This document summarizes a seminar on N-O-E (Naso-orbito-Ethmoid) fractures presented by Dr. Ameera salahudheen. It discusses the surgical anatomy of the NOE complex, classifications of NOE fractures, clinical features, radiological assessment, surgical approaches, and treatment goals and techniques. The key anatomical structures involved in NOE fractures are the frontal bone, nasal bones, ethmoid and frontal sinuses, and orbits. Classification systems include the Rowe and Williams and Markowitz and Manson classifications. Treatment involves open reduction and internal fixation to restore nasal projection, dorsal height, and medial canthal ligament attachment. A variety of surgical approaches can be used including H

1. Seminar on
N-O-E(Naso-orbito-Ethmoid) FRACTURE
Presented by
Dr. Ameera salahudheen
JR Academic 2021 jan batch
Department of dentistry (OMFS)
Under the guidance/ mentorship of
Dr. Naqoosh haidry,
H.O.D & Assistant professor
Department of dentistry (OMFS)
All India Institute of Medical Sciences, Patna – Autonomous
Phulwarishariff, patna, Bihar -801507

2. CONTENTS
• Introduction
• Surgical anatomy
• Classification
• Clinical features
• Radiological assessment
• Surgical approaches
• Management
• references

3. Introduction
• Fractures of the naso-orbito-ethmoid (NOE) complex involve the bones
that form the NOE confluence, including the anterior cranial fossa, the
frontal bone, the bones of the ethmoid and frontal sinuses, the nasal
bones, and the orbits
• Knowledge of regional anatomy is fundamental to understanding the
assessment and management of NOE fractures.
• Any operative intervention will depend on the classification of the NOE
complex fracture, which is based on the status of the medial canthal
tendon.
• Meticulous early primary surgical correction is the key to the aesthetic
restoration of the facial features and prevention of future complications

4. Surgical Anatomy
• The nasoorbitoethmoidal (NOE) complex is a distinct anatomical
region in the central upper midface defined by the interorbital space.
It is circumscribed by the anterior cranial fossa superiorly and the
medial orbital walls laterally

5. • The skeletal foundation has a stronger triangular-shaped frame
• Each side: frontal process of maxilla & nasal process of frontal bone
• Inferiorly to the frame: premaxilla
• Posteriorly: interorbital space (situated between medial orbital walls and
formed by lacrimal bone and lamina papyracea of ethmoid)
• Anteriorly: nasal bones

6. • The interorbital space is supported anteriorly by frontal processes of the maxilla, nasal
processes of the frontal bone, and the paired nasal bones
• Within the interorbital space lie the paired upper nasal fossae separated by the
septum and the perpendicular plate of the ethmoid in the midline.
• The intervals between the nasal fossae and the medial orbital walls are occupied by
the ethmoid labyrinths.

7. • the medial canthal ligament (MCL) is an important soft tissue of the
complex
• It is a band of fibrous tissue that acts as a tendon of insertion for the
orbicularis oculi muscle and tarsal plate to the medial orbital wall
• At its point of insertion, the tendon splits into anterior, posterior, and
superior limbs, attaching to anterior and posterior lacrimal crests.

8. • The lacrimal sac fossa is a depression in the
inferomedial orbital rim bordered by the anterior
lacrimal crest of the maxillary bone and the
posterior lacrimal crest of the lacrimal bone
• The fossa is approximately 16 mm high, 4 to 9mm
wide, and 2 mm deep
• On the frontal process of the maxilla just anterior
to the lacrimal sac fossa, a fine groove termed
the sutura longitudinalis imperfecta of Weber,
runs parallel to the anterior lacrimal crest.
• It is a vascular groove through which small twigs
of the infraorbital artery pass through to supply
the bone and nasal mucosa, and should be
anticipated during lacrimal surgery to avoid
bleeding.
Anatomy of the Lacrimal System Cat N. Burkat and Mark J. Lucarelli

9. • Medial to the caruncle, the ligament bifurcates into a superficial anterior
and a deep posterior limb.
• The anterior limb: which is the stronger is palpable clinically and its
lower border is sometimes visible through the skin.

10. • the length of the anterior limb from the inner canthus to its most medial
fibers of insertion is an average of 11.7 mm., while its width in the A-P
plane averaged 4.9 mm.
• The anterior limb has a broad insertion to the frontal process of the
maxilla with some fibers extending medially towards the nasal bones.
• The area of insertion averages 25.3 sq. mm.
• The thickening of the frontonasal process of the maxilla along the
anterior lacrimal crest is an average of 1.5 mm.
Ref: Rowe &William 1994

11. • The posterior limb: consists of lacrimal
fascia (its strongest component),
Horner's muscle, and areolar tissue.
• Its thickness varied from 1.0 to 3.3 mm.
• Together, the lacrimal fascia and
Horner's muscle, it inserts into the
posterior lacrimal crest which is very
thin and the site of insertion of Horner's
muscle is the more posterior of the two.
• The insertion of the posterior limb lacks
strength not only because of its weak
fibers and a small area of insertion but
also because the underlying bone is
incapable of providing a solid
anchorage.
Ref: Rowe &William 1994

12. • Although the orbicularis oculi muscle causes marked lateral displacement
of the inner canthus when the MCL is detached, the same muscle provides
a dynamic force tending towards the lateral displacement of the
undisturbed inner canthus (Jones, I967).
• The force of this muscular pull must be counteracted by one or more
sturdy structures that are well anchored medially.
• the anterior limb of the medial canthal ligament and its bony attachment
provide such an anchor, while the posterior limb is incapable of such a
task.
• The purpose of the posterior limb is its contraction may facilitate sac
emptying and tear drainage either by the expansion of the sac in a manner
analogous to the action of the diaphragm on inspiration or by direct
compression of the sac as its insertion is posterolateral to the lacrimal sac.

