative synthesis and quantitative meta-analysis. The complete selection process is outlined in the PRISMA flowchart (Figure 1).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.2. Study Characteristics\u003c/strong\u003e The final analysis included 20 studies published between 2000 and 2022, comprising a total cohort of 2,119 patients. These studies represent a diverse global population spanning four continents (Asia, Europe, North America, and South America), ensuring high generalizability of the findings across different healthcare systems. The included literature consisted of 4 randomized controlled trials (RCTs), 12 comparative cohort studies, and 4 case series. A detailed summary of the included studies and baseline characteristics for the included population is presented in Tables 1, 2.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.3. Quality Assessment\u003c/strong\u003e The methodological quality of the included literature was evaluated using design-specific appraisal tools. \u003cstrong\u003eRandomized Controlled Trials (RCTs):\u003c/strong\u003e Four RCTs were assessed using the Cochrane Risk of Bias 2 (RoB 2) tool. \u0026nbsp;Evaluation across the five domains revealed that most studies presented \u0026quot;some concerns,\u0026quot; particularly regarding the randomization process and potential for reporting bias. Two trials [15, 16] were judged as \u0026quot;high risk\u0026quot; of bias, largely due to limitations in allocation concealment and selective outcome reporting. Conversely, the domain addressing missing outcome data consistently showed a low risk of bias across all trials\u003cstrong\u003e\u0026nbsp;(Supplementary Figure 1)\u003c/strong\u003e. \u003cstrong\u003eCohort Studies:\u003c/strong\u003e Twelve observational cohort studies were evaluated using the Newcastle\u0026ndash;Ottawa Scale (NOS). Total scores ranged from 4 to 9 stars, indicating heterogeneity in methodological rigor. Higher-quality studies (scores \u0026ge;8) were characterized by strong cohort selection and adequate follow-up protocols, whereas lower-scoring studies often lacked clarity in comparability or failed to meet criteria for follow-up adequacy\u003cstrong\u003e\u0026nbsp;(Supplementary Figure 2)\u003c/strong\u003e. \u003cstrong\u003eCase Series:\u003c/strong\u003e Four non-comparative studies were appraised using the NIH Quality Assessment Tool\u003cstrong\u003e\u0026nbsp;(Supplementary Figure 3)\u003c/strong\u003e. All studies achieved a score of 7 out of 9, corresponding to \u0026quot;fair\u0026quot; quality. While these studies clearly defined their research questions and outcome measures, limitations were noted regarding incomplete reporting of temporal associations and insufficient follow-up duration. However, their internal validity was deemed adequate for inclusion in the qualitative synthesis.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.4. Clinical Outcomes\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEctropion (Figure 2A).\u003c/strong\u003e Data from three studies were available for the comparative analysis of ectropion. The pooled random-effects analysis demonstrated a statistically significantly higher risk of ectropion in the autologous reconstruction group compared to the alloplastic group (RR = 2.245; 95% CI: 1.135\u0026ndash;4.442; \u003cem\u003ep\u003c/em\u003e = 0.020). The pooled event rate was 11.3% (95% CI: 3.9%\u0026ndash;28.4%) for autologous grafts versus 6.8% (95% CI: 4.6%\u0026ndash;10.0%) for alloplastic implants. Heterogeneity was negligible (I\u0026sup2; = 0.000%).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eImplant Malposition (Figure 2B)\u003c/strong\u003e Five studies contributed data regarding implant malposition. Descriptive pooled analysis of the full dataset indicated a higher event rate in the autologous group (16.0%; 95% CI: 3.5%\u0026ndash;50.3%) compared to the alloplastic group (8.9%; 95% CI: 4.7%\u0026ndash;16.1%). While the primary comparative analysis showed no statistical significance with moderate heterogeneity (I\u0026sup2; = 33.1%), a sensitivity analysis was performed by excluding one outlier study [17]. This adjustment eliminated statistical heterogeneity (I\u0026sup2; = 0.000%) and revealed a statistically significant difference, confirming that autologous bone grafts are associated with a significantly higher risk of malposition compared to alloplastic implants (RR = 2.074; 95% CI: 1.269\u0026ndash;3.389; \u003cem\u003ep\u003c/em\u003e = 0.004).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePostoperative Pain (Figure 2C)\u003c/strong\u003e Two studies reported on postoperative pain. The pooled analysis revealed no statistically significant difference between the groups (\u003cem\u003ep\u003c/em\u003e = 0.052), although a strong trend toward higher risk in the autologous group was observed (RR = 1.864; 95% CI: 0.994\u0026ndash;3.496). The pooled event rate was markedly higher in the autologous group (18.5%; 95% CI: 11.0%\u0026ndash;29.4%) compared to the alloplastic group (9.4%; 95% CI: 6.1%\u0026ndash;14.3%). Heterogeneity was negligible (I\u0026sup2; = 0.000%).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eReoperation (Figure 3A).\u003c/strong\u003e Reoperation rates were analyzed across three studies. No statistically significant difference was found (RR = 1.560; 95% CI: 0.882\u0026ndash;2.759; \u003cem\u003ep\u003c/em\u003e = 0.126). The pooled reoperation rate was 13.2% (95% CI: 6.2%\u0026ndash;25.7%) in the autologous group and 6.4% (95% CI: 2.2%\u0026ndash;17.4%) in the alloplastic group. Heterogeneity was low (I\u0026sup2; = 19.6%).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInfraorbital Nerve Alterations (Figure 3B).\u003c/strong\u003e Five studies assessed infraorbital nerve sensory recovery. The analysis showed no statistically significant difference between reconstruction modalities (RR = 1.719; 95% CI: 0.854\u0026ndash;3.459; \u003cem\u003ep\u003c/em\u003e = 0.129). The pooled event rate for persistent nerve alteration was 21.6% in the autologous group compared to 17.1% in the alloplastic group. Heterogeneity was low (I\u0026sup2; = 25.6%).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEnophthalmos (Figure 3C).\u003c/strong\u003e Three studies provided comparative data on enophthalmos. The pooled analysis indicated no statistically significant difference (RR = 1.397; 95% CI: 0.837\u0026ndash;2.334; \u003cem\u003ep\u003c/em\u003e = 0.201). Event rates were 11.4% for autologous grafts and 7.6% for alloplastic implants. Heterogeneity was negligible (I\u0026sup2; = 0.000%).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDiplopia (Figure 4A)\u003c/strong\u003e Six studies evaluated postoperative diplopia. The pooled analysis revealed no statistically significant difference between the groups (RR = 1.251; 95% CI: 0.874\u0026ndash;1.792; \u003cem\u003ep\u003c/em\u003e = 0.221). The pooled event rate was 16.8% (95% CI: 8.2%\u0026ndash;31.4%) in the autologous group and 10.8% (95% CI: 6.0%\u0026ndash;18.7%) in the alloplastic group, with negligible heterogeneity (I\u0026sup2; = 0.000%).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInfection (Figure 4B)\u003c/strong\u003e Infection rates were reported in five studies. No statistically significant difference was observed (RR = 1.456; 95% CI: 0.605\u0026ndash;3.503; \u003cem\u003ep\u003c/em\u003e = 0.402). The pooled infection rate was 5.4% (95% CI: 3.0%\u0026ndash;9.4%) in the autologous group and 3.6% (95% CI: 1.9%\u0026ndash;7.0%) in the alloplastic group. Heterogeneity was negligible (I\u0026sup2; = 0.000%).