This study evaluated 36 cases of traumatic telecanthus (abnormal widening of the distance between the eyes) resulting from naso-orbito-ethmoid fractures that were treated primarily with either direct or indirect canthopexy. Direct canthopexy resulted in a smaller intercanthal distance and less relapse compared to indirect canthopexy. Early primary treatment within 2 weeks led to fewer cases of epiphora (watery eyes) or dacryocystitis (blocked tear duct) compared to later treatment. The study concludes that traumatic telecanthus should receive early primary treatment to achieve the best aesthetic and functional results.

1. M. A. W. Merkx, H. P. M. Freihofer, W. A. Borstlap, M. A.
van "t Hoff. Effectiveness of primary correction of
traumatic telecanthus. Int. J. Oral Maxillofac. Surg. 1995;
24: 344-347.
PRESENTED BY –
DR. SHEETAL KAPSE
GUIDED BY –
DR. RAJASEKHAR G.

2. 1. M. A. W. Merkx - Oral and Maxillofacial Surgery
2. H. P. M. Freihofer - Oral and Maxillofacial Surgery
3. W. A. Borstlap - Oral and Maxillofacial Surgery
4. M. A. van "t Hoff - Medical Statistics
 University Hospital St Radboud, Nijmegen, The Netherlands.

3.  Introduction
 Aim
 Materials and methods
 Results & Discussion
 Cross references
 Conclusion
 Pros and Cons of study
 References

4.  In frontobasal or naso-orbito-ethmoidal (NOE) trauma, the base of
the nose may be wedged between the orbits or the nasal skeleton may
be shattered. This leads to traumatic telecanthus.
 Can be treated with Indirect/Direct Canthopexy.
 Indirect Canthopexy - If the canthal ligament is still fixed to a
piece of bone of reasonable size, the intercanthal distance may be
restored by fixing this fragment by using a three-dimensional
microplate or wire ligature.
BOWERMAN JE. Fractures of the middle third of the facial skeleton. In: Royce N, WILLIAMS J, eds.: Maxillofacial
injuries. 3rd ed. Edinburgh: Livingstone, 1985: 363-434.

5.  Direct Canthopexy - If the piece of bone holding the canthal
ligament is too small for fixation or if it has been torn loose from the
bone completely, the ligament is fixed with a transnasal 0.2- mm
stainless-steel wire to the opposite medial orbital wall.
BOWERMAN JE. Fractures of the middle third of the facial skeleton. In: Royce N, WILLIAMS J, eds.: Maxillofacial
injuries. 3rd ed. Edinburgh: Livingstone, 1985: 363-434.

6. This retrospective study was done to compare the results of
the direct with the indirect technique, and early primary with
late primary reconstruction.

7.  36 cases between 1982-1991 –treated primarily of NOE fracture with
telecanthus .
Unilateral Telecanthus Bilateral Telecanthus
16 20
Indirect
Canthopexy
Direct
Canthopexy
6 10
Indirect
Canthopexy
Direct
Canthopexy
13 7
Early
primary
(<2wks)
Late
primary
(>2wks)
4 2
Early
primary
(<2wks)
Late
primary
(>2wks)
5 5
Early
primary
(<2wks)
Late
primary
(>2wks)
11 2
Early
primary
(<2wks)
Late
primary
(>2wks)
4 3

8.  Immediate & Late postoperative transverse intercanthal distances (ICD)
were measured with a pair of callipers.
 Resulting ICD was assessed in relation to
1. Type of injury (unilateral versus bilateral fracture)
2. Fixation technique
3. Time interval between injury and repair
4. Disturbed lacrimal Drainage – Epiphora /Dacrocystitis
 By a three-way analysis of variance ANOVA (Statistical Analysis)

9. Direct canthopexy
Direct-canthopexy
(17 patients)
Coronal incision ("retrograde
indirect approach")
Approach through wounds
or Open sky approach/W-
shaped incision

10. • Epiphora or dacryocystitis - 2/24 patients (8%) with early primary
treatment & 5/12 patients (42%) with late primary treatment.

12.  Gruss et al. n recommend immediate treatment of fractures in the NOE
region.
 Ellis states that the ICD should be1/2 of the IPD.
 In extensive facial fractures, displacement of the orbits and orbital
contents may disturb those proportions, precluding its use.
 Hence standard values, which vary from 28 to 35 mm independently of
age and sex.
 This study shows that the average ICD after correction of unilateral
telecanthus is 2.7 mm smaller than after correction of bilateral cases.

13.  As the contralateral side will be used as a means for control and
fixation in cases of unilateral canthopexy.
 This proves that’s the result of unilateral canthopexy cannot be
compared with that of bilateral canthopexy.
 Direct canthopexy showed the intercanthal distance to be 3.0 mm
smaller compared to indirect, while also less relapse was seen (2.1 mm).
 The position of the medial canthus is apparently more precisely
determined with direct fixation and is less sensitive to relapse.
 According to Stranc obstruction to the Nasolacrimal Duct is more in
cases of closed/indirect approach.

16.  Pointed out that only 5% of their group of primarily treated NOE
fractures needed a DCRS.
 Apart from damage to the canaliculi, we did not find any indication to
include the lacrimal drainage pathways in the early primary treatment.

17.  ELLIS argues that the intercanthal distance should be half of the
interpupillary distance.
 However, if there are extensive facial fractures, displacement of the
orbits and orbital contents may have disturbed those proportions,
precluding the use of this parameter.
 It is probably better to use standard values, which vary from 28 to 35
mm independently of age and sex.

18.  This article presents a strategy for treating naso-orbito-ethmoid
fractures.
 Eight steps for the management of such injuries are presented:
1. surgical exposure,
2. identification of the medial canthal tendon/ tendon-bearing bone
fragment,
3. reduction/reconstruction of medial orbital rim,
4. reconstruction of the medial orbital wall,
5. transnasal canthopexy,
6. reduction of septal fractures,
7. nasal dorsum reconstruction/ augmentation,
8. soft tissue adaptation

19.  Many variables  Racial variation for ICD

20.  Traumatic telecanthus should receive early primary treatment.
 This will produce the best possible results, both aesthetically and
functionally.
 One should try to achieve overcorrection of approximately 2 mm
when using a direct technique and 4 mm when using the indirect
technique.

21. 1. ELLIS E. Sequencing treatment for nasoorbito- ethmoid fractures. J Oral
Maxillofac Surg 1993: 51: 543-58.
2. GRuss JS, HtrRWITZ J J, NIK NA, KASSEL EE. The pattern and incidence of
lacrimal injury in naso-orbital-ethmoid fractures: the role of delayed
assessment and dacryocystorhinostomy. Br J Plast Surg 1985: 38: 116-21.
3. MARKOWlTZ BL, MANSON PN, SARGENT L, et al. Management of the
medial canthal tendon in the nasoethmoid orbital fractures: the importance of
the central fragment in classification and treatment. Plast Reconstr Surg 1991:
87:843 53.