13. • But in 2006, the concept has changed.
• The medial wall becomes thicker posteriorly at the body of the sphenoid
and again anteriorly at the posterior lacrimal crest of the lacrimal bone
• The thinnest portion of the medial wall is the lamina papyracea,
Anatomy of the Lacrimal System Cat N.
Burkat and Mark J. Lucarelli

14. • Lacrimal drainage system:
• At the junction of the medial and inferior
orbital rims, at the base of the anterior
lacrimal crest, a small lacrimal tubercle may be
palpated externally, the lacrimal sac is located
posterior and superior to it.
• The nasolacrimal canal originates at the base
of the lacrimal fossa and is formed by the
maxillary bone laterally and the lacrimal and
inferior turbinate bones medially.
• The width of the superior opening of the canal
is an average of, 4–6 mm.
• The duct courses posteriorly and laterally in
the bone shared by the medial wall of the
maxillary sinus and the lateral nasal wall for 12
mm to drain into the inferior meatus of the
nasal cavity.

15. • The lacrimal excretory pathway begins at a 0.3-
mm opening on the medial portion of each eyelid
termed the punctum
• The punctal opening widens into the ampulla,
which is 2 mm in height and directed
perpendicular to the eyelid margin, before making
a sharp turn into the canaliculi
• The canaliculi measure 8–10 mm in length and
0.5–1.0 mm in diameter, and course parallel to
the eyelid margins
• The functional valve between the common
canaliculus and the lacrimal sac is called the valve
of Rosenmuller
• the valve of Krause is between the sac and duct. A
mucosal flap, Hasner’s valve (or plica lacrimalis),
may be present at the opening of the duct into
the inferior meatus of the nose

16. Blood supply
• The blood supplying for the midface and nasal region comes from
branches of both ECA and ICA
• Anterior and posterior ethmoid arteries descend from Internal carotid
artery
• The maxillary artery from the external carotid artery and subsequent
branches play a mainstay role for supporting midface.

17. Nerve supply
• The NOE region is innervated by ophthalmic and maxillary nerves

18. CLASSIFICATION OF N-O-E FRACTUTRES
• Rowe and Williams classification:
1) Isolated nasoethmoid and frontal region injury without other
fractures of midface
a) Bilateral
b) Unilateral
2) Combined nasoethmoid and frontal region injury with other
fractures of the midface
a) Bilateral
b) unilateral

19. 1a) isolated bilateral nasoethmoid injury:
• Results from a direct blow over the nasal
bridge
• clinically, characterized by nasal deformity
• Base of the nose driven backward into the
IOS results upturned nasal tip, stretched
philtrum, and deep transverse cleft at the
base of the nose.
• The glabella skin frequently ruptures

20. 1b) isolated unilateral nasoethmoid injury:
• The classical presentation is a unilateral nasal deformity
• Displaced fracture of the frontal process of the maxilla can be seen
• Medial canthal ligament is rarely displaced in this type of fracture

21. 2a) combined bilateral nasoethmoid injury:
• Nasoethmoid injury combines with severe midface
fractures at Le Fort II and Le Fort III levels
• Traumatic telecanthus with prominent epicanthal
folds
• Elongation of both midface and nose
2b) combined unilateral nasoethmoid injury:
• Frequently combined with severe comminution of
orbit and zygomatic complex
• Unilateral displacement of MCL.
• Characteristic antimongoloid slant to the palpebral
fissure(if associated with ZMC comminution)

22. • Markowitz and Manson classification:
• Type 1: single segment central fragment
• Type2: comminuted central segment with fractures remaining external to
the medial canthal insertion, but with the medial canthal ligament
attached to a fragment large enough to be stabilized with a plate
• Type 3: comminuted central fragment with fractures extending into the
bone which bears the canthal insertion. In this case, the canthal ligament
is either attached to a bone fragment too small for plate fixation, or
detached

23. • Paediatric NOE Fractures Classification (Burstein et al.’s ):
• Burstein type I fracture—localized to the upper NOE complex and frontal
bone, medial to superior orbital foramen
• Burstein type II fracture—involves half of the superior orbital wall,
although it does not involve the NOE
• Burstein type III fracture—is bilateral and involves the superior orbital
walls, upper NOE and bilateral frontal bones

25. Clinical Features
Main indicators suggesting unyielding NOE
fractures:
• Depressed nasal bridge (with or without
upturned nasal tip)
• Traumatic telecanthus is a direct indicator of
the MCL disruption or widening of the
fragments, The almond shape of the palpebral
fissure is lost and becomes larger, and the
Bowstring test becomes positive

