|CASE REPORT - TRAUMA
|Year : 2019 | Volume
| Issue : 2 | Page : 407-410
Bone cements in depressed frontal bone fractures
Alagappan Meyyappan, Eswari Jagdish, Jessica Yolanda Jeevitha
Department of Oral and Maxillofacial Surgery, Chettinad Dental College and Research Institute, Kancheepuram, Tamil Nadu, India
|Date of Web Publication||11-Dec-2019|
Jessica Yolanda Jeevitha
Department of Oral and Maxillofacial Surgery, Chettinad Dental College and Research Institute, Kancheepuram, Tamil Nadu
Skull fractures can be classified into four major types; linear, depressed, diastatic, and basilar. Of these, a depressed skull fracture presents a high risk of increased intracranial pressure or hemorrhage to the brain. A compound depressed skull fracture results when a laceration over the fracture exposes the internal cranial cavity to the outside environment. Such depressed skull fractures are indicated for elevation if the defect is more than 10 mm and in the presence of brain injury. Frontal bone contour defects result in marked facial deformity which becomes obvious to the observer. Esthetic correction of the depressed frontal bone fracture can be done with autogenous bone grafts or alloplastic materials. Autogenous bone grafts are meant to be the gold standard method of reconstruction, but they harbor the risk of donor-site morbidity. There are various materials available for the reconstruction of depressed frontal bone fractures. This is a case report which illustrates the use of easily injectable, self-setting calcium phosphate bone cement in the correction of a depressed frontal bone fracture measuring approximately 3 cm × 2.5 cm × 1.5 cm.
Keywords: Bone cement, calcium phosphate cements, contour defects, craniofacial trauma, frontal bone, reconstruction
|How to cite this article:|
Meyyappan A, Jagdish E, Jeevitha JY. Bone cements in depressed frontal bone fractures. Ann Maxillofac Surg 2019;9:407-10
| Introduction|| |
The frontal bone is the most frequently fractured cranial bone in craniofacial trauma patients and accounts for 37% of cranial fractures. In maxillary fractures, isolated Le Fort I fractures have significant association with frontal bone fracture. The frontal bone consists of three parts, the squamous part which is the largest and forms majority of the forehead, supraorbital margins and the superciliary arch. The frontal bone is more protected from traumatic events due to the prominence of the nasal pyramid which protects the naso-orbital region as well. The frontal bone also has a higher resistance to mechanical impacts. The frontal bone can withstand 800–1600 pounds of force, thus conferring resistance against most forms of traumatic injury. Motor vehicle accidents are the most common cause followed by assaults and sports-related injuries.
| Case Report|| |
A 25-year-old male reported to the hospital with an alleged history of road traffic accident and history of loss of consciousness and nasal bleed. The patient was conscious, stable, and oriented. The patient presented with a laceration wound measuring approximately 5 cm × 3 cm in the left forehead region running parallel to the eyebrow [Figure 1], which was debrided immediately and sutured to control bleeding. Diffuse edema of the left upper and middle third of the face was evident along with circumorbital edema and subconjunctival hemorrhage of the left eye. The patient's mouth opening was adequate with bilaterally stable occlusion. Assessment of the computed tomography [Figure 2] revealed an incomplete and undisplaced Le Fort I fracture and a left frontal bone fracture which was approximately 3 cm × 2.5 cm × 1 cm. The frontal bone fracture involved both the cortices without involvement of the frontal sinus, and there was no evidence of dural tear as discussed with the neurosurgical team. The patient was observed for any neurosurgical deficit and was found to be devoid of the same. Since the patient's mouth opening was adequate, occlusion was stable with no mobility of the maxilla, and the Le Fort I fracture was decided to be managed conservatively. The frontal bone was minimally depressed without involvement of the frontal sinus; therefore; bone cement was used as an alternate to the standard approach based on esthetic concerns.
|Figure 2: Computed tomography revealing left frontal bone fracture and Lefort I fracture|
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The existing laceration was utilized to approach the fracture site [Figure 3]a. The fracture site was exposed [Figure 3]b and isolated. A calcium phosphate-based cement  (HydroSet™) which is a synthetic bone graft substitute was used in the reconstruction of the depressed frontal bone fracture. The bone cement [Figure 3]c consisted of powder and liquid components, was mixed to attain a flowable consistency and then was applied over the defect and was manipulated. The cement was designed to set in the presence of water, blood and cerebrospinal fluid. Once the cement had set, closure was done in layers with Vicryl 3-0 and ethilon 4-0 [Figure 3]d.
|Figure 3: (a) Exposure of fracture site, (b) calcium phosphate bone cement, (c) reconstruction of the defect with the bone cement, (d) closure done in layers|
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The patient was assessed postoperatively [Figure 4] for any pain, edema or bleeding at the surgical site. A postoperative computed tomography [Figure 5] was done to evaluate the adaptation and contour of the bone cement placed over the defect.