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eExtraocular Muscle Movement Impairment (Figure 4C)\u003c/strong\u003e Three studies assessed extraocular muscle movement. The analysis showed no statistically significant difference (RR = 0.884; 95% CI: 0.153\u0026ndash;5.118; \u003cem\u003ep\u003c/em\u003e = 0.891). The pooled event rate was 9.2% in the autologous group and 7.4% in the alloplastic group. Moderate statistical heterogeneity was detected (I\u0026sup2; = 51.2%).\u003c/p\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eThe restoration of orbital volume following \u0026quot;blow-out\u0026quot; fractures represents a critical balance between anatomical precision and the minimization of surgical morbidity. While the primary objectives, prevention of enophthalmos and diplopia, are well-established, the choice of reconstructive material has historically remained a subject of polarized debate. For decades, autologous bone grafts were heralded as the \u0026quot;gold standard\u0026quot; largely due to their biocompatibility [18]. However, the systematic review and meta-analysis conducted here challenges this historical precedence. By synthesizing data from comparative studies, our findings indicate that alloplastic implants are not merely a non-inferior alternative to autologous bone regarding functional outcomes, but are statistically superior in terms of periocular safety, specifically regarding the risk of ectropion. This suggests a necessary paradigm shift in maxillofacial trauma management, moving away from the routine harvesting of donor bone toward the use of precision-manufactured biomaterials as the first-line standard of care.\u003c/p\u003e\n\u003cp\u003ePerhaps the most clinically significant finding of this analysis is the marked divergence in eyelid complications. Our comparative analysis demonstrated a statistically higher risk of postoperative ectropion in the autologous group (RR = 2.245; \u003cem\u003ep\u003c/em\u003e = 0.020), with a pooled event rate of 11.3% compared to just 6.8% in the alloplastic group. This disparity is likely multifactorial but fundamentally rooted in the surgical approach; the harvesting of autologous bone often necessitates a \u0026quot;double setup\u0026quot; or prolonged operative duration. Furthermore, the aggressive retraction required to place typically bulkier, rigid bone grafts into the orbital floor may exacerbate soft tissue edema and scarring, thereby predisposing the patient to lower lid malposition [1]. This increased morbidity profile extends beyond the orbit. We observed a strong trend toward higher postoperative pain in the autologous group (\u003cem\u003ep\u003c/em\u003e = 0.052), with pooled pain rates nearly double those of the alloplastic group (18.5% vs. 9.4%). These data reinforce the argument that the biological \u0026quot;cost\u0026quot; of harvesting autologous tissue outweighs its theoretical benefits in routine reconstruction [19].\u003c/p\u003e\n\u003cp\u003eRegarding structural stability, our initial analysis suggested a trend toward higher malposition in the autologous group. However, upon conducting a sensitivity analysis by excluding outlier data [17], which contributed to statistical heterogeneity, the findings became definitive. The excluded study by \u003cem\u003eNowinski et al.\u003c/em\u003e involved medial wall reconstructions where implants were not rigidly fixed, representing a learning curve issue rather than intrinsic material failure. Adjusting for this confounder demonstrated a statistically significant superiority of alloplastic materials (\u003cem\u003ep\u003c/em\u003e = 0.004), with autologous grafts carrying more than double the risk of malposition (RR = 2.074). This finding is clinically consistent with the physical properties of the materials; autologous bone is rigid and notoriously difficult to contour to the complex, S-shaped anatomy of the orbital floor [20], whereas modern titanium and porous polyethylene implants allow for precise, anatomical adaptation [21]. Moreover, the unpredictability of graft resorption, often described as \u0026quot;creeping substitution,\u0026quot; likely drives the higher pooled reoperation rate observed in the autologous group (13.2%) compared to the alloplastic group (6.4%), as surgeons are forced to intervene secondarily to correct late-onset enophthalmos or graft displacement [22].\u003c/p\u003e\n\u003cp\u003eCritically, this study alleviates the historical apprehension that \u0026quot;foreign\u0026quot; materials placed in the orbit act as a nidus for infection. Our results show no statistically significant difference in infection rates between the two modalities (\u003cem\u003ep\u003c/em\u003e = 0.402). In fact, the pooled infection rate was numerically lower in the alloplastic group (3.6%) compared to the autologous group (5.4%). This supports the safety profile of modern porous polymers and titanium, suggesting that when rigorous aseptic techniques are employed, the risk of extrusion or bacterial colonization is negligible [6].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFurthermore, in terms of primary functional restoration, alloplastic implants demonstrated clear non-inferiority. The rates of persistent diplopia (\u003cem\u003ep\u003c/em\u003e = 0.221) and enophthalmos (\u003cem\u003ep\u003c/em\u003e = 0.201) were statistically indistinguishable between the groups, confirming that the restoration of binocular single vision is achieved effectively with off-the-shelf implants [23].\u003c/p\u003e\n\u003cp\u003eThe interpretation of these findings must be tempered by the limitations inherent to the primary literature. First, the robustness of the meta-analysis is influenced by the variable quality of included studies. Application of the RoB 2 tool to the randomized controlled trials (e.g., Ram et al. [23], Kozakiewicz et al. [15]) revealed \u0026quot;some concerns\u0026quot; or \u0026quot;high risk\u0026quot; of bias in the randomization process. This is a frequent challenge in surgical trials where blinding the operating surgeon is impossible. Furthermore, the observational cohorts demonstrated significant variability when assessed via the Newcastle\u0026ndash;Ottawa Scale. A critical recurrent deficit was the lack of \u0026quot;Comparability\u0026quot; (scores of 0 stars for studies such as Guo [24] and Prowse [25]). This indicates a failure to control for key confounders, most notably the size of the orbital defect (cm\u0026sup2;). Since larger defects are inherently more prone to complications [26], the inability to stratify results by defect surface area prevents a definitive conclusion regarding material performance in massive versus minimal defects. Additionally, statistical heterogeneity was moderate for extraocular muscle movement impairment (I\u0026sup2; = 51.1%), likely reflecting diversity in surgical timing and follow-up duration across the dataset. Finally, cost-effectiveness remains a key consideration; while alloplastic implants entail higher upfront material costs, they may offset this through reduced operative time and elimination of donor-site management, a variable that warrants specific health-economic analysis in future studies.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn conclusion, the evidence gathered in this systematic review indicates that the era of routine autologous bone harvesting for orbital floor fractures should be reconsidered. Alloplastic implants demonstrate a superior safety profile regarding ectropion and donor-site morbidity, while offering a lower burden of reoperation and significantly reduced risk of implant malposition compared to autologous grafts. Given that they are also non-inferior in preventing infection and restoring visual function, alloplastic materials, specifically titanium mesh and porous polyethylene, should be regarded as the preferred standard for orbital floor reconstruction.