frontal bone fracture and their management

1. FRONTAL BONE FRACTURE AND
ITS MANAGEMENT
 A presentation by Dr. Abhijeet Kamble
Junior resident II

2. GOOD MORNING

3. CONTENTS
1 Introduction
2 embryology
3 SURGICAL ANATOMY
4 DIAGNOSIS
5 TREATMENT PLANNING
19th Century skull showing sword-blade
trauma on frontal bone.

4. INTRODUCTION
Fontal sinus is most frequently damaged as a result of high
velocity motor vehicle accidents. 70% of frontal sinus
fractures were due to automobile accidents and 20% due to
assaults..
Fractures involving frontal bone is rather rare because of its
protected location
1 . It is basically protected from trauma by the prominence
formed by the nasal pyramid.
2 . Incidence of fractures involving this area ranges between
5-15%
3 . Fractures involving this bone is considered to be rather
dangerous because of its proximity to brain as well as due to
the cosmetic defects it can produce. The proximity of this
bone to the orbit and naso frontal duct doesn’t help matters
either.
Fractures involving this area if not treated promptly can lead
to :
1. Meningitis 2. Mucopyocele 3. Encephalitis 4. Cerebral
abscess
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5. EMBRYOLOGY
FRONTAL BONE
FRACTURE

6. EMBRYOLOGY OF FRONTAL BONE
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Structure of the frontal bone
The frontal bone is one of the skull bones enclosing the brain
(neurocranium) and it consists of the following parts:
•The squamous part;
•The nasal part;
•Two orbital plates;
•Two zygomatic processes.
Begin as an outgrowth from nasal chamber in utero
Absent at birth
Do not develop until 2" year of life
Develop from ethmoidal infundibular air cells by invagination of
frontal bone through frontal recess or from superior meatus
Cannot be identified radiographically until about age of 8
years
Development
Orbital surface of frontal
bone

7. EMBRYOLOGY OF FRONTAL BONE
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8. EMBRYOLOGY OF FRONTAL BONE
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Structure of the frontal bone
The frontal bone is made up of two main parts. These are the squamous part, and the orbital part.
The squamous part marks the vertical, flat, and also the biggest part, and the main region of
the forehead. The orbital part is the horizontal and second biggest region of the frontal bone. It
enters into the formation of the roofs of the orbital and nasal cavities. Sometimes a third part is
included as the nasal part of the frontal bone, and sometimes this is included with the squamous
part. The nasal part is between the brow ridges, and ends in a serrated nasal notch that articulates
with the nasal bones inferiorly, and with the lacrimal and maxilla bones laterally
The frontal bone is presumed to be derived from neural crest cells.[3]
The frontal bone is ossified in membrane from two primary centers, one for each half, which appear
toward the end of the second month of fetal life, one above each supraorbital margin. From each of these
centers, ossification extends upward to form the corresponding half of the squama, and backwards to
form the orbital plate. The spine is ossified from a pair of secondary centers, on either side of the middle
line; similar centers appear in the nasal part and zygomatic processes.
At birth the bone consists of two pieces, separated by the frontal suture, which is usually obliterated
by Intramembranous ossification, except at its lower part, by the eighth year, but occasionally persists
throughout life. It is generally maintained that the development of the frontal sinuses begins at the end of
the first or beginning of the second year, but may begin at birth. The sinuses are of considerable size by
the seventh or eighth year, but do not attain their full proportions until after puberty.
Development

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SURGICAL ANATOMY
From the Nasion the bone extends approximately 12.5cm
superiorly, 8.0 cm laterally and 5.5 cm posteriorly.
Two frontal tuberosities are noted lateral to the midline and
superior to the supraorbial rim.
The thickest area of the bone is the supraorbial rim from the
frontozygomatic process to the nasal bones.
The supraorbital foramen are located at the most superior
portion of orbital rim.
supratrochlear foramen is located medial to the
supraorbital foramen or notch and lateral to the nasal
bones.
A spine or concavity exists on the frontal bone along the
medial orbital roof; the trocha of the superior oblique
muscle is attached to this spine.