|Figure 4: Postoperative frontal view of the patient depicting bilateral symmetry of the frontal bone|
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|Figure 5: (a) Preoperative axial section of computed tomography demonstrating the depressed frontal bone fracture, (b) postoperative axial section of computed tomography demonstrating the reconstructed site|
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| Discussion|| |
The frontal bone fracture is classified as follows  [Figure 6]:
|Figure 6: Classification of frontal bone fracture. Type 1 fractures are isolated to the frontal sinus without a vertical trajectory (purple). Type 2 fractures are vertically oriented and extend into the orbit but not the frontal sinus (blue). Type 3 fractures are vertically oriented and extend into the frontal sinus but not the orbit (yellow). Type 4 fractures are vertically oriented and extend into ipsilateral frontal sinus and orbit (green). Type 5 fractures extend into the frontal sinus and extend into the orbit on both sides of the face or the contralateral side of the face (red)|
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- Type 1 fractures: Nonvertical fractures
Comminuted fractures of the frontal sinus without a vertical trajectory
- Type 2 fractures: Vertical fractures
Vertical fractures involving the orbit but not the frontal sinus
- Type 3 fractures
Vertical fractures involving the frontal bone and sinus but not the orbit
- Type 4 fractures
Fractures involve both the frontal sinus and the ipsilateral orbit
- Type 5 fractures
Fractures crossing the midline of the face, involving the frontal sinus and the contralateral or bilateral orbits.
Skull base penetration depths are classified as follows [Figure 7]:
|Figure 7: Skull base penetration depths. Depth A fractures involve the anterior table of the frontal bone with or without posterior table involvement and do not extend into the anterior cranial fossa (purple). Depth B fractures involve the floor of the anterior cranial fossa (blue). Depth C fractures involve the middle cranial fossa (yellow). Depth D fractures extend into the posterior cranial fossa (red)|
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- Depth A – Involvement of the frontal bone without extension into the skull base.
- Depth B – Extension into the anterior cranial fossa (orbital roof, fovea ethmoidalis, and cribriform plate)
- Depth C – Extension into the middle cranial fossa (sella, sphenoid body, carotid canal, and optic chiasm sulcus)
- Depth D – Involvement of the posterior cranial fossa (clivus, petromastoid temporal bone, and petrosal segment of the carotid canal).
Depressed comminuted fractures should be elevated and stabilized with a titanium mesh, or the use of an alloplastic reconstructive material can combat the contour defect that could occur. Frontal bone fractures can be approached surgically through many ways such as the coronal approach, gullwing incision, open-sky approach, subbrow approach, or through the existing laceration. There are various modalities available for the reconstruction of frontal bone defects. The materials used for cranioplasty should fulfill several criteria such as the material should be biologically inert, moldable, nonreactive, noncorrosive, nonresorbable, nonantigenic, stable, durable, and ability to withstand impact.
Accounts from the early 1900s relate how metal or hammered gold plate was used. Evolution has led to the shift from hammered gold to precast metal alloy followed by silicone rubber to the use of autogenous grafts . Alloplastic materials, such as methyl methacrylate, hydroxyapatite cement, hydroxyapatite block, hydroxyapatite granules, carbonated calcium phosphate bone cement, titanium, or porous polyethylene, are also used to repair frontal bone fractures. Autogenous bone grafts are the gold standard for the reconstruction of any bony defect, but its use is limited due to unpredictable resorption and possible donor-site morbidity. The most commonly used alloplastic material of choice is the methyl methacrylate, but it is also not ideal. Despite its favorable characteristics, methyl methacrylate has a higher infection rate than autologous bone, low composite tensile displacement profile, accelerating crack velocity, exothermic polymerization, and lack of retention. Since displacement/fracture has been reported with the use of polymethyl methacrylate alloplastic materials cranioplasties, numerous techniques such as miniplates, mesh, and wires have been developed to stabilize the construct.
An alternative to autogenous grafts and methyl methacrylate is the hydroxyapatite, which is of two generations: the ceramic and nonceramic. The ceramic hydroxyapatite ( first generation) is produced by a sintering process. It is characteristic of osteoconductivity. The disadvantages are brittleness and inability to mold in case of a hydroxyapatite block, and the granular form is difficult to contain in the area of reconstruction and has reduced structural stability. The second generation consists of calcium phosphate cement which is manufactured as powder and liquid components. The two components on mixing undergo a physicochemical reaction resulting in a flowable material that promotes a chemical bond with the host bone. HydroSet / Stryker has been designed to have wet-field characteristics to overcome the demerits of first generation cements, wherein the latter starts to disintegrate on early contact with blood and other fluids. These types of cement tend to harden at a faster rate and get converted to carbonated hydroxyapatite in 24 h after which it undergoes a phase of remodeling through osteoclastic resorption and new bone formation, thereby exhibiting excellent osteoconductive property. This trait makes it to stand ahead of titanium mesh as there is the formation of new bone. Hannink et al. state that new bone was found to be deposited over the surface of the cement material in 6 weeks.
In summary, the use of calcium phosphate bone cements in the reconstruction of depressed frontal bone fractures has proved to be an efficient method to correct contour defects of the frontal bone and has gained popularity in the esthetic realm. This is due to the osteoconductive nature which paves the way for new bone formation, thereby maintaining adequate strength. the properties of being nonallergic, noncytotoxic, endothermic, retentive and allowing tissue ingrowth adds to the benefits of bone cements.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]