27. Diagnosis
• Criteria for diagnosis are:
1) High index of suspicion
2) Measurement
• According to Rowe and William, an ICD in excess of 35mm, in
conjunction with other positive physical signs indicate canthal spread
and if the figure approaches 40mm it is more diagnostic
3) Palpebral fissure
• Narrowed and almond-shaped

28. 4) Eyelids
• Eyelids become lax and epicanthal folds more prominent
5) Canthal ligament
• Diminished tension of canthal ligament on palpation
• Tests to Assess the Integrity of MCT are Bowstring or bimanual tests.
• Bowstring Test: When the eyelid is pulled laterally, a lack of resistance or
detection of movement of the underlying bone at the tendon area is
indicative of a fracture.
• Bimanual Test: An instrument is placed in the nose and pushed laterally.
Instability and crepitation felt at the tendon area suggest NOE fracture.
6) eyes:
• Diplopia- common finding, but not itself diagnostic of traumatic telecanthus

29. Radiological assessment
• The most useful radiograph for diagnosis was- occipito frontal view taken
at 25° angle
• Occipito-mental projection and lateral view of skull were also essential

30. • Computerised tomography has now superseded the conventional radiography
• Coronal images clearly demonstrate fractures through the anterior cranial
base, medial orbital rim, and medial orbital wall
• The axial sections show if there is disruption of the nasal complex or there is
splaying of the ethmoid complex
• 3-D images are particularly useful to demonstrate the orientation and
displacement of the central fracture fragment and to plan how to approach the
NOE injury

31. Treatment
• Conventionally the nasal complex was treated with closed reduction till Adam et al.
reported on the importance of nasal wiring.
• The importance of involving the medial canthal region in the treatment plan was
initiated by Converse and Smith in 1963.
• They emphasized the importance of manipulating the segment with the MCL,
forward positioning the fragment, and transnasal wiring over a perforated plate.
• The case for open reduction and internal fixation (ORIF) was highlighted by
Dingman and Natvig. They reported superior results have been achieved in the
more serious injuries (with a minimum of effort and with the greatest degree of
comfort to the patient) by open reduction with direct fixation.
• The need and feasibility of identifying MCL and anchoring it across to the other side
was described by Mustarde in 1964.
• The need for primarily bone grafting when there is severe comminution of the nasal
dorsum rendering primary reduction incomplete and also helping achieve single-
stage reconstruction was highlighted by Cruse and Gruss

32. Treatment goals of NOE fracture
• Restoring the nasal projection
• Restoring nasal dorsal height with adequate nasofrontal angle
• Re-establishing the MCL attachment
• Restoring the patency of the nasolacrimal duct

33. Surgical approach
1) Through an existing laceration
• Usually incorporates parts of transverse W-shaped incison

34. 2) H-shaped approach:
• Mustarde(1966) advocated curved lateral nasal incision
• Later in 1970 Converse &Hogan comes with ‘open sky’ approach
• Excellent exposure of nasal bridge and canthal ligaments but
inadequate exposure to frontal bone

35. 3) Bilateral ‘Z’ approach:
• This incision anterior to the medial canthal area was described by
Dingman et al(1969)

36. 4) Midline vertical approach:
• 2-3cm vertical incision is made from the forehead down to the base of
nose
• Visibility is good in this approach but difficulty in wiring techniques

37. 5) Glabella approach:
• Horizontal skin incision over glabella

38. 6) Gullwing or eyeglass incision
• It is an incision across the nasion, extending laterally under or above the
eyebrows.
• This approach provides excellent exposure of the upper two thirds of the
nasal skeleton, but has the disadvantage of a very visible scar, and
possible transection of the supratrochlear and supraorbital nerves.

39. 7) W- shaped approach or Butterfly incision:
• combination of Gullwing and open sky incision
Described by Bowerman(1975)
• A curved transverse incision is made across the base of the nose within a
skin crease and extended on both sides upwards and laterally just below
the eyebrows
• Inevitably leave a scar ,like H-shaped approach

40. 8) Bicoronal approach:
• The coronal or bi-temporal approach is used to expose the anterior
cranial vault, the forehead, and the upper and middle regions of
the facial skeleton giving excellent exposure for the repair of the
NOE complex.
• The scalp incision is extended lateroinferiorly into the preauricular
region to gain access to the zygomatic arch and/or
temporomandibular joint (TMJ)

41. • Technique:
1) Locating the scalp incision line
• the incision may be placed anteriorly over the vertex slightly
behind the palpable coronal suture, leaving 4 – 5 cm hairline in
front.

42. 2) Design of incision
• There are several alternatives for the design of the scalp incision.
The bow-like incision is traditional.
• Geometric patterns (zigzag, sawtooth, stepwise, stealth, or
wavelike designs) may be used because the scars may be less
noticeable especially when the hair is wet. Furthermore, these
types of incision allow an accurate reapproximation during
closure.

43. 3) Hair preparation
• The hair is separated into fields, twisted, and each bundle is
secured with elastic bands.