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll data generated or analyzed during this study are included in this published article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; Contributions\u003c/strong\u003e ME conceptualized the study, designed the methodology, and wrote the original manuscript draft. ASG served as the project administrator, managed team tasks, performed the formal analysis, and wrote the final manuscript. AOS, AZ, MMF, AAE, RA, and AA were responsible for data curation, including the literature search, study screening, data extraction, and quality assessment. All authors critically revised the manuscript for important intellectual content and approved the final version submitted for publication.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u003c/strong\u003e Not applicable.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eClinical trial number\u003c/strong\u003e: not applicable\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eBoyette JR, Pemberton JD, Bonilla-Velez J. Management of orbital fractures: challenges and solutions. Clin Ophthalmol. 2015;9:2127\u0026ndash;37. \u003c/li\u003e\n\u003cli\u003eIftikhar M, Canner JK, Hall L, Ahmad M, Srikumaran D, Woreta FA. Characteristics of Orbital Floor Fractures in the United States from 2006 to 2017. Ophthalmology. 2021 Mar;128(3):463\u0026ndash;70. \u003c/li\u003e\n\u003cli\u003eUjazda D, W\u0026oacute;jtowicz J, Dominiak O, Głąb W, Komoń A, Grobelny A, et al. The functional and aesthetic aspects of blow-out fracture treatment. Biuletyn Gł\u0026oacute;wnej Biblioteki Lekarskiej. 2025 July 2;58:187\u0026ndash;98. \u003c/li\u003e\n\u003cli\u003eSeifert LB, Mainka T, Herrera-Vizcaino C, Verboket R, Sader R. Orbital floor fractures: epidemiology and outcomes of 1594 reconstructions. Eur J Trauma Emerg Surg. 2022 Apr;48(2):1427\u0026ndash;36. \u003c/li\u003e\n\u003cli\u003eSivam A, Enninghorst N. The Dilemma of Reconstructive Material Choice for Orbital Floor Fracture: A Narrative Review. Medicines (Basel). 2022 Jan 13;9(1):6. \u003c/li\u003e\n\u003cli\u003eMauriello JA, Hargrave S, Yee S, Mostafavi R, Kapila R. Infection after insertion of alloplastic orbital floor implants. Am J Ophthalmol. 1994 Feb 15;117(2):246\u0026ndash;52. \u003c/li\u003e\n\u003cli\u003eMok D, Lessard L, Cordoba C, Harris PG, Nikolis A. A review of materials currently used in orbital floor reconstruction. Can J Plast Surg. 2004;12(3):134\u0026ndash;40. \u003c/li\u003e\n\u003cli\u003eShah K, Gupta P. Orbital floor fracture reconstruction using autologous bone graft: its outcome, advantages and disadvantages. International Surgery Journal. 2025 July 28;12:1325\u0026ndash;9. \u003c/li\u003e\n\u003cli\u003eHamdy E, Yehia M. Biomaterials for Orbital Fracture Repair in Adults: A Systematic Review. \u003c/li\u003e\n\u003cli\u003eSeen S, Young S, Lang SS, Lim TC, Amrith S, Sundar G. Orbital Implants in Orbital Fracture Reconstruction: A Ten-Year Series. Craniomaxillofac Trauma Reconstr. 2021 Mar;14(1):56\u0026ndash;63. \u003c/li\u003e\n\u003cli\u003eAbd El Ghafar AE, Shawky N, Shaheen MH, Aziz KA, Diab MM. Long-term clinical outcomes of isolated orbital floor fracture reconstruction using nonresorbable implants. Indian J Ophthalmol. 2025 Feb 1;73(2):191\u0026ndash;8. \u003c/li\u003e\n\u003cli\u003ePage MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ. 2021 Mar 29;372:n71. \u003c/li\u003e\n\u003cli\u003eSterne JAC, Savović J, Page MJ, Elbers RG, Blencowe NS, Boutron I, et al. RoB 2: a revised tool for assessing risk of bias in randomised trials. BMJ. 2019 Aug 28;366:l4898. \u003c/li\u003e\n\u003cli\u003eWells G, Wells G, Shea B, Shea B, O\u0026rsquo;Connell D, Peterson J, et al. The Newcastle-Ottawa Scale (NOS) for Assessing the Quality of Nonrandomised Studies in Meta-Analyses. In 2014 [cited 2025 Dec 14]. Available from: https://www.semanticscholar.org/paper/The-Newcastle-Ottawa-Scale-(NOS)-for-Assessing-the-Wells-Wells/c293fb316b6176154c3fdbb8340a107d9c8c82bf\u003c/li\u003e\n\u003cli\u003eKrasovsky A, Hija A, Zeineh N, Capucha T, Haze DA, Emodi O, et al. Comparison of patient specific implant reconstruction vs conventional titanium mesh reconstruction of orbital fractures using a novel method. J Craniomaxillofac Surg. 2024 Apr;52(4):491\u0026ndash;502. \u003c/li\u003e\n\u003cli\u003eDe-Moraes SLC, Pereira R dos S, Afonso AM de P, Mattos RP, Ribeiro da Silva J, Santos RG, et al. A prospective study of resolution of post-traumatic orbital complications using PRECLUDE\u0026reg; MVP: A randomized controlled trial. Annals of Medicine and Surgery. 2021 Jan 1;61:139\u0026ndash;44. \u003c/li\u003e\n\u003cli\u003eTreatment of orbital fractures: evaluation of surgical techniques and materials for reconstruction - PubMed [Internet]. [cited 2025 Dec 14]. Available from: https://pubmed.ncbi.nlm.nih.gov/20613564/\u003c/li\u003e\n\u003cli\u003eVasile VA, Istrate S, Iancu RC, Piticescu RM, Cursaru LM, Schmetterer L, et al. Biocompatible Materials for Orbital Wall Reconstruction\u0026mdash;An Overview. Materials (Basel). 2022 Mar 16;15(6):2183. \u003c/li\u003e\n\u003cli\u003eO\u0026rsquo;Connell JE, Hartnett C, Hickey-Dwyer M, Kearns GJ. Reconstruction of orbital floor blow-out fractures with autogenous iliac crest bone: a retrospective study including maxillofacial and ophthalmology perspectives. J Craniomaxillofac Surg. 2015 Mar;43(2):192\u0026ndash;8. \u003c/li\u003e\n\u003cli\u003eEllis E, Tan Y. Assessment of internal orbital reconstructions for pure blowout fractures: cranial bone grafts versus titanium mesh. J Oral Maxillofac Surg. 2003 Apr;61(4):442\u0026ndash;53. \u003c/li\u003e\n\u003cli\u003eSp\u0026auml;ter T, Menger MD, Laschke MW. Vascularization Strategies for Porous Polyethylene Implants. Tissue Eng Part B Rev. 2021 Feb;27(1):29\u0026ndash;38. \u003c/li\u003e\n\u003cli\u003eSaluja H, Sachdeva S, Shah S, Dadhich A, Tandon P, More V, et al. Autogenous Grafts for Orbital Floor Reconstruction: A review. International Journal of Oral and Craniofacial Science. 2017 Oct 25;3(2):046\u0026ndash;52. \u003c/li\u003e\n\u003cli\u003eRam H, Singh RK, Mohammad S, Gupta AK. Efficacy of Iliac Crest vs. Medpor in Orbital Floor Reconstruction. J Maxillofac Oral Surg. 2010 June;9(2):134\u0026ndash;41. \u003c/li\u003e\n\u003cli\u003eGuo L, Tian W, Feng F, Long J, Li P, Tang W. Reconstruction of orbital floor fractures: comparison of individual prefabricated titanium implants and calvarial bone grafts. Ann Plast Surg. 2009 Dec;63(6):624\u0026ndash;31. \u003c/li\u003e\n\u003cli\u003eProwse SJB, Hold PM, Gilmour RF, Pratap U, Mah E, Kimble FW. Orbital floor reconstruction: A case for silicone. A 12 year experience. Journal of Plastic, Reconstructive \u0026amp; Aesthetic Surgery. 