Surgical Treatment of Severe Frontal Bone Fracture

Craniofacial trauma can lead to several complications. The combined fractures of anterior and posterior walls of the frontal bone are almost always followed by lesions in nasofrontal orifices and disruption of nasofrontal ostia or ducts, a significant factor for the development of early and late complications after sinus fractures. This article reports a case of trauma patient, who underwent neurological evaluation and at first showed good general condition. Computed tomography noted fracture of the anterior and posterior walls of the frontal sinus and small foci of pneumocephalus in the cerebral cortex. The patient was monitored periodically and 9 days after trauma showed increased areas of pneumocephalus in prefrontal cortex, cerebrospinal fluid draining, and large dura mater lesion, with signs of necrosis and inflammation (meningitis). The necrotic tissues were removed, and dura mater was repaired through the approximation with resorbable wire polyglactin 910 5-0, oxidized cellulose application, and bonding with human fibrin sealant (fibrinogen, thrombin, and calcium chloride). Sinusectomy, frontal sinus, and nasofrontal duct obliteration with pedicled pericranium flap were performed. Tomographically, a reanatomization was noted in frontal region, and a 12-month follow-up showed no complication. The use of fibrin glue to repair dura mater lacerations, as well as the pedicle pericranium flap for frontal sinus and nasofrontal duct obliteration, is an efficient method for treating fractures of the frontal bone.

Extensive Frontoparietal Abscess: Complication Of Frontal Sinusitis (pott's Puffy Tumor).

First described in 1768, the Pott's puffy tumor is a subperiosteal abscess associated with frontal bone osteomyelitis, resulting from trauma or frontal sinusitis. The classic clinical presentation consists of purulent rhinorrhea, fever, headache, and frontal swelling. The diagnosis is confirmed by CT scan and treatment requires intravenous antibiotics, analgesia, and surgical intervention. Early diagnosis and aggressive medical and surgical approach are essential for a good outcome. It rare and the early diagnosis is important; we describe the case of a 14-year-old adolescent with Pott's puffy tumor who was initially treated inadequately, evolving with extensive frontoparietal abscess. The patient underwent surgical treatment with endoscopic endonasal and external approaches combined. Intravenous antibiotics were prescribed for a prolonged time, with good outcome and remission of the complaints.

Bone repair and augmentation using block of sintered bovine-derived anorganic bone graft in cranial bone defect model

To histomorphometrically investigate the repair of critical size defects (CSDs) and bone augmentation in cranial walls using block of sintered bovine-derived anorganic bone (sBDAB) graft. Forty guinea-pigs were divided into test (n=20) and CSD control (n=20) groups. In each animal, a full-thickness bone defect with 9.5 mm diameter was made in the frontal bone. The defects were filled with an sBDAB block soaked in blood in the test group and with blood clot in the CSD control group. The skulls were collected at 0 h (n=2) and 30, 90 and 180 days (n=6/group and period) postoperatively. The volume density and total volume of newly formed bone, sBDAB, blood vessels and connective tissue, vertical thickness of removed bone plug, sBDAB block and graft area were evaluated. The vertical thickness of the adapted sBDAB block was 3.8 times higher than that of the removed bone plug and did not show significant difference between periods, filling in average 29.8% of the total graft region. The sBDAB block exhibited complete osseointegration with the borders of the defect at 90 days. At 90 and 180 days, the vertical thickness of the graft was 279% in the average, and the total volume of bone augmentation was, respectively, 78.8% and 148.5% higher compared with the removed bone plug. The defects of the CDS control group showed limited osteogenesis and filling by connective tissue plus tegument. The sBDAB block can be used to promote repair of CSDs and bone augmentation in the craniomaxillofacial region, due to its good osteoconductive and slow resorptive properties. To cite this article:Cestari TM, Granjeiro JM, de Assis GF, Garlet GP, Taga R. Bone repair and augmentation using block of sintered bovine-derived anorganic bone graft in cranial bone defect model.Clin. Oral Impl. Res. 20, 2009; 340-350.doi: 10.1111/j.1600-0501.2008.01659.x.

Development of Craniofacial Bone Defect Reconstruction Implant Based on Fibre-Reinforced Composite with Photopolymerisable Resin Systems. Experimental studies in vitro and in vivo.