44. 4) Hemostatic techniques
• Infiltration of a vasoconstrictor into the subgaleal plane.
• Insertion of running mattress sutures along the sides of the
planned incision lines
• Use of heated or cautery scalpels during the incision
• Use of hemostatic clips (Raney clips) after elevation of the wound
edges

45. 5) Incision :
• The initial scalp incision extends from one superior temporal line
to the other and stays between the upper origins of the temporal
muscles.
• The incision is made with a No.10 blade or a special cautery
scalpel to the depth of the pericranium or to the bone.
• Dissect the flap in the subgaleal or subpericranial plane for 2-4
cm anteriorly.

46. • Temporal extension of the skin incision line:
• Below the superior temporal line the subgaleal plane continues
deep to the temporoparietal fascia and top of the temporalis
fascia to the level of the zygomatic arch.

47. • Once the tip of the scissors reach the insertion area of the
zygomatic arch, the skin, subcutaneous tissues, as well as the
temporoparietal fascia are successively incised with a scalpel.

48. • A preauricular extension of the incision can be made within a
preauricular skin fold or over the tragus downwards to the level of
the earlobe.
• The skin is undermined at the depth of the temporalis fascia and
the soft-tissue dissection proceeds under meticulous hemostasis
with the use of bipolar cautery as required.
• The preauricular muscles are transected and the cartilaginous
portion of the tragus and the external auditory canal may be
directly exposed.

49. 6) Elevation of the coronal flap:
• The coronal flap elevation proceeds anteriorly with a bilateral
dissection.
• Over the temporalis muscles the silvery white temporalis fascia is
gently exposed using sharp dissection.
• The temporalis fascia fuses with the pericranium at the superior
temporal line.

50. • The plane of dissection strictly follows the temporalis fascia
downwards and forwards just to the zone where the yellow
superficial temporal fat pad shines through.
• This zone begins in the lower preauricular area at the level of the
root of the zygomatic arch, which is palpable and extends across
the temporal fossa to the posterior aspect of the zygomatic body.
• When the coronal flap has been sufficiently released anteriorly and
inferiorly — more than several centimeters — it can be turned
inside out and will passively remain in this reflected position.

51. • If the pericranium has been left on the skull, there are two options
to enter the subperiosteal plane and reach the superior orbital
rims and expose the facial skeleton:
1) Cross-forehead horizontal incision of the pericranium 2-3 cm
above and parallel to the supraorbital rims from one superior
temporal line to the other

52. • The extensive pericranial flap provides a large apron of
vascularized tissue for repair of the frontal sinus and anterior skull
base.

53. 7) Incision of the superficial temporal fascia for exposure of the
zygomatic arch
• The lateral dissection of the coronal flap is continued from the
subgaleal plane of the scalp to the temporal region. The dissection
strictly follows the temporalis fascia.
• As soon as the yellow outline of the superficial temporal fat pad is
visible through the superficial layer of temporalis fascia, an oblique
incision through the fascia extending from the root of the zygomatic
arch to the superior-posterior aspect of the lateral orbital rim is
made.

54. • The dissection downward to the arch and the posterior (temporal)
margin of the zygoma is made immediately on the lateral surface
of fat pad right underneath the superficial layer of the temporalis
fascia.
• Alternatively, the elevation of the superficial layer of the
temporalis fascia in the dissection to the zygomatic arch can be
done bluntly using scissors.

55. • The superficial layer of the temporalis fascia is progressively
dissected in an anterior direction and then turned laterally to reach
the periosteum along the superior surface of the zygomatic arch.
• The periosteum is incised at the superior aspect and reflected
over the arch, posterior border of the body of the zygoma and the
lateral orbital rim.

56. 8) Subperiosteal exposure of the orbits and upper midface
• Release of the supraorbital neurovascular bundle
• If a supraorbital foramen is found this is converted into a notch. A
small osteotome or a piezosurgery tip can be used to remove a
small bone wedge underneath the bundle and subsequent
release.

57. • Once the neurovascular bundle has been released from its
foramen, a complete subperiosteal dissection is performed
allowing access to the orbital roof and medial wall.

58. • Further retraction of the flap inferiorly is accomplished by
subperiosteal dissection into the orbits.
The periorbita is dissected 180° off the adjacent superior medial
and lateral orbital walls into the midorbit
• For exposure of the nasofrontal and the nasoethmoid region as
well as the medial orbit, the trochlea needs to be disinserted
together with its connective tissue attachments from the frontal
bone.

59. • The lateral subperiosteal dissection can be continued from the
lateral orbital rim downward over the body to the inferior border of
the zygoma.
• Via this dissection maximum amount of midfacial exposure is
obtained

60. • The anterior fibrous and muscular components of the medial
canthal tendon fan out medially and insert into the nasofrontal
maxillary process
• The anterior branch of the medial canthal tendon is identified as a
firm fibrous strand
• The dissection is stopped at the upper end of the nasolacrimal
sac within the lacrimal fossa.

