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.

AUTHORS

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.

CONTENTS

IntroductionAim Materials and methodsResults & DiscussionCross referencesConclusionPros and Cons of studyReferences

Introduction

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.

Introduction

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.

Aim

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

Materials and methods

36 cases between 1982-1991 –treated primarily of NOE fracture with telecanthus .

Unilateral Telecanthus Bilateral Telecanthus16 20Indirect 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

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)

Direct canthopexy

Direct-canthopexy (17 patients)

Coronal incision ("retrograde indirect

approach")

Approach through wounds or Open sky approach/W-

shaped incision

Results

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

Discussion

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.

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.

Cross references

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.

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.

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

Pros Cons Many variables Racial variation for ICD

Pros and Cons of study

Conclusion

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.

References

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.