Reconstruction of defects in the craniomaxillofacial (CMF) area has mainly been based on bone grafts or metallic fixing plates and screws. Particularly in the case of large calvarial and/or craniofacial defects caused by trauma, tumours or congenital malformations, there is a need for reliable reconstruction biomaterials, because bone grafts or metallic fixing systems do not completely fulfill the criteria for the best possible reconstruction methods in these complicated cases. In this series of studies, the usability of fibre-reinforced composite (FRC) was studied as a biostable, nonmetallic alternative material for reconstructing artificially created bone defects in frontal and calvarial areas of rabbits. The experimental part of this work describes the different stages of the product development process from the first in vitro tests with resin-impregnated fibrereinforced composites to the in vivo animal studies, in which this FRC was tested as an implant material for reconstructing different size bone defects in rabbit frontal and calvarial areas. In the first in vitro study, the FRC was polymerised in contact with bone or blood in the laboratory. The polymerised FRC samples were then incubated in water, which was analysed for residual monomer content by using high performance liquid chromatography (HPLC). It was found that this in vitro polymerisation in contact with bone and blood did not markedly increase the residual monomer leaching from the FRC. In the second in vitro study, different adhesive systems were tested in fixing the implant to bone surface. This was done to find an alternative implant fixing system to screws and pins. On the basis of this study, it was found that the surface of the calvarial bone needed both mechanical and chemical treatments before the resinimpregnated FRC could be properly fixed onto it. In three animal studies performed with rabbit frontal bone defects and critical size calvarial bone defect models, biological responses to the FRC implants were evaluated. On the basis of theseevaluations, it can be concluded that the FRC, based on E-glass (electrical glass) fibres forming a porous fibre veil enables the ingrowth of connective tissues to the inner structures of the material, as well as the bone formation and mineralization inside the fibre veil. Bone formation could be enhanced by using bioactive glass granules fixed to the FRC implants. FRC-implanted bone defects healed partly; no total healing of defects was achieved. Biological responses during the follow-up time, at a maximum of 12 weeks, to resin-impregnated composite implant seemed to depend on the polymerization time of the resin matrix of the FRC. Both of the studied resin systems used in the FRC were photopolymerised and the heat-induced postpolymerisation was used additionally.

Immediate reconstruction of frontal sinus fractures: review of 26 cases

Purpose: the purpose of this study was to evaluate complications occurring after immediate reconstruction of severe frontal sinus fractures, including cases where the fracture was not limited to the anterior wall and also involved the posterior wall and/or sinus floor.Patients and Methods: the records of twenty-six patients presently undergoing follow-up for frontal sinus fracture reconstruction were reviewed. Information regarding demographics, fracture characteristics and causes, associated facial fractures, use of grafts or implants, type of fixation used, nasofrontal duct management, use of antibiotics, and complications were noted. Patients were asked to return for clinical and radiographic follow-up to access late complications.Results: the average age of patients with frontal fractures was 29.1 years and 92.3% were male. Mean follow-up was 3.6 years. The most common causes of fracture were motor vehicle accidents and physical aggression. All patients presented with comminuted and dislocated anterior wall fractures, 34.6% presented with posterior wall fractures, and 46% had sinus floor fractures. Complications occurred in 7 patients (26.92%) and included pneumoencephalus, frontal cutaneous fistula, frontal bone irregularity, and sinusitis.Conclusions: Frontal sinus reconstruction is a good procedure for immediate fracture treatment if there is not excessive comminution, dislocation, or instability of the posterior wall and if the frontonasal duct area is intact or can be repaired. Most complications result from incorrect indication for reconstruction. (C) 2004 American Association of Oral and Maxillofacial Surgeons.

Evaluation of hydroxyapatite cement for frontal sinus obliteration after mucocele resection

OBJECTIVES: To retrospectively evaluate our experience with frontal sinus obliteration using hydroxyapatite cement (BoneSource; Stryker Biotech Europe, Montreux, Switzerland) and compare it with fat obliteration over the approximate same period. Frontal sinus obliteration with hydroxyapatite cement represents a new technique for obliteration of the frontal sinus after mucocele resection. METHODS: Exploration of the frontal sinus was performed using bicoronal, osteoplastic flaps, with mucosal removal and duct obliteration with tissue glue and muscle or fascia. Flaps were elevated over the periorbita, and Silastic sheeting was used to protect the BoneSource material from exposure as it dried. The frontal table was replaced when appropriate. RESULTS: Sixteen patients underwent frontal sinus obliteration with fat (fat obliteration group), and 38 patients underwent obliteration with BoneSource (BoneSource group). Fat obliteration failed in 2 patients, who underwent subsequent BoneSource obliteration, and none of the patients in the BoneSource group has required removal of material because of recurrent complications. Frontobasal trauma (26 patients [68%] in the BoneSource group and 9 patients [56%] in the fat obliteration group) was the most common history of mucocele formation in both groups. Major complications in the BoneSource group included 1 patient with skin fistula, which was managed conservatively, and 1 patient with recurrent ethmoiditis, which was managed surgically. Both complications were not directly attributed to the use of BoneSource. Contour deficit of the frontal bone occurred in 1 patient in the fat obliteration group and in none in the BoneSource group. Two patients in the fat obliteration group had donor site complications (hematoma and infection). Thirteen patients in the BoneSource group had at least 1 prior attempt at mucocele drainage, and no statistical relation existed between recurrent surgery and preservation of the anterior table. CONCLUSION: Hydroxyapatite is a safe, effective material to obliterate frontal sinuses infected with mucoceles, with minimal morbidity and excellent postoperative contour.