61. • According to Ed.Ellis et al, steps in management of NOE fracture include;
1) Step1: Good exposure
2) Step 2: Identify the medial canthal tendon/tendon bearing bone
3) Step 3: Reduce and reconstruct medial orbital rim
4) Step 4: Reconstruction of medial orbital wall
5) Step 5: Trans nasal canthopexy
6) Step 6: Reduce septal fracture/displacement
7) Step 7: Nasal dorsum reconstruction/augmentation with bone graft
8) Step 8: Soft tissue readaptation (nasal splint, trans nasal bolsters, silicone
sheeting)
Ellis E III. Sequencing treatment for naso-orbito-ethmoid fractures. J Oral Maxillofac Surg. 1993;51:543–558.

62. osteosynthesis techniques
• Reduction sequence:
• The craniofrontal and zygomaticomaxillary regions have a higher impact
tolerance than the NOE region and tend to fracture into larger segments.
Accurate 3-D reconstruction of the upper (craniofrontal) and outer
zygomaticomaxillary facial skeletal frame is technically simpler and
anatomically more reliable and is therefore always completed first
• Also there is another concept, In the upper midfacial unit, the NOE area is
reduced first. It is important to establish a narrow intercanthal distance by
first tightening the transnasal wires, thereby narrowing the intercanthal
distance.
Oleh Antonyshyn et al, a AO textbook of trauma

63. • The NOE area, reduced with interfragmentary transnasal wires, is then linked
superiorly to the frontal bar reconstruction and inferiorly to the maxillary Le Fort I
level by plate and screw fixation. This technique is called junctional rigid fixation
• This step stabilizes projection of the entire reassembled NOE complex.
• Within the NOE complex itself, reconstruction proceeds from the deepest and
most inaccessible areas toward the surface.
• The critical points of bony reduction and alignment in NOE fractures are:
1) Frontal bone to frontal bone
2) Frontal process of maxilla to frontal bone and zygomatic bone
3) Nasal cap to frontal bone
Ref: Rowe &William 1994

64. • If combined nasoethmoid injury, (associated with LeFort2 and 3)
• These should be disimpacted together with NOE complex.
• Disimpaction of NOE complex frequently unmasks mobility of frontal
process of maxilla at their suture with the frontal bone.
• If this is unrecognised, the pull of orbicularis oculi at the medial canthal
ligament will result in post-operative telecanthus.
• This was the most common cause of post-traumatic telecanthus when
fracture is treated by closed manipulation.

65. • the upper NOE region, the functional forces acting on fracture
segments are those exerted by the orbicularis oculi muscle through the
medial canthal tendon, and the forces generated by overlying soft
tissue, particularly during the phase of postinjury edema and
subsequent soft-tissue contracture.
• Titanium miniplates 1.3 or corresponding Matrix Midface plates are
therefore generally sufficient.
• Lower NOE fractures, ie, fractures of the medial buttresses of the
maxilla, must resist transmitted forces of mastication and, therefore,
larger plate systems (1.5, 2.0, or corresponding Matrix Midface plates)
are most commonly used for this purpose.
Principles of Internal Fixation of the Craniomaxillofacial Skeleton—Trauma and Orthognathic
Surgery Michael Ehrenfeld, Paul N Manson, Joachim Prein

66. • Frontal bone :
• A fracture of the posterior wall of the frontal sinus is an indication of a cranial
approach
• Posterior wall of the sinus is completely removed and mucosa is curetted
away.
• The fracture of anterior cranium and anterior wall of sinus should be reduced
and fixed at this stage, loose fragments removed, assembled and fixed with
micro-plate and relocated.
• Missing bone should be replaced immediately by bone grafts using either
calvarial bone or split rib.

67. • Frontal process of the maxilla:
• This bone should align now with the frontal bone.
• Alternatively simultaneous control of canthal detachment may be
achieved by bone plating. (stoll et al 1983)
• Application of 2 contoured mini bone plates screwed centrally to the
frontal bone above and below on each side to the frontal process of
maxilla.
• nasal cap:
• The nasal cap is now located and fixed to the base of frontal bone either
by wire or plate osteosynthesis( Y- shaped or inverted Y- shaped)
• the advantage of wire osteosynthesis is- sequential tightening of wires
facilitates accurate reduction

68. • Reduction of the nasal complex may be done with Walsham’s forceps to
realign the deviated/displaced complex.
• The collapsed complex may be out-fractured, and the complex opened
out may need to be in-fractured.
• The depressed complex may be elevated into position by the septal
forceps (Ash’s).
• In displaced or comminuted scenarios, closed reduction isn’t optimal.
Hence trans nasal wiring may be needed to keep the splayed segments
well reduced and minimize telecanthus.
• In the absence of gross comminution, closed reduction and transnasal
wiring have been proved quite useful and adequate to achieve optimal
results
aliga S, Urolagin SB. Transnasal fxation of NOE fracture: minimally invasive approach. J Maxillofac Oral Surg. 2012;11(1):34–7

69. Primary bone grafting
• Primary bone grafting may be necessary to restore bony defects of the
cranial vault, orbital roof, orbital wall and floor, supraorbital margin and
the facial skeleton.
• Bone grafts may be obtained from the calvarium, inner and outer table, rib
or iliac bone.
• Zins & Whitaker(1983) –demonstrated that the advantages of a calvarial
graft that it is a membraneous bone, stronger than endochondral bone and
resists reabsorption.
• It can be harvested near the area of trauma and donour site is hidden
• Disadvantages: limit on its size and thickness and difficulty in contouring

