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National Journal of Maxillofacial Surgery
 
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Table of Contents
CASE REPORT
Year : 2011  |  Volume : 2  |  Issue : 1  |  Page : 69-72  

Esthetic correction of depressed frontal bone fracture


Department of Oral and Maxillofacial Surgery, S.G.T. Dental College and Hospital, Budhera, Gurgaon, Haryana, India

Date of Web Publication10-Oct-2011

Correspondence Address:
J K Dayashankara Rao
Departments of Oral and Maxillofacial Surgery, SGT Dental College and Hospital, Budhera, Gurgaon, Haryana - 123 505
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0975-5950.85858

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   Abstract 

Depressed frontal bone fractures are occasionally seen in maxillofacial trauma patient. If untreated, they look un-esthetic. Although there are numerous options available for correction of these defects, use of bone cement (polymethylmethacrylate or PMMA) is simple and reliable. This is the report of one such case.

Keywords: Alloplasts, esthetic correction of frontal bone, frontal bone fracture


How to cite this article:
Dayashankara Rao J K, Malhotra V, Batra RS, Kukreja A. Esthetic correction of depressed frontal bone fracture. Natl J Maxillofac Surg 2011;2:69-72

How to cite this URL:
Dayashankara Rao J K, Malhotra V, Batra RS, Kukreja A. Esthetic correction of depressed frontal bone fracture. Natl J Maxillofac Surg [serial online] 2011 [cited 2019 Nov 18];2:69-72. Available from: http://www.njms.in/text.asp?2011/2/1/69/85858


   Introduction Top


Fractures of the upper face and anterior skull base are a challenging neurosurgical, plastic, maxillofacial surgery problem. After clinical and radiographic evaluation of the fracture, prompt surgical intervention should be immediately instituted to excise any necrotic tissues inside or outside the cranial cavity, brain isolation by meticulous dural closure [1] ablation of the frontal air sinuses and bony coverage of the region by either immediate or delayed frontal bone reconstruction.

If frontal bone is comminuted, it is difficult to replace the small bony fragment by rigid bone plate fixation. [2] In such cases, it is prudent to leave the bony fragments where they are and camouflage the defect. [2]

Literature has many articles describing simple procedures for contouring the craniofacial skeleton. These procedures include use of hydroxyapatite cement, hydroxyapatite block, hydroxyapatite granules, carbonated calcium phosphate bone cement, norian craniofacial repair system (CRS) or carbonated calcium phosphate plate (CCPP), high-density porous polythene implants or bioactive glass ceramic implant and acrylic (methylmethacrylate). [3],[4]

We have used polymethylmethacrylate or PMMA for correction of frontal bone defect in one patient and has found it to be a convenient, safe and simple method.


   Case report Top


A 28-year-old male patient reported to our department with H/O of RTA. On clinical examination, there was depressed frontal bone and zygoma fracture [Figure 1] a and b.
Figure 1a: Pre operative lateral view of depressed frontal bone fracture
Figure 1b: Pre operative depressed frontal bone close up view


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Axial and spiral computerized tomography (CT) scanning of head was done to rule out any head injury. Radiograph revealed depressed comminuted fracture of frontal bone on left side leading to obliteration of frontal sinus on that side.

Treatment plan

As the comminuted bony fragments of frontal bone could not be brought back into the normal position, it was decided to camouflage the defect with gentamicin impregnated PMMA (poly methylmethacrylate) bone cement.

Surgical procedure

Patient was operated under general anesthesia. After proper scrubbing of operating field and draping, 2% lignocaine with 1:200000 adrenaline was infiltrated in the area to achieve vasoconstriction and to get fluid dissection. The fracture site was exposed via extending the existing lacerated wound [Figure 2]. It was a depressed comminuted fracture of frontal bone. Since it was not associated with any head injury, the defect was flushed and dried to make it ready to receive the bone cement.
Figure 2: Exposure of the fracture site through the lacerated wound

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The bone cement was then mixed as per manufacturer's instructions [Figure 3]. Once it reached dough stage, it was used to fill up the defect and manipulated to the desired shape [Figure 4]. Closure was done 3'0 silk suture [Figure 5].
Figure 3: Bone cement being prepared as per manufacturer instructions

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Figure 4: Bone cement placed and adopted over the defect

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Figure 5: Immediate post operative picture

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   Results Top


Patient recovered from anesthesia uneventfully. He received post operative broad spectrum antibiotics for five days. The wound healed very well and there was no sign of infection or any other complication at the time of discharge [Figure 6]. Suture removal was done on seventh day postoperatively. Patient was happy and satisfied with the result.
Figure 6: Three-months post operative photograph

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   Discussion Top


Management algorithms for frontal sinus fractures vary widely. Appropriate treatment depends on an accurate diagnosis, focusing on the physical examination and data from computed tomography scans.