Salmonella epidural abscess in sickle cell disease: failure of the nonsurgical treatment.

In patients suffering from sickle cell disease (SCD), bone is a preferred site of infection. We report the case of a five-year-and-eight-month-old black African boy with homozygous-SS disease who developed a cranial epidural abscess. This intracranial infectious complication originated from a Salmonella enteritidis osteitis of the frontal bone. Antibiotic treatment alone did not control the disease, so surgery was necessary to remove the necrotic bone and to evacuate the epidural pus. The numerous factors interfering with normal healing of a septic focus in sickle cell anemia, particularly in this previously undescribed intracranial complication, emphasize the need for a primary and early surgical treatment in similar situations.

Different locations of dermoid cysts in the orbital region.

BACKGROUND: Dermoid cysts are frequent unilateral congenital benign tumors that can be found at different locations throughout the body. In the orbital region, dermoid cysts occur predominantly in the supero-temporal quadrant. However, different orbital locations are possible, making this entity an important differential diagnosis for orbital tumors. PATIENTS AND METHODS: We retrospectively reviewed the charts of 23 consecutive patients operated in our institution between 2005 and 2014 for orbital tumors that were diagnosed as congenital dermoid or epidermoid cysts. RESULTS: There were 21 dermoid and 2 epidermoid cysts. The median age at surgery time was 7 years (range 1-41). There were 15 females and 8 males. Eleven cysts were located supero-temporally (47.8%), seven supero-medially (30.4%), two temporally (8.7%), one at the frontal bone (4.4%) and two in the fossa of the lacrimal gland (8.7%). The mean cyst diameter was 13.1 mm±5.0 (SD). None had signs of malignant disease. No recurrence was observed after complete excision. CONCLUSION: Dermoid cysts of orbital region are mostly located in the supero-temporal quadrant. However, other orbital locations are possible and dermoid cysts must thus be considered in the differential diagnosis of any mass in the orbital region.

Aesthetic correction of a hypertrophic sinus frontalis: A long-term follow-up evaluation and refinement of the method

Two cases treated for hypertrophy of the frontal sinus are presented. In both patients, the excised frontal bone was inverted, and the resultant cavity was filled with either bone dust from the parietal region or Medpor. The first patient is shown with an excellent result after a follow-up period of 16 years. The second patient, who also achieved an excellent result, is presented after a follow-up period of 5 years. Using Medpor instead of bone dust resulted in the advantage that the operation could be performed with the patient under local anesthesia with sedation and prevention of an additional donor site. The use of Medpor has certain advantages over the use of hydroxyapatite, not least of which is its significant lower cost.

Albright's syndrome: review of the literature and case report.

Albright's syndrome is characterized by the presence of polyostotic fibrous dysplasia, endocrinopathies and brown spots on the skin. In the present article the authors describe a case occurring in a 20-year-old female patient, who is currently being followed radiographically after a mandibular bone biopsy.

Tometes camunani (Characiformes: Serrasalmidae), a new species of phytophagous fish from the Guiana Shield, rio Trombetas basin, Brazil

Uma espécie nova de Serrasalmidae, Tometes camunani, é descrita para as drenagens superiores da bacia do rio Trombetas, estado do Pará, Brasil. A espécie nova distingue-se dos congêneres pela presença de uma ligeira concavidade no neurocrânio na altura do frontal (vs. concavidade ausente, perfil dorsal do neurocrânio reto). Também pode ser adicionalmente distinguido dos seus congêneres por possuir dentes com a cúspide central mais alta e cume agudo (vs. cúspide central mais baixa e com cume arredondado em T. trilobatus), a boca terminal (vs. boca orientada para cima em T. lebaili), e 12-26 espinhos pré-pélvicos (vs. 0-9 em T. makue). A espécie nova é estritamente reofílica, como as demais espécies de Tometes, e ocorre exclusivamente nas zonas encachoeiradas dos rios de escudo, biótopos complexos, frágeis e ameaçados por ações antropogênicas. Uma chave de identificação para as espécies do grupo Myleus é apresentada.