70. Calvarial bone graft
• The parietal bone is the most appropriate source for cranial bone
grafts. The inner and the outer cortex is thick with a wide diploë in
between.
• The harvesting area should stay away 1.0 to 1.5 cm from the
cranial suture lines, in particular from the midline, in order to
prevent injury to the sagittal sinus.
• There are several types of calvarial bone grafts that may be taken:
1) Shaved corticocancellous outer table graft with attached
pericranium

71. 2) In situ split outer table grafts:
3) Full thickness parietal bone grafts

72. 4) Bone paste or bone dust:
• Bone paste or bone dust may be harvested with a hand-powered
instrument or a large neurosurgical perforator at very low speed
passing through the outer table into the diploë.
• Additional cancellous bone can be harvested from the diploic
layer using bone curettes or bone splitters.

73. • Medial canthal ligament:
• According to Rowe & William, the posterior limb is weak, poorly defined
and can be ignored for all practical purpose during any repair.
• In unilateral detachment, reattachment of MCL done to anterior lacrimal
crest.
• Callahan (1963)- knotting a piece of supramed and passing it through a
hole drilled in the anterior lacrimal crest to which MCL is sutured
• Mathog & Bauer(1979)- direct wiring to posterior lacrimal crest
• Shore et al(1992)- use of cantilevered mini plate fixation of canthus
especially for unilateral detachment
• Rowe &William (1994)- with avulsion either unilateral or bilateral
transnasal wiring is mandatory

74. Transnasal canthopexy
• The commonly used methods are the trans nasal wiring or using a
canthal barb
• Using a K wire driver or an awl will help pass a transnasal wire of
0.35mm diameter across the nasal complex and help narrow the area
by bringing the sides together
• The objectives of trans nasal canthopexy are:
• To medialize the central fragment
• To position the tendon posterior and superior to posterior lacrimal
crest that would give an ideal vector

75. • The identifed ligament edges are either anchored with a suture (size 2–
0 prolene) or a wire (26 gauge) and guided to the opposite side.
• The entry point is posterior and superior to lacrimal crest to ensure
adequate positioning.
• One way to help achieve this is to adapt a plate in medial aspect
extending from lateral nose onto the medial wall extending just beyond
the lacrimal crest

77. • The wire or suture anchoring the MCL is passed through a hole
of the plate just beyond the lacrimal crest brought to the
opposite side and secured around a screw in the forehead
adjacent to the midline or a plate to prevent the wire from
cutting through the bone.
• Special barbed wires have been advocated by certain authors
to engage the MCL and anchor it to help with medial
canthopexy with small incisions around the medial canthus.
This help especially when there is medial canthal disruption
without bony disruption

79. Novel techniques for medial canthopexy
1) Using the Frontoglabellar Area for Wire Fixation
• After the reflection of a coronal flap, a shallow hole is created in the
glabellar area of the frontal bone using a bur.
• Then, the medial canthal ligament is located and a wire is passed
through it.
• Two holes are created in the frontoglabellar region and the wires are
fastened.
• The advantages of this approach include, the prevention of injury to
contralateral delicate bones and lacrimal apparatus, and the
invisibility of the wires due to the presence of thick soft tissue
Kelly CP, Cohen AJ, Yavuzer R, Moreira-Gonzalez A, Jackson IT. Medial canthopexy: a proven technique.
Ophthal Plast Reconstr Surg. 2004;20(5):337–41. [PubMed: 15377898].

81. 2) Transcutaneous Medial Canthal Tendon Incision to the Medial Orbit
• An incision of 1.5 - 2 cm in length is made anterior to the anterior part
of the medial canthal ligament.
• Then, the anterior part of the medial canthal ligament, the medial wall
of the orbit, and the nasal bridge are exposed.
• The incision used in this approach is more posterior, smaller in size, and
more esthetic than a Lynch incision.
• Moreover, this approach allows the management of the fracture
without complications such as telecanthus, diplopia, and a considerable
scar
Timoney PJ, Sokol JA, Hauck MJ, Lee HB, Nunery WR. Transcutaneous medial canthal tendon incision to
the medial orbit. Ophthal Plast Reconstr Surg. 2012;28(2):140–4. doi: 10.1097/IOP.0b013e318248e62c.
[PubMed: 22410662].

83. 3) Using Micro-Anchor Devices:
• This method involves a nickel-titanium (nitinol) anchor (1.3 mm in
diameter and 3.7 mm in height), 4 - 0 Ethibond suture, and the
associated inserter and perforator devices.
• After making a cutaneous incision anterior to the medial canthal
ligament, subperiosteal dissection is continued to the lacrimal crest.
• A hole is created posterior and superior to the lacrimal crest using the
perforator device.
• Thereafter, the micro-anchor is placed by the inserter device and held by
the suture. This technique has the advantage of eliminating the
dissection of the contralateral side
Goldenberg DC, Bastos EO, Alonso N, Friedhofer H, Ferreira MC. The role of micro-anchor devices in medial
canthopexy. Ann Plast Surg. 2008;61(1):47–51. doi: 10.1097/SAP.0b013e3181534a30. [PubMed: 18580149]