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FRONTAL SINUS
Anatomy
Evolution over age
The frontal sinus is generally absent at birth. At one year
the anterior ethmoid air cells begin to invade the frontal
bone. Frontal sinus growth is then complete at
approximately 15 years of age.
The frontal sinus is irregularly shaped and scalloped at its
margins. Asymmetry of the sinus is the rule rather the
exception (10% of individuals have a unilateral sinus, 9%
of individuals have a rudimentary or absent sinus).
Applied Anatomy of Frontal Sinus

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FRONTAL SINUS
Functions of Frontal Sinus
Following are the various functions of
the frontal sinus:
1. Production and storage of mucus
2. Resonator for voice
3. Humidification and warming of
inhaled air
4. Accessory area of olfaction
5. Conservation of heat from the nasal
fossae
6. Definition of facial contours
7.“ Surge Tank” to dampen the
pressure differential that develops
during inspiration

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FRONTAL SINUS
Anatomic relationships
The frontal sinus has several critical anatomic
relationships. These include:
Sinus floor -> orbital roof/anterior ethmoid air cells
Posterior table -> anterior cranial fossa
Anterior table -> frontal contour
Drainage
The frontal sinus drains via a small outflow tract into the
ethmoid sinus/nasal cavity. The outflow tract is hour-glass
shaped with the true ostium (3-4 mm) at the narrowest
portion.

13. Epidemiolog
y
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Frontal sinus fractures are relatively uncommon and account for only 5-15% of maxillofacial fractures with
a preponderance of male patients.
The most common frontal sinus fractures involve a combination of the anterior and posterior tables with or
without frontal recess involvement (about 2/3).
Isolated posterior table fractures are extremely uncommon
(< 1%).
This 3D CT reconstruction shows an isolated anterior
table fracture.

14. CLASSIFICATION
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Frontal sinus fractures are usually classified
based on:
•Location
•Extent of injury
•Involvement of frontonasal duct
•Current injury to the dura
Stanley’s Classification of Frontal Sinus
Fracture
•Type I: Anterior Table Fracture
• Isolated to anterior table
• Accompanied by supraorbital rim fracture
• Accompanied by naso-ethmoid complex
fracture
•Type II: Anterior and Posterior Table Fractures
• It is a linear fracture either on transverse
direction or in vertical direction
•Type III: Comminuted Fractures
• Isolated to both tables
• Accompanied by naso-ethmoid complex
Gonty Et al. Classification of Frontal Sinus
Fracture
•Type I: Anterior Table Fracture
• Isolated to anterior table
• Accompanied by supraorbital rim fracture
• Accompanied by naso-ethmoid complex
fracture
•Type II: Anterior and Posterior Table Fractures
• A linear fracture either on transverse
direction or in vertical direction
• Comminuted fracture either isolated to both
tables or accompanied by naso-ethmoid
complex fracture
•Type III: Posterior Table Fracture
•Type IV: Through and Through Frontal Sinus
Fracture

15. CLASSIFICATION
1 5
Type I : Anterior table fracture with minimum
comminution
Type II : Anterior Wall comminuted fracture with -
Possible NOE or Orbital rim fracture
Type III : Anterior & Posterior Wall fracture
(Posterior wall fracture without significant
displacement or ductal injury)
Type IV : Anterior & Posterior Wall fracture with
Dural injury & CSF leak
Type V :Anterior & Posterior Wall fracture with
Dural injury, CSF leak, soft tissue or bone loss
and/or severe disruption of anterior cranial fossa
Gerbino G, Roccia F, Benoch A, ot al. Analyss of 158 fontalsinus fractures: Current surgical management
and complications. J Craniomaxilofac Surg 2000; 28133