2010 July 1;63(7):1105\u0026ndash;9. \u003c/li\u003e\n\u003cli\u003eSchlund M, Lutz JC, Sentucq C, Bouet B, Ferri J, Nicot R. Prediction of Post-Traumatic Enophthalmos Based on Orbital Volume Measurements: A Systematic Review. J Oral Maxillofac Surg. 2020 Nov;78(11):2032\u0026ndash;41. \u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp dir=\"\"\u003e\u003cspan dir=\"\"\u003eTABLE 1: Summary of the included studies\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n\u003cdiv align=\"\" dir=\"\"\u003e\n \u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" align=\"\" width=\"833\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 15.8404%;\"\u003e\n \u003cp dir=\"LTR\"\u003e\u003cstrong\u003eStudy ID\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 17.1705%;\"\u003e\n \u003cp dir=\"LTR\"\u003e\u003cstrong\u003eStudy Design\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 7.497%;\"\u003e\n \u003cp dir=\"LTR\"\u003e\u003cstrong\u003eCountry\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 10.399%;\"\u003e\n \u003cp dir=\"LTR\"\u003e\u003cstrong\u003eSample Size\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 24.5466%;\"\u003e\n \u003cp dir=\"LTR\"\u003e\u003cstrong\u003eStudy Duration\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 23.821%;\"\u003e\n \u003cp dir=\"LTR\"\u003e\u003cstrong\u003eFollow up period ( months )\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd height=\"50\" style=\"width: 0.7203%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 0.7203%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 15.8404%;\"\u003e\n \u003cp dir=\"LTR\"\u003e\u003cstrong\u003eKinnunen, 2000\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.1705%;\"\u003e\n \u003cp dir=\"LTR\"\u003eProspective Cohort\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.497%;\"\u003e\n \u003cp dir=\"LTR\"\u003eFinland\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.399%;\"\u003e\n \u003cp dir=\"LTR\"\u003e28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24.5466%;\"\u003e\n \u003cp dir=\"LTR\"\u003e7 years (1991\u0026ndash;1997)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.821%;\"\u003e\n \u003cp dir=\"LTR\"\u003e42\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 0.7203%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 15.8404%;\"\u003e\n \u003cp dir=\"LTR\"\u003e\u003cstrong\u003eEllis, 2003\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.1705%;\"\u003e\n \u003cp dir=\"LTR\"\u003eCase Series\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.497%;\"\u003e\n \u003cp dir=\"LTR\"\u003eUSA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.399%;\"\u003e\n \u003cp dir=\"LTR\"\u003e58\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24.5466%;\"\u003e\n \u003cp dir=\"LTR\"\u003e7 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.821%;\"\u003e\n \u003cp dir=\"LTR\"\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 0.7203%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 15.8404%;\"\u003e\n \u003cp dir=\"LTR\"\u003e\u003cstrong\u003eGuo, 2009\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.1705%;\"\u003e\n \u003cp dir=\"LTR\"\u003eRetrospective Cohort\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.497%;\"\u003e\n \u003cp dir=\"LTR\"\u003eChina\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.399%;\"\u003e\n \u003cp dir=\"LTR\"\u003e61\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24.5466%;\"\u003e\n \u003cp dir=\"LTR\"\u003e22 months (2006\u0026ndash;2008)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.821%;\"\u003e\n \u003cp dir=\"LTR\"\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 0.7203%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 15.8404%;\"\u003e\n \u003cp dir=\"LTR\"\u003e\u003cstrong\u003eAsamura, 2010\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.1705%;\"\u003e\n \u003cp dir=\"LTR\"\u003eProspective Cohort\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.497%;\"\u003e\n \u003cp dir=\"LTR\"\u003eJapan\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.399%;\"\u003e\n \u003cp dir=\"LTR\"\u003e38\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24.5466%;\"\u003e\n \u003cp dir=\"LTR\"\u003e3 years (2005\u0026ndash;2007)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.821%;\"\u003e\n \u003cp dir=\"LTR\"\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 0.7203%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 15.8404%;\"\u003e\n \u003cp dir=\"LTR\"\u003e\u003cstrong\u003eNowinski, 2010\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.1705%;\"\u003e\n \u003cp dir=\"LTR\"\u003eRetrospective Cohort\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.497%;\"\u003e\n \u003cp dir=\"LTR\"\u003eSweden\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.399%;\"\u003e\n \u003cp dir=\"LTR\"\u003e177\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24.5466%;\"\u003e\n \u003cp dir=\"LTR\"\u003e7 years (2000\u0026ndash;2007)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.821%;\"\u003e\n \u003cp dir=\"LTR\"\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 0.7203%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 15.8404%;\"\u003e\n \u003cp dir=\"LTR\"\u003e\u003cstrong\u003eProwse, 2010\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.1705%;\"\u003e\n \u003cp dir=\"LTR\"\u003eRetrospective Cohort\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.497%;\"\u003e\n \u003cp dir=\"LTR\"\u003eAustralia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.399%;\"\u003e\n \u003cp dir=\"LTR\"\u003e81\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24.5466%;\"\u003e\n \u003cp dir=\"LTR\"\u003e12 years (1995\u0026ndash;2007)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.821%;\"\u003e\n \u003cp dir=\"LTR\"\u003e63\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 0.7203%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 15.8404%;\"\u003e\n \u003cp dir=\"LTR\"\u003e\u003cstrong\u003eRam, 2010\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.1705%;\"\u003e\n \u003cp dir=\"LTR\"\u003eRCT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.497%;\"\u003e\n \u003cp dir=\"LTR\"\u003eIndia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.399%;\"\u003e\n \u003cp dir=\"LTR\"\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24.5466%;\"\u003e\n \u003cp dir=\"LTR\"\u003e3 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.821%;\"\u003e\n \u003cp dir=\"LTR\"\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 0.7203%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 15.8404%;\"\u003e\n \u003cp dir=\"LTR\"\u003e\u003cstrong\u003eKirby, 2011\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.1705%;\"\u003e\n \u003cp dir=\"LTR\"\u003eRetrospective Cohort\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.497%;\"\u003e\n \u003cp dir=\"LTR\"\u003eUSA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.399%;\"\u003e\n \u003cp dir=\"LTR\"\u003e317\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24.5466%;\"\u003e\n \u003cp dir=\"LTR\"\u003e18 years (1991\u0026ndash;2009)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.821%;\"\u003e\n \u003cp dir=\"LTR\"\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 0.7203%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 15.8404%;\"\u003e\n \u003cp dir=\"LTR\"\u003e\u003cstrong\u003ePoeschl, 2011\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.1705%;\"\u003e\n \u003cp dir=\"LTR\"\u003eCase Series\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.497%;\"\u003e\n \u003cp dir=\"LTR\"\u003eAustria\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.399%;\"\u003e\n \u003cp dir=\"LTR\"\u003e60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24.5466%;\"\u003e\n \u003cp dir=\"LTR\"\u003e5 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.821%;\"\u003e\n \u003cp dir=\"LTR\"\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 0.7203%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 15.8404%;\"\u003e\n \u003cp dir=\"LTR\"\u003e\u003cstrong\u003eWajih, 2011\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.1705%;\"\u003e\n \u003cp dir=\"LTR\"\u003eRetrospective Cohort\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.497%;\"\u003e\n \u003cp dir=\"LTR\"\u003eMalaysia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.399%;\"\u003e\n \u003cp dir=\"LTR\"\u003e35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24.5466%;\"\u003e\n \u003cp dir=\"LTR\"\u003e18 months (2006\u0026ndash;2008)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.821%;\"\u003e\n \u003cp dir=\"LTR\"\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 0.7203%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 15.8404%;\"\u003e\n \u003cp dir=\"LTR\"\u003e\u003cstrong\u003eGierloff, 2012\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.1705%;\"\u003e\n \u003cp dir=\"LTR\"\u003eRetrospective Cohort\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.497%;\"\u003e\n \u003cp dir=\"LTR\"\u003eGermany\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.399%;\"\u003e\n \u003cp dir=\"LTR\"\u003e194\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24.5466%;\"\u003e\n \u003cp dir=\"LTR\"\u003e6 years (2005\u0026ndash;2011)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.821%;\"\u003e\n \u003cp dir=\"LTR\"\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 0.7203%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 15.8404%;\"\u003e\n \u003cp dir=\"LTR\"\u003e\u003cstrong\u003eKozakiewicz, 2013\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.1705%;\"\u003e\n \u003cp dir=\"LTR\"\u003eRCT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.497%;\"\u003e\n \u003cp dir=\"LTR\"\u003ePoland\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.399%;\"\u003e\n \u003cp dir=\"LTR\"\u003e57\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24.5466%;\"\u003e\n \u003cp dir=\"LTR\"\u003e6 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.821%;\"\u003e\n \u003cp dir=\"LTR\"\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 0.7203%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 15.8404%;\"\u003e\n \u003cp dir=\"LTR\"\u003e\u003cstrong\u003eBaek, 2014\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.1705%;\"\u003e\n \u003cp dir=\"LTR\"\u003eRetrospective Cohort\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.497%;\"\u003e\n \u003cp dir=\"LTR\"\u003eKorea\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.399%;\"\u003e\n \u003cp dir=\"LTR\"\u003e78\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24.5466%;\"\u003e\n \u003cp dir=\"LTR\"\u003e5 years 7 months (2007\u0026ndash;2012)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.821%;\"\u003e\n \u003cp dir=\"LTR\"\u003e25 / 33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 0.7203%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 15.8404%;\"\u003e\n \u003cp dir=\"LTR\"\u003e\u003cstrong\u003eO\u0026rsquo;Connell, 2014\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.1705%;\"\u003e\n \u003cp dir=\"LTR\"\u003eCase Series\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.497%;\"\u003e\n \u003cp dir=\"LTR\"\u003eIreland\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.399%;\"\u003e\n \u003cp dir=\"LTR\"\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24.5466%;\"\u003e\n \u003cp dir=\"LTR\"\u003e10 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.821%;\"\u003e\n \u003cp dir=\"LTR\"\u003e26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 0.7203%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 15.8404%;\"\u003e\n \u003cp dir=\"LTR\"\u003e\u003cstrong\u003eHoltmann, 2016\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.1705%;\"\u003e\n \u003cp dir=\"LTR\"\u003eRetrospective Cohort\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.497%;\"\u003e\n \u003cp dir=\"LTR\"\u003eGermany\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.399%;\"\u003e\n \u003cp dir=\"LTR\"\u003e492\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24.5466%;\"\u003e\n \u003cp dir=\"LTR\"\u003e8 years (2005\u0026ndash;2012)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.821%;\"\u003e\n \u003cp dir=\"LTR\"\u003e2\u0026ndash;36\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 0.7203%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 15.8404%;\"\u003e\n \u003cp dir=\"LTR\"\u003e\u003cstrong\u003eD\u0026uuml;zg\u0026uuml;n, 2020\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.1705%;\"\u003e\n \u003cp dir=\"LTR\"\u003eRetrospective Cohort\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.497%;\"\u003e\n \u003cp dir=\"LTR\"\u003eTurkey\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.399%;\"\u003e\n \u003cp dir=\"LTR\"\u003e62\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24.5466%;\"\u003e\n \u003cp dir=\"LTR\"\u003e7 years (2011\u0026ndash;2018)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.821%;\"\u003e\n \u003cp dir=\"LTR\"\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 0.7203%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 15.8404%;\"\u003e\n \u003cp dir=\"LTR\"\u003e\u003cstrong\u003eZuo, 2020\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.1705%;\"\u003e\n \u003cp dir=\"LTR\"\u003eRCT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.497%;\"\u003e\n \u003cp dir=\"LTR\"\u003eChina\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.399%;\"\u003e\n \u003cp dir=\"LTR\"\u003e97\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24.5466%;\"\u003e\n \u003cp dir=\"LTR\"\u003e16 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.821%;\"\u003e\n \u003cp dir=\"LTR\"\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 0.7203%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 15.8404%;\"\u003e\n \u003cp dir=\"LTR\"\u003e\u003cstrong\u003eDe-Moraes, 2021\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.1705%;\"\u003e\n \u003cp dir=\"LTR\"\u003eRCT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.497%;\"\u003e\n \u003cp dir=\"LTR\"\u003eBrazil\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.399%;\"\u003e\n \u003cp dir=\"LTR\"\u003e31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24.5466%;\"\u003e\n \u003cp dir=\"LTR\"\u003e5 years 3 months (2003\u0026ndash;2009)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.821%;\"\u003e\n \u003cp dir=\"LTR\"\u003e62\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 0.7203%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 15.8404%;\"\u003e\n \u003cp dir=\"LTR\"\u003e\u003cstrong\u003ePiombino, 2022\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.1705%;\"\u003e\n \u003cp dir=\"LTR\"\u003eCase Series\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.497%;\"\u003e\n \u003cp dir=\"LTR\"\u003eItaly\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.399%;\"\u003e\n \u003cp dir=\"LTR\"\u003e146\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24.5466%;\"\u003e\n \u003cp dir=\"LTR\"\u003e10 years (2010\u0026ndash;2020)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.821%;\"\u003e\n \u003cp dir=\"LTR\"\u003e12\u0026ndash;14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 0.7203%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 15.8404%;\"\u003e\n \u003cp dir=\"LTR\"\u003e\u003cstrong\u003eWilkat, 2022\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.1705%;\"\u003e\n \u003cp dir=\"LTR\"\u003eProspective Cohort\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7.497%;\"\u003e\n \u003cp dir=\"LTR\"\u003eGermany\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.399%;\"\u003e\n \u003cp dir=\"LTR\"\u003e68\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24.5466%;\"\u003e\n \u003cp dir=\"LTR\"\u003e36 months (2017\u0026ndash;2019)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.821%;\"\u003e\n \u003cp dir=\"LTR\"\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 0.7203%;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp dir=\"\"\u003e\u003cspan dir=\"\"\u003eTable 