85. 4) Uni transnasal Canthopexy
• After making an incision 2 mm from the medial canthal ligament, two
holes are created 2 mm apart from each other into the nose.
• polypropylene suture is then passed through each hole using a No. 14
angiocatheter.
• The end of the suture is held by the insertion of a hemostat into the
nose and evicted.
• The ends of the suture are tied.
• Thereafter, the medial canthal ligament is held in place by the other
end of the sutures.
• When using this method, the nasal bone and orbit of the contralateral
side remain undamaged
Turgut G, Ozkaya O, Soydan AT, Bas L. A new technique for medial canthal tendon fixation. J Craniofac
Surg. 2008;19(4):1154–8. doi: 10.1097/SCS.0b013e3181764b6c. [PubMed: 18650751]

87. 5) Transcaruncular-Transnasal Suture:
• After the reflection of the coronal flap, the NOE region is exposed.
• Vicryl or polydioxanone suture is inserted into the periosteum in the
region of the attachment capsule of the medial canthal ligament and
then evicted from the caruncle.
• Next, it is again passed from the caruncle towards the attachment.
• Finally, the suture is tied.
• This approach provides benefits such as requiring less operation time,
excellent control of the magnitude of canthopexy, and the elimination of
foreign body reaction
Lauer G, Pinzer T. Transcaruncular-transnasal suture: a modification of medial canthopexy. J Oral Maxillofac Surg.
2008;66(10):2178–84. doi: 10.1016/j.joms.2008.05.363. [PubMed: 18848123].

89. 6) Precaruncular Medial Canthopexy:
• After the placement of the eye-shield, a conjunctival incision is made
anterior to the caruncle.
• Dissection is continued above the Horner muscle to the posterior
lacrimal crest. Periorbital tissue is reflected from the medial wall
• A 6 mm screw is placed superior and posterior to the lacrimal crest. An
unabsorbable suture is tied around the screw.
• Then, the medial tarsal plate and the closest part to the lid margin are
sutured. This method can be used when ectropion is present.
• Moreover, it does not require the manipulation of the contralateral side
Moe KS, Kao CH. Precaruncular medial canthopexy. Arch Facial Plast Surg. 2005;7(4):244–50. doi: 10.1001/archfaci.7.4.244.
[PubMed: 16027345].

91. 7) Using a transcaruncular Barb and Mini-Plate :
• After the reflection of the coronal flap, the needle is passed through the
caruncle so that the barbs are involved with the caruncle.
• Then, a mini-plate is fixed in the glabella medial to the orbit.
• The barb engages the canthal tendon and the wire is passed through an
intraorbital mini-plate fixed in a stable section of the frontal bone
• The mini-plate hole chosen to pass the wire through should approximate
the vector of the normal canthal tendon position.
• This technique is applicable in cases of the comminution of the medial
wall of the orbit and it does not require the transnasal passage of the
wire.
• Thus, there is no need for the manipulation of the contralateral side
Engelstad ME, Bastodkar P, Markiewicz MR. Medial canthopexy using transcaruncular barb and miniplate:
technique and cadaver study. Int J Oral Maxillofac Surg. 2012;41(10):1176–85. doi: 10.1016/j.ijom.2012.06.019.
[PubMed: 22854168].

94. 8) Using a Malleable Awl:
• A Steinmann pin is used in this technique.
• The pin is bent using a plier into a semilunar shape with the diameter of the
intercanthal distance.
• A cutaneous incision is made in order to locate the medial canthal ligament.
• After the subperiosteal dissection and reflection of the lacrimal sac, two holes
are drilled in the lacrimal fossa of both sides using a 5 mm bur.
• The pin is then inserted from the fractured area into the intact area.
• Four wires are placed in the pin and pulled to the other side.
• Two of these wires are used in order to hold the medial canthal ligament,
while the other two are used for the placement of the bolster.
• This method presents benefits such as the posterior placement of the wires
and the fixation of the bolster using the wires.
• Its disadvantages include the need for wide incisions and a substantial scar
Hwang K, Kim HJ. Making a malleable awl using a Steinmann pin for transnasal medial canthopexy. Ophthal Plast Reconstr
Surg. 2012;28(5):369–71. doi: 10.1097/IOP.0b013e31825fb272. [PubMed: 22965014]

96. • Treatment of NOE fracture according to Fonseca,
• type I fracture is best managed by three-point rigid fixation-
reestablishing the relationships of the nasofrontal junction to the nasal
complex, the nasal complex to the maxillary buttress, and the nasal
complex to the infraorbital rim

97. • Type II fractures require a more extensive superoinferior approach
because a degree of comminution is present by definition
• The small bony fragments must first be anatomically reduced with 28-
to 30-gauge intraosseous wiring or with microplates.
• Rigid internal fixation then proceeds as for a type I fracture to
reestablish the bony buttresses. Reattachment of the medial canthal
tendon is then completed by appropriate reduction of the large central
fragment(s) to which the tendon is attached

98. • The type III NOE fracture involves extensive comminution and
displacement of the osseous structures,
• The principles of access and repair follow the same principles as for type
I and II fractures
• Severe comminution of the nasal region may require a dorsal nasal
cantilever-type bone graft to reestablish dorsal nasal support and nasal
tip projection.
• This bone graft can be placed through the coronal incision and stabilized
with intraosseous screws into the nasal process of the frontal bone