Peripheral osteoma in the ramus of mandible: report of case

The osteomas are benign rare neoplasms, generally asymptomatic which are characterized by the proliferation of a compact or spongy bone. When they are situated in the maxillofacial area, they affect mainly the mandible, the frontal bone and the paranasal sinus. We have described the case of a female caucasian patient who presented an increased volume in the posterior region of the oral vestibule on the left side. During the clinical examination an oral lesion was observed in the region of the left ramus of mandible. This lesion was motionless, consistent, and painless when palpated. In the image obtained from the computed tomography cone–beam (CBCT), we could observe an hyperdense, cylindrical region, with well defined borders, located in the medial surface of the left ramus of mandible, right below the mandibular notch. Based on clinical data and in the obtained images, we could confirm the presence of the peripheral osteoma in the left side of the ramus of mandible region.

Osteologia craniana comparada de Caracara cheriway (Jacquin, 1784) e Caracara plancus (Miller, 1777) (AVES: FALCONIDAE)

The Caracara genus (Aves: Falconidae) is composed by species C. cheriway, ("Crested Caracara"), and C. plancus (Southern Caracara). This study aimed to describe in detail and compared the cranial osteology of C. cheriway and C. plancus, identifying osteological cranial characters for a future systematic work. The two common characters of Caracara species are: the projection of rostro parasphenoid reaches 50% of the distance from the occipital condyle to the pterygoid; the upper maxilla has about 4/9 of the total length of theskull, the symphysial portion of mandible occupies about 1/7 of its total length, the proximal portion of lacrimal bone ends in a rounded shape and has about 1/4 of the width of the distal portion. The unique characters of C. cheriway are: the interorbital width is about 1/2 of the parietal region, shows a frontal bone prominence; presence of lacrimal process of frontal bone; the proximal portion of the lacrimal bone reaches 1/5 of the distance from the orbital arc to the jugal bone; the distance between the distal portions of two lacrimal bones reach 5/6 of the parietal width, the ratio between the interorbital diameter and parietal region ranges from 2 times; the zygomatic process occupies about 40% of the distance between its origin in the skull and jugal bone. The unique characters of C. plancus are: the interorbital width is approximately 4/7 of the parietal width; show a rostral medial concavity; the proximal portion of the lacrimal bone is about 1/4 of the width of the distal; the proximal portion of the lacrimal bone reaches 1/7 of the distance from the orbital arc to the jugal bone; the distance between the distal portions of two lacrimal bones reaches 6/7 of the width parietal one; the ratio between the interorbital diameter and parietal region varies 1, 75 times, the zygomatic process occupies about 35% of the distance between its origin in the skull and jugal bone.

Late-onset social anxiety disorder following traumatic brain injury

Background: Neuropsychiatric sequelae are the predominant long-term disability after traumatic brain injury (TBI). This study reports a case of late-onset social anxiety disorder (SAD) following TBI. Case report: A patient that was spontaneous and extroverted up to 18-years-old started to exhibit significant social anxiety symptoms. These symptoms became progressively worse and he sought treatment at age 21. He had a previous history of traumatic brain injury (TBI) at age 17. Neuroimaging investigations (CT, SPECT and MRI) showed a bony protuberance on the left frontal bone, with mass effect on the left frontal lobe. He had no neurological signs or symptoms. The patient underwent neurosurgery with gross total resection of the lesion and the pathological examination was compatible with intradiploic haematoma. Conclusions: Psychiatric symptoms may be the only findings in the initial manifestation of slowly growing extra-axial space-occupying lesions that compress the frontal lobe from the outside. Focal neurological symptoms may occur only when the lesion becomes large. This case report underscores the need for careful exclusion of general medical conditions and TBI history in cases of late-onset SAD and may also contribute to the elucidation of the neurobiology of this disorder.

Symptomatic plate removal after treatment of facial fractures

AIMS: To identify the rates and reasons for plate removal (PR) among patients treated for facial fractures. MATERIALS AND METHODS: A retrospective review of files of 238 patients. RESULTS: Forty-eight patients (20.2%) had plates removed. The reason for removal was objective in 33.3% and subjective in 29.2%. The most common subjective reason was cold sensitivity, and the most common objective reason was wound dehiscence/infection. Women had PR for subjective reasons more often than men (p=0.018). Removal was performed more often for subjective reasons after zygomatico-orbital fractures than after mandibular fractures (p=0.002). Plates inserted in the mandible from an intraoral approach were removed more frequently than extraorally inserted mandibular plates, intraorally inserted maxillary plates, and extraorally inserted plates in other locations (p<0.001). Orbital rim plates had a higher risk of being removed than maxillary or frontal bone plates (p=0.02). CONCLUSIONS: Subjective discomfort is a notable reason for PR among Finnish patients, suggesting that the cold climate has an influence on the need for removal. Patients receiving mandibular osteosynthesis with miniplates from an intraoral approach are at risk of hardware removal because of wound dehiscence/infection and loose/broken hardware, reminding us that more rigid fixation devices should not be forgotten despite the widespread use of miniplates.