2: baseline characteristics for the included population\u003c/span\u003e\u003cspan dir=\"\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"1280\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 93px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003eStudy ID\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 154px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003eAge\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e(Mean \u0026plusmn; SD, years)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 87px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003eGander\u003c/span\u003e\u003c/p\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e( percentage )\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 632px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003eType of Mesh\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 314px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003eLocation of the Fracture\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 421px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003eAlloplastic\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 211px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003eAutologous\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 93px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003eKinnunen, 2000\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 154px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e34.1 \u0026plusmn; 10\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003eM 60.7% / F 39.3%\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 421px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003eBioactive glass (S53P4)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 211px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003eEar cartilage \u0026plusmn; lyophilized dura\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 314px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003eOrbital floor fractures (includes blow-out: 15 cases; zygomaticomaxillary + orbital rim: 13 cases)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 93px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003eEllis, 2003\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 154px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e37 \u0026plusmn; 10.5\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003eM 90% / F 10%\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 421px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003eTitanium mesh\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 211px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003eCranial bone graft\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 314px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e38 orbital floor; 4 isolated medial wall; 16 combined floor + medial wall\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 93px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003eGuo, 2009\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 154px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e38.13 \u0026plusmn; 10.21\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003eM 59% / F 41%\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 421px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003eTitanium mesh\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 211px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003eCalvarial bone graft\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 314px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003eUnilateral orbital floor fracture: 29 left, 32 right\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 93px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003eAsamura, 2010\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 154px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e41.5 \u0026plusmn; 12.75\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003eM 71% / F 28%\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 421px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003ePeriosteum-polymer composite\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 211px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003eIliac bone graft\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 314px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003eOpen-type inferior orbital floor\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 93px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003eNowinski, 2010\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 154px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e39 \u0026plusmn; 19\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003eNA\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 421px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003ePPE / Titanium mesh\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 211px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003eBone grafts (rib, iliac crest, calvarium), cartilage/local bone fragments\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 314px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003eOrbital floor; medial wall; combined inferomedial\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 93px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003eProwse, 2010\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 154px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e31.2 \u0026plusmn; 11.67\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003eM 79% / F 21%\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 421px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003eSilicone / Titanium mesh / Lactosorb / Resorb-x\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 211px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003eAutogenic bone / Autogenic cartilage\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 314px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003ePure orbital floor fractures (25%); impure fractures (75%)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 93px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003eRam, 2010\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 154px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e29.88 \u0026plusmn; 9.53\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003eM 85% / F 15%\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 421px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003ePorous polyethylene (Medpor)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 211px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003eIliac crest graft\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 314px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003eOrbital floor fractures associated with other maxillomandibular fractures\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 93px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003eKirby, 2011\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 154px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e33.7 \u0026plusmn; 17.8\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003eM 75.1% / F 24.9%\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 421px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003ePorous polyethylene / Titanium mesh / Porous polyethylene + Titanium\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 211px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003eOrbital floor repair, cranial bone, cartilage, fracture fragments, dermal fat, rib\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 314px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003eImpure