oral and maxillofacial

1. 1

2. FRONTAL BONE
FRACTURE: A CASE
REPORT
Dr. Junaid Nadeem Malik
FCPS II Resident,
OMFS,
SBDC.
2

3. INTRODUCTION
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•The frontal bone is an
important component
of the complex skeletal
junction
between the cranium and
face

4. CLINICAL ANATOMY
AND ITS IMPLICATIONS
SQUAMOUS: EXTERNAL PART SQUAMOUS: INTERNAL PART
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5. CLINICAL ANATOMY AND ITS
IMPLICATIONS
ORIBTAL PART
NASAL PART
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6. CLINICAL ANATOMY AND ITS
IMPLICATIONS
ANTERIOR CRANIAL FOSSA
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7. CLINICAL ANATOMY AND ITS
IMPLICATIONS
FRONTAL SINUS RELATIONSHIP WITH THE BRAIN
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8. CLINICAL ANATOMY AND ITS
IMPLICATIONS
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9. FRONTAL BONE FRACTURE
• Frontal bone fractures are
usually uncommon
•Constitute 5-15% of all
facial fractures [2]
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2. ANURAG SINGH. VIKRANTBHARDWAJ. S SHARMA. FRONTAL SINUS
FRACTURE: A CASE REPORT. JOURNAL OF ORAL AND MAXILLOFACIAL

10. CLASSIFICATION OF
FRONTAL SINUS FRACTURES
Fractures of
the Frontal
Sinus
Anterior
Table
Displaced
Non
Displaced
Posterior
Table
Comminute
d
Displaced/
Nondisplac
ed
Nasofront
al Duct
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11. CLASSIFICATION OF
FRONTAL SINUS FRACTURES
Anterior Table Fractures Posterior Table Fractures
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12. CASE PRESENTATION:
HISTORY
• Male
• 16 years old
• Depression in the middle of the forehead
• Road-traffic accident 25 days
before presentation
• No loss of consciousness or discharge
from the nose at the site of injury
• Primary concern was esthetics 12

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14. EXAMINATION
EXTRAORAL
•Disturbed symmetry in the forehead region
•No subconjunctival hemorrhage
•No periorbital ecchymosis
•No tenderness
•No paresthesia
•No crepitations
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15. EXAMINATION
PROVISIONAL DIAGNOSIS
•Based on initial examination, we formed a provisional
diagnosis of depressed frontal bone in the midline
RADIOGRAPHIC
•Depressed, comminuted fracture of the frontal bone in
the region of the glabella
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16. 16

17. DIAGNOSIS AND PRE-OP
EVALUATION
DEFINITIVE DIAGNOSIS
•Fracture of the frontal bone
PRE-OP EVALUATION
•Pre-anesthetic evaluation
•Patient declared fit for surgery
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18. SURGICAL PROCEDURE
•Supine
•General anesthesia
•Incision line for a coronal or bi-temporal incision
with stealth modification
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19. SURGICAL PROCEDURE
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• Local anesthesia with
vasoconstrictor was infiltrated
• Incision was placed
• Stealth modification of the incision:
to minimize post-operative scar
formation

20. SURGICAL PROCEDURE
•Subgaleal flap was raised
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21. SURGICAL PROCEDURE
•About 3 cm above the
supraobital rim,
the plane of dissection
was changed to subperiosteal
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22. SURGICAL PROCEDURE
•Frontal bone fracture was exposed
•Fracture site was
identified along with the callus
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23. SURGICAL PROCEDURE
•2 support screws were drilled onto
the fracture site in the anterior table
•Reduction of the fracture was attempted
but was not fully achieved
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24. SURGICAL PROCEDURE
•Due to the inability to reduce the fracture completely,
owing to the post-op delay in reporting, a per-op
decision
was made to harvest a graft from the iliac crest
•An incision was placed 20 mm lateral to the iliac crest
•Blunt dissection of the subcutaneous tissues was
carried out 24

25. SURGICAL PROCEDURE
• Next we incised the periosteum over the crest
• Bone graft from the crestal area was
harvested using an oscillating bone saw aided by a
chisel and mallet
• Bone wax was used to seal the defect
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26. SURGICAL PROCEDURE
•Surface of the frontal bone
where the graft was supposed
to be applied was roughened with a bone drill
•The graft was applied
on the defect in the frontal bone
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27. SURGICAL PROCEDURE
•Fixation was done with twelve-hole,
horizontal mini-plate
with 6 screws
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28. SURGICAL PROCEDURE
•Flap was reapproximated
•Layer by layer suturing
with three-zero Vicryl and Prolene
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29. POST-OPERATIVE
EVALUATION
•Recovered from anesthesia uneventfully
•Healing ensued normally
•Suture removal done after one week
•Patient was kept on follow-up
•No active bleeding, infections,
hematomas or neurological defects
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30. DISCUSSIONS
Initial treatment plan according to the patient’s main
concern being esthetics:
•Coronal Flap
The best surgical approach
•provide maximum exposure of the fractured segments
•minimum damage to the surrounding facial
structures
•allow satisfactory cosmetic result
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31. CORONAL
APPROACH
ADVANTAGES OF CORONAL FLAP
 Provides access to the cranium and upper
one third of the craniofacial skeleton
 Minimal morbidity
 Ease of performance
 Esthetic advantage
 Minimal injury of vital structures.
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32. ALTERNATIVE APPROACHES
ALTERNATIVES FOR CORONAL FLAP
•Transnasal and Brow approach
•Howarth Lynch approach
•Gullwing approach and its butterfly
modification
•Open Sky approach
•Pre-existing lacerations 32

