Customized guided box osteotomies in pediatric patients with orbital hypertelorism

Orbital hypertelorism is a rare and surgically demanding craniofacial anomaly requiring highly accurate three-dimensional repositioning of the orbital complexes. This retrospective case series reports the use of virtual surgical planning with patient-specific cutting guides for orbital box osteotomy in five pediatric patients (mean age at surgery 5.8 years; range 5-8 years) treated at a tertiary craniofacial center between 2021 and 2024. Osteotomy and ostectomy lines were planned on CT data and transferred intraoperatively using customized fronto-orbital and infraorbital guides, followed by medialization of the orbital boxes, rigid fixation, and medial canthopexy. Mean interorbital distance was reduced from 34.7 ± 2.66 mm to 19.06 ± 2.95 mm (mean reduction 45.3%). Surgical transfer accuracy was high, with a root mean square deviation of 0.40 mm between planned and postoperative dacryon distances. No postoperative infections, intracranial hemorrhages, material failure, or plate displacement occurred; one patient developed new-onset strabismus. Despite substantial bony correction, mild residual pseudo-hypertelorism remained clinically apparent in all patients, highlighting the relevance of soft-tissue limitations. Patient-specific guided workflows enabled precise and reproducible skeletal correction and may support predictability in complex and revision craniofacial procedures.