16. CLASSIFICATION
1 Frontal recess
involvement
A frontal recess injury involves the floor of the
frontal sinus and the outflow tract. It may also
involve the anterior skull base.
Anterior table
fractures
Fractures of the anterior table of the
frontal sinus vary from minimally
displaced to severely
displaced/comminuted depending
upon the severity of the trauma and
size of the sinus.
Minimal displacement
Less severe trauma may result in
fractures of the anterior table which
are minimally (as illustrated) or
nondisplaced. 2
3
4
Posterior table
fracture
Posterior table fractures carry a higher
risk of intracranial injury because they
create a communication with the
intracranial space. The degree of
fracture displacement gives some
insight into the severity of the injury.
While there is no commonly agreed
upon classification for displacement,
many authors have used the width of
the posterior table (0.1 mm – 4 mm) as
a “measuring stick” to describe
displacement because it is readily
visible on axial CT-scans.
3
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17. DIAGNOSIS
 The diagnosis of frontal bone fracture is based upon
proper history and physical examination of the patient
 This includes Inspection and palpation of the affected
area
Detailed History includes:
 Information about events
 Visual difficulties
 Numbness
 Pain
 Rhinorrhea
 Sense of smell
 Previous history of nasal or sinus disease
surgery
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18. CLINICAL FEATURES
Forehead laceration
(58%)
Forehead pain (82%)
swelling
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Frontal bone depression (25%)
Csf rhinorrhea (1/3rd patients
Periorbital ecchymosis

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Clinical evaluation
General
Facial pain
Forehead paraesthesia or anaesthesia
Forehead laceration
Visible and/or palpable frontal bone depression
CSF Rhinorrhoea
Neurological injuries
Cerebral contusion
Subdural & epidural haematoma.
Ophthalmic injuries
Pupillary defect
Optic neuropathy
Hyphaema
Disc oedema
Corneal defect
Loss of globe integrity
Associated maxillofacial Injuries
NOE fracture
Orbital fracture
Zygomatic fracture

20. RADIOGRAPHIC
EVALUATION
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PLAIN RADIOGRAPHS are of little use in the diagnosis of frontal sinus
fractures
Caldwell's view
EVIDENCE OF AIR FLUID LEVEL, CLOUDING
OF FRONTAL SINUS, PNEUMOCEPHALUS
Lateral view High Resolution CT Scan
CT Scans are the GOLD standard for imaging
of these fracture

21. CT SCANS
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AXIAL CT VIEW
Axial images reveals location, severity and degree of
comminution of anterior and posterior table fractures.
A thin cut (1.0 to 1.5 mm), axial computed tomography (CT) scan is
the gold standard.
It is recommended to obtain coronal, sagittal, and
three-dimensional (3-D) reconstructions for
diagnostic accuracy
Coronal images for the Frontal sinus floor and orbital Roof fracture
Coronal CT VIEW

22. CT SCANS
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Sagittal images can be useful in assessing
the patency of the frontal recess
while 3-D reconstructions help define the shape,
location, and orientation of individual bone
fragments that are seen less clearly on 2-D views
sagittal CT VIEW
The 3-D information can
reduce the need for surgical
dissection, because the
surgeon knows the number,
location, and orientation of the
larger bone fragments. It can
also help the patient and/or
family to understand the bony
anatomy and severity of the
injury.

23. MANAGEMENT.
FRONTAL BONE FRACTURE
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24. PRINCIPLES OF FRONTAL BONE FRACTURE MANAGEMENT
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SAFE
SINUS
RESTORE
FACIAL
CONTOUR
AVOID
SHORT &
LONG
TERM
COMPLICATIONS

25. Objectives of management
• To avoid immediate and short-term complications such as CSF
leak, meningitis, spreading infection.
• To avoid long-term complications such as frontal bone
osteomyelitis, chronic frontal sinusitis, mucocele,
mycopyocele, and brain abscess.
• To provide adequate exposure for anatomic reduction of naso-
orbito-ethmoidal (NEO) fractures.
• To restore proper aesthetic contour of the forehead.
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TREATMENT OPTIONS
Conservative
Fracture reduction & fixation
Sinus obliteration
Sinus cranialization