It is not uncommon for post craniofacial trauma patients to require augmentation of depressed craniofacial skeleton. Reconstruction and recontouring of these defects in natural esthetic fashion can pose challenge to clinician. Various autogenous bone graft and alloplastic materials have been in use for this purpose i.e. titanium mesh, polymethyl methacrylate [5],[6] autogenous bone, hydroxyapatite, HTR-PMI (hard tissue replacement patient matched implant) [7] have been used with varying success. All materials and grafts have merits and demerits in their use.

Titanium mesh [2] is costly and its shaping and moulding is difficult and time consuming.

Autogenous bone grafts [7] such as iliac or rib require a second surgical site. This may lead to donor site morbidity, inability to obtain adequate bone for large defect.

Cranial defect caused by trauma can be satisfactorily treated using cranioplast implant [7] made from HTR-PMI process. This implant consists of polymethyl methacrylate and polyhydroxyethyl methacrylate. Infection and foreign body reaction and availability are the main demerits of this alloplastic material.

Other alloplastic materials [7] that have been used for such defects are hydroxyapatite, silicon rubber, acrylic metal plates and proplast. These have following advantages and disadvantages.

Advantages of alloplast:

  1. Availability
  2. Nonresorbability
  3. Ease of surgical procedure
  4. Excellent post operative cosmetic result


Disadvantages include:

  1. Foreign body reaction
  2. Potential for infection which may produce fistula, slippage, extrusion, granuloma and erosion.
  3. Polymethylmethacrylate [8] is the most commonly used alloplastic material.


Advantage:

  • tissue tolerance
  • reliable recounstructive material


Disadvantages include infection, limitation of growth and it may fracture and requires time for shaping and curing. [7] The risk of infection may be reduced by adding antibiotic i.e. gentamycin to the acrylic and using it under sterile conditions, beneath well-vascularized skin. Growth limitation may be obviated by not placing acrylic across sutures in children with enlarging skulls. [8]

This technique, apart from being affordable, also ensures shorter operative time and good esthetic result. [9] so we have chosen this technique in our patient and did one patient using PMMA and got initial promising results.

 
   References Top

1.EL-Rifaie KM, Taher AA. Frontobasal fractures. Guidelines to management Egypt. J Plast Reconstr Surg 2006;27:113-9.   Back to cited text no. 1
    
2.Stanley RB Jr. Management of complications of frontal sinus and frontal bone fractures. Oper Tech Plastic Reconstr Surg 1998;5:296-301.  Back to cited text no. 2
    
3.Elshahat A. Correction of craniofacial skeleton contour defects using bioactive glass particles. Egypt J Plast Reconstr Surg 2006;30:113-9.   Back to cited text no. 3
    
4.Chen TM, Wang HJ, Chen SL, Lin FH. Reconstruction of post-traumatic frontal-bone depression using hydroxyapatite cement. Ann Plast Surg 2004;52:303-8.   Back to cited text no. 4
[PUBMED]  [FULLTEXT]  
5.Persing JA, Cronin AJ, Delashaw JB, Edgerton MT, Henson SL, Jane JA. Late surgical treatment of unilateral coronal synostosis using methyl methacrylate. J Neurosurg 1987;66:793-9.   Back to cited text no. 5
[PUBMED]  [FULLTEXT]  
6.Marbacher S, Andres RH, Fathi AR, Fandino J. Primary recounstruction of open depressed fracture with titanium mesh. J Cranifac Surg 2008;19:490-5.   Back to cited text no. 6
    
7.none Roberson JB, Rosenberg WS. Traumatic cranial defects reconstructed with the HTR-PMI cranioplastic implant the. J Craniomaxillofac Trauma 1997;3:8-13.   Back to cited text no. 7
    
8.Schultz RC. Restoration of frontal contour with methyl methacrylate. Ann Plast Surg 1979;3:295-303.  Back to cited text no. 8
[PUBMED]    
9.Abdulai A, Iddrissu M, Dakurah T. Cranioplasty using polymethyl methacrylate implant constructed from an alginate impression and wax elimination technique. Ghana Med J 2006;40:18-21.  Back to cited text no. 9
[PUBMED]  [FULLTEXT]  


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]


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