blow-out: 162; pure blow-out: 64; cracked: 57; comminuted: 49; hinged: 13\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 93px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003ePoeschl, 2011\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 154px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e36 \u0026plusmn; NR\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003eM 63.3% / F 36.7%\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 421px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003eEthisorb\u0026reg; patch / Resorb-X / Titanium mesh\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 211px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003eBone grafts\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 314px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003eNR\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 93px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003eWajih, 2011\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 154px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003eAutogenous: 24.5 \u0026plusmn; 4.27; Medpor: 24.5 \u0026plusmn; 11.57\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003eM 84.6% / F 15.4%\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 421px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003eMedpor\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 211px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003eAutogenous graft\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 314px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003eOrbital floor fracture\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 93px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003eGierloff, 2012\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 154px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003eM: 37 \u0026plusmn; NR; F: 51 \u0026plusmn; NR\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003eM 72% / F 28%\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 421px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003eResorbable aliphatic polyester polymer\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 211px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003eNA\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 314px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003eZygomaticomaxillary fractures: 81 (41%); isolated orbital floor: 69 (36%); complex midfacial: 44 (23%)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 93px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003eKozakiewicz, 2013\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 154px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e34 \u0026plusmn; 14\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003eM 81% / F 19%\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 421px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003eTitanium / UHMW-PE\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 211px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003eNR\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 314px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003eIOMF: 39; ZMOF: 12; ZOF: 3; COSF: 3\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 93px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003eBaek, 2014\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 154px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003eInferior wall: 31.9 \u0026plusmn; 14.9; Medial wall: 29.4 \u0026plusmn; 12.2\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003eM 89% / F 11%\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 421px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003eTitanium mesh\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 211px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003eAbsorbable bone graft\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 314px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003eInferior wall fracture; medial wall fracture; combined inferomedial fracture\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 93px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003eO\u0026rsquo;Connell, 2014\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 154px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e29 \u0026plusmn; NR\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003eM 90% / F 10%\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 421px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003eNR\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 211px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003eIliac crest bone graft\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 314px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003eLeft: 14; right: 5 (one unspecified)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 93px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003eHoltmann, 2016\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 154px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e46 \u0026plusmn; 20.87\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003eM 69% / F 31%\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 421px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003eResorbable Polydioxanone Sheeting\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 211px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003eNot used\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 314px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003eIsolated orbital floor fractures; orbital floor fractures combined with other midfacial fractures\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 93px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003eD\u0026uuml;zg\u0026uuml;n, 2020\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 154px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e32 \u0026plusmn; NR\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003eM 76% / F 24%\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 421px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003ePorous polyethylene / Titanium mesh\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 211px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003eIliac bone graft / Auricular cartilage graft\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 314px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003eOrbital floor\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 93px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003eZuo, 2020\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 154px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003eObs: 40.29 \u0026plusmn; 4.51; Ctr: 41.14 \u0026plusmn; 4.53\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003eM 66% / F 34%\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 421px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003eMedpor / Titanium + Medpor\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 211px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003eNA\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 314px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003eObs group: 13 lower wall; 20 medial wall; 9 inferomedial /Ctrl group: 14 lower wall; 21 medial wall; 10 inferomedial\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 93px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003eDe-Moraes, 2021\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 154px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e43.5 \u0026plusmn; 19\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003eM 65% / F 