26. Management generally based on
Three clinical factors:
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• Fracture location and displacement
• Dural and cerebral involvement
• Damage to the frontal sinus drainage systems

27. Guiding Principles for Frontal Sinus Management
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•To separate nasal cavity from sinus
•To eliminate dead space
•To separate the frontonasal duct from frontal
sinus by obstructing the duct
•To eliminate a functional sinus, sinus mucosa
is removed, and sinus is obliterated

28. MANAGEMENT
Surgical Access
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1. Through existing laceration
2. Butterfly incision
3. Gullwing or eyeglass incision
4. Bicoronal approach suggests sterile surgical glove tourniquet intraoperatively to get the hemorrhage
control and blood less surgical field in elevation of bicoronal flap for the surgical management of frontal
sinus fracture.
Gullwing or eyeglass incision

29. Surgical Access
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Use of existing laceration to access left-sided
frontal sinus fracture.
Extensive transverse laceration of the forehead with easy
access to the frontal sinus. The fractured segments have
been removed to gain access to the nasofrontal duct.
Through existing laceration

30. Surgical Access
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Irregular outline of a coronal incision in two different patients

31. Surgical Access
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Bicoronal approach
Access areas
The following areas can be
exposed:
•Entire calvarial vault
•Anterior and lateral skull base
•Frontal sinus/Ethmoid
•Zygoma
•Zygomatic arch
•Orbit (lateral/cranial/medial)
•Nasal dorsum
•Temporomandibular joint (TMJ)
and condylar/subcondylar region

32. 3 2 p r e s e n t a t i o n t i t l e 2 0 X X
Indications of Surgery in Frontal Sinus
Fractures
1. To avoid immediate complications such as CSF leak, meningitis
2. To avoid long-term complications such as frontal sinusitis, meningitis and brain abscess formation
3. To provide aesthetic contour to the forehead
4. To provide exposure for anatomic reduction of NOE fractures

33. 3 3 p r e s e n t a t i o n t i t l e 2 0 X X
History of frontal sinus surgery
 Surgical approaches to frontal sinus
• Frontal sinus surgery was first described in the
18th century. It is noted that as early as 1750
Runge performed an obliteration procedure of
the frontal sinus.
• The first published report in 1870 by Wells
described an external and intracranial drainage
procedure for a frontal sinus mucocele.
• In 1884 Alexander Ogston described a
trephination procedure through the anterior
table to evacuate the frontal sinus
• Kuhnt in 1895 described removing the
anterior wall of the frontal sinus in an attempt
to clear disease
In 1898 Riedel/Schenke described the first
procedure for obliteration of the frontal sinus
the Lynch and Howarth
operation
Lynch incision (A) with resulting access
to frontal sinus and ethmoid sinuses (B)

34. 3 4 p r e s e n t a t i o n t i t l e 2 0 X X
History of frontal sinus surgery
 Surgical approaches to frontal sinus

35. MANAGEMENT.
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36. 3 6 p r e s e n t a t i o n t i t l e 2 0 X X
Management of Anterior Table Fracture
Decision-Making
•Simple greenstick or undisplaced fracture does not
require surgical intervention.
•In depressed anterior wall fracture, frontal sinus explored,
careful irrigation carried out, fragments reduced and
stabilize by internal fixation. In posterior wall fracture
without CSF leak or pneumocephalus, reconstruction of
only anterior wall is done.
• Other than surgical intervention, antibiotics,
sinus decongestants and analgesics are
prescribed to keep the frontonasal duct patent
and to prevent infection.
Rai et al. suggested bone mapping/sketching in management of
anterior table frontal sinus fracture with great success
Bone mapping/sketching in management of
anterior table frontal sinus fracture
Yoo MH et al. suggested endoscopic trans nasal reduction of
anterior table fracture To support the reduced fragments, they
advocated use of custom made latex glove balloon to be inserted
into the frontal sinus then expanded and maintained for 3 weeks