33. TRANSNASAL
AND BROW
APPROACH
Transnasal approach:
•Provides minimal
exposure
Brow approach:
•Damage to the hair
follicles of the brows
and injury to the
supraorbital/trochlear 33

34. HOWARTH
LYNCH
APPROACH
•Limited access
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35. GULL-WING
APPROACH AND
ITS BUTTERFLY
MODIFICATION
•Indicated when the
coronal flap cannot be
raised, as in patients
with alopecia or when
limited exposure is
required
•Esthetically
unfavourable
•The possibility of 35

36. OPEN SKY
APPROACH
•H-shaped scar very
visible over the
region of Nasion
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37. DISCUSSIONS
ALTERNATIVES FOR REDUCTION AND
FIXATION
•Autogenous bone graft
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38. SUBSTITUTE FOR BONE
The ideal substitute for bone
•Should provide scaffold for osteoconduction, growth
factors for osteoinduction, and progenitor cells for
osteogenesis
•Biocompatible
•Biodegradable
•Mechanically similar to surrounding bone
•Nonmagnetic and chemically inert
•Readily available, inexpensive and easily secured
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39. AUTOLOGOUS GRAFT
Autologous graft is the transfer of bone from one anatomic site to another within
the same individual
•Cortical Bone
enhanced mechanical properties
•Cancellous Bone
provides cells and growth factors
•Corticocancellous Component
combines the ideal properties of cortical and cancellous bone
Gold standard for reconstruction
•Advantage of retaining at least some osteogenic cells
•Decreased chance of immune reaction
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40. ILIAC CREST GRAFT
Advantages:
 Provides cortical, cancellous and corticocancellous components
of the bone
 Mechanically stable
 Minimally invasive
 Decreased operative time
 No growth disturbance or any significant
disabilities
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Properties of Graft
•volume of the bone
•donor-site morbidity
•ease of access
•operating time

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42. AUTOLOGOUS
GRAFTS
Disadvantages of Split-Cranial Bone
Graft
• Less biomechanically stable
• Limited size of the graft available
• Thickness of the calvarium is highly
variable
• Dura is tightly adherent to the inner
cortex and can easily be injured
• Various important vascular structures
exist immediately beneath the bone 42

43. CONCLUSIONS
•Main objective was to restore
patient’s cosmetic
deformity
•Post-op healing was uneventful
•Patient was satisfied with the outcome
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44. REFERENCES
1. Holla V, Kini R, Rao P, Shetty DN, Nair SL. Frontal bone fracture -A case report.International Journal of Maxillofacial
Imaging, January-March,2018;4(1):30-32
2. Singh A, Sharma VS. Frontal Sinus Fracture: A Case Report. Journal of Oral and Maxillofacial Surgery, 2015. Mar;
14(Suppl 1): 1–3
3. Gray’s Anatomy, 3rd Edition. Page no 856.
4. Fonseca Oral and Maxillofacial Surgery, 3rd Edition. Page number 233-234.
5. Pavri SN, Arnaud E, Renier D, Persing JA. The Posterior Coronal Incision. J Craniofac Surg. 2015 Jan;26(1):243-4
6. Rao JKD, Malhotra V, Batra RS, Kukreja A. Esthetic correction of depressed frontal bone fracture. Natl J Maxillofac
Surg. 2011 Jan;2(1):69-72.
7. Fiamoncini ES, Capelari MM, Marzola C, Dreyer JU. Surgical Approaches for the Fractures of the Anterior Wall of the
Frontal Sinus – A Review of Literature and Five Case Reports. Rev. Odontologia (ATO), Bauru, SP., v. 15, n. 9, p. 594-
642, set., 2015.
8. Thiagarajan B. Versatility of Bicoronal flap approach in Head and Neck Surgeries. Case Report - Otolaryngology
Online Journal (2011) Volume 1, Issue 1
9. Agrawal A, Lakshmi NG. Split Calvarial Bone Graft for the Reconstruction of Skull Defects. Journal of Surgical
Technique and Case Report 3(1):13-16 · March 2011
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45. THANK YOU
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