35%\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 421px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003ePolypropylene Mesh\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 211px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003eNA\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 314px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003eOrbital floor and/or medial wall\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 93px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003ePiombino, 2022\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 154px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e46 \u0026plusmn; NR\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003eM 72% / F 28%\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 421px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003eTitanium mesh / Collagen / SU-POR / Medpor / Thin titanium mesh / BioGide / Bovine pericardium / SynPOR\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 211px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003eBone grafts\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 314px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003eIsolated orbital floor: 96 (65.8%); zygomatic: 24 (16.5%); NOE: 17 (11.7%); lateral wall: 6 (4%); medial wall: 3 (2%)\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 93px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003eWilkat, 2022\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 154px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003ePSI: 45.6 \u0026plusmn; 20.54; PDS: 43.0 \u0026plusmn; 19.95\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 87px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003eM 73.5% / F 26.5%\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 421px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003eBioresorbable PDS foil / Patient-specific implant\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 211px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003eNA\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 314px;\"\u003e\n \u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003eOrbital floor; medial orbital wall\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n\u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n\u003cp dir=\"RTL\"\u003e\u003cspan dir=\"LTR\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"oral-and-maxillofacial-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"omfs","sideBox":"Learn more about [Oral and Maxillofacial Surgery](http://link.springer.com/journal/10006)","snPcode":"10006","submissionUrl":"https://submission.nature.com/new-submission/10006/3","title":"Oral and Maxillofacial Surgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Orbital fractures, Orbital reconstruction, Autologous bone, Alloplastic implants, Ectropion, Meta-Analysis","lastPublishedDoi":"10.21203/rs.3.rs-8368389/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8368389/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003ePurpose:\u003c/strong\u003e The choice of reconstructive material for orbital floor fractures remains a subject of debate. While autologous bone has historically been considered the \"gold standard,\" alloplastic implants offer potential advantages in reducing surgical morbidity. This meta-analysis aimed to compare the safety and efficacy of autologous bone grafts versus alloplastic implants in orbital floor reconstruction.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e A systematic review was conducted in accordance with PRISMA guidelines (PROSPERO: CRD420251140583). Electronic databases (PubMed, Scopus, Web of Science, Cochrane Library) were searched from inception to August 2025. Randomized controlled trials and comparative cohort studies evaluating functional outcomes (diplopia, enophthalmos) and complications (ectropion, infection, malposition) were included. Data were synthesized using a random-effects model, with risk ratios (RR) and 95% confidence intervals (CI) calculated.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e Twenty studies comprising 2,119 patients were included. Alloplastic implants demonstrated statistically significant superiority in periocular safety, with a reduced risk of postoperative ectropion compared to autologous grafts (RR = 2.245; \u003cem\u003ep\u003c/em\u003e= 0.020). Furthermore, sensitivity analysis revealed a significantly higher risk of implant malposition in the autologous group (RR = 2.074; \u003cem\u003ep\u003c/em\u003e = 0.004). Autologous reconstruction was associated with a strong trend toward increased postoperative pain (\u003cem\u003ep\u003c/em\u003e = 0.052) and inherent donor-site morbidity. No statistically significant differences were observed regarding infection (\u003cem\u003ep\u003c/em\u003e = 0.402), enophthalmos (\u003cem\u003ep\u003c/em\u003e = 0.201), or diplopia (\u003cem\u003ep\u003c/em\u003e= 0.221), confirming the functional non-inferiority of alloplastic materials.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e Alloplastic implants demonstrate a superior safety profile regarding ectropion and implant positioning while offering functional efficacy equivalent to autologous bone. Given the elimination of donor-site morbidity and reduced periocular complications, alloplastic biomaterials should be considered the preferred standard of care for routine orbital floor reconstruction.\u003c/p\u003e","manuscriptTitle":"Autologous Bone Grafts versus Alloplastic Implants for Orbital Floor Reconstruction: A Systematic Review and Meta-Analysis","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-16 15:50:01","doi":"10.21203/rs.3.rs-8368389/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-05-18T19:43:38+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"259619379286073506474727520506406897083","date":"2026-05-09T10:32:27+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-16T13:03:28+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"70975560632051515304315121886977743176","date":"2026-01-13T19:25:07+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"128013580379541738161673108118373587272","date":"2026-01-13T18:05:28+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-01-13T12:48:46+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-12-19T06:50:34+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-12-19T06:49:44+00:00","index":"","fulltext":""},{"type":"submitted","content":"Oral and Maxillofacial Surgery","date":"2025-12-15T15:58:44+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"oral-and-maxillofacial-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"omfs","sideBox":"Learn more about [Oral and Maxillofacial Surgery](http://link.springer.com/journal/10006)","snPcode":"10006","submissionUrl":"https://submission.nature.com/new-submission/10006/3","title":"Oral and Maxillofacial Surgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"8a860bef-2a15-4648-aa50-0f7c9a5c1a82","owner":[],"postedDate":"January 16th, 2026","published":true,"recentEditorialEvents":[{"type":"editorInvitedReview","content":"","date":"2026-05-18T19:43:38+00:00","index":28,"fulltext":""},{"type":"reviewerAgreed","content":"259619379286073506474727520506406897083","date":"2026-05-09T10:32:27+00:00","index":27,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-01-16T15:50:01+00:00","versionOfRecord":[],"versionCreatedAt":"2026-01-16 15:50:01","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8368389","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8368389","identity":"rs-8368389","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}