37. ANTERIOR table fracture
FRONTAL BONE FRACTURE
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(Nondisplaced, linear/isolated)
Conservative treatment
• Local wound care
• Antibiotics, nasal decongestant, analgesics
• Follow up evaluation

38. Operative Indication of FS injury
FRONTAL BONE FRACTURE
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• Nasofrontal duct involvement/obstruction
• Displacement of posterior table with underlying
neurological injury
• Aesthetic forehead deformity

39. ANTERIOR table fracture
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Modified treatment algorithm for highly selected patients

40. ANTERIOR table fracture
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(Displaced)
Approaches
Intraoperative assessment
• Any kind of fluid
• Nasofrontal duct patency
Nasofrontal duct injury
• Nasofrontal duct filling with frontal sinus obliteration
Grafting
Reduction & fixation
• Existing laceration
• Butterfly/seagull/open sky approaches, coronal
flap

41. Isolated Anterior Table Fracture
FRONTAL BONE FRACTURE
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• Open Reduction Internal Fixation
If the degree of displacement, as
visualized on axial or sagittal sections of
CT scans, is >1–2 mm, that is, more than a
table’s width, it warrants an open reduction
and fixation within 7–10 days*

42. Open reduction internal fixation
4 2
Principle
s
The goal of open reduction is to reapproximate the bone fragments into their premorbid position
and use internal fixation hardware to maintain them in their position.
Approac
h
coronal
approach
Reduction
General considerations
The anterior table of the frontal sinus
is normally convex. Compressive
forces on the frontal bone deform the
convexity into a concavity. This may
or may not result in fracture
comminution.
Mobilization of the depressed bone
fragment(s) may require significant
effort to overcome compressive
forces between bone fragments.

43. Reduction techniques
4 3
Mobilizing the bone fragments
using an elevator
There are several techniques to reduce the fragments:
Inserting a screw into a bony
fragment and reducing it by
pulling it outwards
Fixation
Simple reduction

44. Postop care following management of frontal sinus
fractures
4 4
Evaluation of the patient’s vision
performed as soon as they are awakened from anesthesia and then at
regular intervals until they are discharged from the hospital.
Postoperative
positioning Keeping the patient’s head in a raised position both
preoperatively and postoperatively may significantly
improve edema and pain.
Nose-
blowing
Nose-blowing should be avoided for at least 3 weeks
following frontal sinus and skull base repair.

45. Frontal sinus Obliteration
FRONTAL BONE FRACTURE
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• Steps
• Sinus Exploration
• Mucosal Exenteration
• Nasofrontal Duct obturation
• Frontal sinus Obliteration
• Fracture Reduction

46. Frontal sinus
FRONTAL BONE FRACTURE
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• Filling materials for obturation and obliteration
• Autogenous Material Synthetic materials
- Autologous Fat Polyfluorotetraethylene, ePTFE
- Cancellous bone’ Methylmethacrylate, MMA
- Muscle
- Pericranial flap
- Banked cadaveric tissue

47. Indication for Bone Grafting
FRONTAL BONE FRACTURE
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1. Extensive loss of support at the skull base over the fovea
ethmoidalis and cribriform plate, in combination with a
peri cranial flap.
2. Superior orbital roof fractures, to avoid pulsatile
exophthalmos and orbital deformity.
3. Extensive bone loss of the anterior table, which cannot be
replaced with elements of the posterior table.
4. In combination with NOE and orbital reconstruction
as layered bone grafts to obliterate the ethmoids and reconstruct
the medial orbital wall.