99. Nasolacrimal system injury
• During NOE fracture repair, the nasolacrimal sac should be identified but
not probed or intubated unless obviously lacerated.
• The upper lacrimal pathway is protected by the medial canthal ligament.
• Obstruction usually occurs in the bony nasolacrimal canal, and can arise as
a consequence of bone displacement, impingement, or swelling and duct
stenosis.
• Postoperative epiphora is generally due to eyelid malposition or edema,
and will resolve spontaneously in more than 80% of patients.
• Formal assessment with probing and dacryocystography is undertaken only
in those patients with persistent epiphora more than 2 months following
primary fracture repair.
• When dacryocystorhinostomy is necessary, it should be performed at least
3 months after the primary repair.

100. • Patency of the naso-
lacrimal duct and sac can
be verified by the Jones
tests 1 and 2 or by a simple
lacrimal probing test with
insertion of a Crawford
silicone intubation tubes
though the canaliculi and
visualization of the same at
the distal end of the
disruption.
• ROPLAS test or
regurgitation on pressure
over lacrimal sac may be
performed clinically to elicit
post-traumatic blockage of the

101. Nasal reconstruction
• The degree of nasal disruption dictates the requirements for optimal
restoration and maintenance of nasal projection.
• This is determined clinically by the resistance of the nasal dorsum to
direct digital pressure, ie, the Brown-Gruss vault compression test

102. • Nasal bone fixation:
• Open reduction and fixation of the fractured nasal bones can effectively
restore dorsal nasal projection provided two conditions are met.
• First, the nasal fracture segments must be of an adequate size to permit
mini- or microplate fixation.
• Second, the residual structural integrity in the septum and upper lateral
cartilages must be sufficient to support the middle third of the nose.

103. • Nasal cantilever bone graft:
• Telescoping collapse of the nasal dorsum with direct digital pressure indicates
complete loss of support and the need for cantilever bone graft
reconstruction
• A split skull bone graft is best used for this purpose. The bone is fixed as a
cantilever graft
• The bone graft must be of adequate length to support the nasal dorsum.
• If nasal tip support is adequate, the bone graft extends only as far as the alar
domes. If, however, nasal tip support is inadequate, the graft must span the
distance from the root to the tip of the nose.
• Stabilization must be adequate and is achieved by a single miniplate from the
glabella to the dorsal nasal graft.
• Finally, it is imperative that the nasofrontal angle be maintained and not
obliterated by the bone graft.

105. Soft Tissue Readaptation
• A post-operative nasal bolster splint is very important after ORIF or NOE
fractures.
• It reduces post-operative swelling due to edema and hematoma
• Redrapes soft tissues to underlying skeletal framework and prevents
pseudo telecanthus (increase in intercanthal distance, despite accurate
reduction and fixation of fracture fragments this occurs due to non-
adaptation of soft tissues to the underlying NOE complex, with resultant
fibrosis of tissues)
• After reduction and fixation of NOE, nasal packing has been done with a
ribbon gauge soaked in paraffin/flavine emulsion or bismuth iodoform
paraffin paste (BIPP).
• Overpacking should be avoided. Sometimes it obstructs the airway and is
a potential source of infection and required removal after 72 h post-
surgery.

107. Post-operative Evaluation
• It includes evaluation of:
• Nasofrontal angle
• Nasal prominence and
• Intercanthal width
• The average distance between the
medial canthus should be
approximately 1/3rd (33%) of the
distance between lateral canthus.
• The distance from the lateral canthus
of the eye to cornea and cornea to
nasofrontal junction will be compared,
and they should be in 1:1 relationship.
• The ideal naso-orbital angle is
approximately 115–130°. All the three
parameters should be checked post-
operatively to assess the surgical
results

109. References
• Rowe &William’s maxillofacial injuries – 2nd edition
• Fonseca trauma- 4th edition
• AO textbook of trauma
• AOMSI textbook
• Alan S. Herford, DDS, MD,* Thomas Ying, DDS,† and Brandon Brown, DDS‡ J Oral
Maxillofac Surg 63:1266-1277, 2005
• Anatomy of the Lacrimal System Cat N. Burkat and Mark J. Lucarelli
• Management of Naso-Orbito-Ethmoid Fractures: A 10-Year Review Milad Etemadi
Sh,1 Shirin Shahnaseri,1 Parisa Soltani,2 and Mahmood Reza Kalantar Motamedi3
• The management of naso-orbital-ethmoid (NOE) fractures Jun-Jun Wei, Zhao-Long
Tang, Lei Liu, Xue-Juan Liao, Yun-Bo Yu, Wei Jing*
• Precaruncular Medial Canthopexy Kris S. Moe, MD; Chuan-Hsiang Kao, MD
• THE ANATOMY OF THE MEDIAL CANTHAL LIGAMENT By T. J. ROBINSON, M.D.,
L.M.C.C., D.A.N.B. and M. F. STRANC, L.R.C.P.&S.I., F.R.C.S.

110. THANK YOU