48. posterior table fracture
FRONTAL BONE FRACTURE
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CSF leak Absent and No displacement
Frontal Sinus Obliteration
CSF leak Absent and/or Displacement
Frontal Sinus Cranialization

49. Frontal Sinus Cranialization
FRONTAL BONE FRACTURE
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• It is another technique to minimize the dead
space in sinus. It involves removing
posterior table thus permitting brain to
expand into frontal sinus resulting in
confuence between sinus cavity and
anterior cranial fossa.
• It is done in cases with CSF leak and
neurological injury due to displaced
posterior table fracture. To isolate the
splanchnocranium from the frontal sinus, a
pericranial fap is used.

50. Frontal Sinus Cranialization
FRONTAL BONE FRACTURE
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Although obliteration has been touted as the gold standard
and safest method to treat the injured frontal sinus, there
are many disadvantages including :

51. Complications
FRONTAL BONE FRACTURE
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52. Recent Advancements
FRONTAL BONE FRACTURE
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Virtual Surgery
Augmented Reality
Stereolithography or 3D printing
Virtual Endoscopy

53. Preoperative Photographs and radiographs
5 3 A 48-year-old female patient who sustained a frontal bone fracture right side having a H/O fall from a hill

54. Intraoperative & postoperative Photographs
5 4 A 48-year-old female patient who sustained a frontal bone fracture right side having a H/O fall from a hill

55. Preoperative Photographs and radiographs
5 5 A 22-year-old male patient who sustained a frontal bone having a H/O RSA, having fallen form his bike

56. Intraoperative & postoperative Photographs
5 6 A 22-year-old male patient who sustained a frontal bone having a H/O RSA, having fallen form his bike

57. Follow up Photographs
5 7 A 22-year-old male patient who sustained a frontal bone having a H/O RSA, having fallen form his bike

58. Conclusion
The management of NOE and frontal sinus fracture is
always a challenging task .The proper handling of MCL
and nasofrontal duct is mandatory to get good post-
operative results. Proper treatment planning in the form of
incision selection, method of fixation and use of bone graft
should be done to avoid unaesthetic results.
5 8 p r e s e n t a t i o n t i t l e 2 0 X X

59. references
5 9 N O E F R A C T U R E S 2 0 X X
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• 2. Brasileiro BF, Passeri LA. Epidemiological analysis of maxillofacial fractures in Brazil: a 5-year prospective study. Oral Surg Oral Med
Oral Pathol Oral Radiol Endod. 2006;102(1):28–34.
• 3. Rosenberger E, Kriet JD, Humphrey C. Management of nasoethmoid fractures. Curr Opin Otolaryngol Head Neck Surg. 2013;21:410–6.
(Anatomy of MCL, physical examination of the complex and displacement)
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• 6. Heine D, Catone GA, Bavitz B, Grenadier MR. Naso-orbitalethmoid injury: report of a case and review of the literature. Oral Surg Oral
Med Oral Path. 2005;69(5):542–9.
• 7. Rowe NL. Rowe and Williams’ maxillofacial injuries, vol. 2. 2nd ed. Edinburgh: Churchill Livinstone; 1994.
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the central fragment in classifcation and treatment. Plast Reconstr Surg. 1991;87:843–853.
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• 11. Ellis E III. Sequencing treatment for naso-orbito-ethmoid fractures. J Oral Maxillofac Surg. 1993;51:543–558.
• 12. Nguyen M, Koshy JC, Hollier LH Jr. Pearls of nasoorbitoethmoid trauma management. Semin Plast Surg. 2010;24:383–8.
• 13. Dingman RO, Grabb WC, Oneal RM. Management of injuries of the naso-orbital complex. Arch Surg. 1969;98:566–71.
• 14. Mustarde JC. Epicanthus and telecanthus. Int Opthalmol Clin. 1964;4:359.
• 15. Cruse C, Blevins PK, Luce EA. Naso-ethmoid-orbital fractures. J Trauma. 1980;20:551.

60. THANK YOU