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Objective: Frontal and naso-orbito-ethmoidal (NOE) fractures are rare but important injuries due to their anatomical complexity and proximity to vital structures. This study aims to describe the patient factors, procedural factors, and postoperative outcomes in the surgical management of these fractures., Study Design: Retrospective review of patients aged 18 years or older who were surgically treated for these fractures at two Australian tertiary hospitals (2014-2020). Patient factors (demographics, mechanism of injury, fracture pattern, concomitant injuries); procedural factors (operation timing, surgical approach); and postoperative outcomes (complications, revision surgeries) were recorded., Results: 60 cases were included (41 frontal; 29 NOE; 10 combined). Mean age was 37 (frontal) and 39 years (NOE). Most cases were male (87.8%; 75.9%). The most common mechanism was traffic accidents (29.3%; 34.5%). The most common associated facial fractures were Le Fort fractures (46.3%; 89.7%). The most common associated systemic injuries were brain injuries (36.6%; 34.5%). Mean operation timing was 13 days (frontal) and 11 days (NOE). Coronal flap was most commonly used (68.3%; 82.8%). Postoperative complication rates were 39.0% (frontal) and 37.9% (NOE). Three cases required revision surgeries., Conclusion: Further larger longitudinal studies are required to build knowledge and improve patient outcomes., Competing Interests: Declaration of Interests The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this article., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Frontal bone fractures are amongst the most common facial fractures and surgical management, which has traditionally involved access via a coronal flap, can result in unsightly scarring, alopecia, paraesthesia, facial nerve weakness and temporal hollowing. Alternative approaches include use of endoscopically-assisted surgery, often through the eyebrow, which minimises the risk of unsightly scarring but may also sacrifice access in the process. In this technical note, we discuss a surgical technique for open reduction and internal fixation of fractures of the bone overlying the frontal sinus and supra-orbital rim, which the authors have not found in the literature, which involves the making of a "zig-zag" incision through the eyebrow in a trichophytic manner which reduces the risk of unsightly scarring whilst simultaneously allowing for sufficient surgical access to the fracture site., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Masson SAS. All rights reserved.)

A frontoorbitozygomaticomaxillary fracture, also known as a complex midface fracture or "quadripod fracture," is a type of facial fracture involving multiple midface region bones. This includes the frontal bone (forehead), orbitozygomatic complex (which includes the zygomatic bone or cheekbone and the orbital bones around the eye), and the maxillary bone (upper jaw). These complex midface fractures associated with temporoparietal bone fractures can occur in clinical practice. However, a single-piece fracture of these has not been reported before. This study reports a 44-year-old male patient with a significant frontoorbitozygomaticomaxillary fracture associated with a temporoparietal bone fracture combined with epidural hematoma at the superior aspect of unilateral frontoparietotemporal convexity. Surgical treatment was performed 3 weeks after the traumatic event. Despite craniotomy of the parietal bone fragment, the reduction was not possible. The facial bone reduction was finally achieved following an additional single osteotomy at the unilateral zygomaticomaxillary buttress. The follow-up CT scan taken immediately and 3 weeks postoperatively showed successful realignment of craniofacial bone fracture. In conclusion, a single-piece fracture of frontoorbitozygomaticomaxillary bone connected to a temporoparietal bone can require additional osteotomy to achieve successful outcomes in an acute setting., Competing Interests: The authors declare no conflicts of interests., (Copyright © 2023 by Mutaz B. Habal, MD.)

Purpose: The purpose of this study was to provide detailed information about the eyebrow approach for the reduction of the frontal bone and its esthetic results with the help of clinical data available. Thus, suggesting this technique is minimally invasive and highly esthetic for frontal bone management., Method: In this series, 96 cases were studied, and results were based on variable clinical criteria and satisfaction of patients. All the surgeries were performed through eyebrow incision for the management of fractures. Intraoperatively, minimal tissue dissection, less invasion with reduced operating time was observed., Results: Postoperatively, the eyebrow approach leads to its normal contour and esthetics. No complications related to the procedure were seen with partially recoverable neuropraxia and speedy recovery. This makes it an important technique to consider in carefully selected patients., Conclusion: In craniofacial trauma, frequently involved site is the frontal bone, and its treatment should be completed more esthetically. Eyebrow approach is a good alternative to other surgical approaches, and it is a minimally invasive technique and thus should be practiced for esthetic management of frontal bone fractures.

Surgical procedures undergone in life, autopsies and anatomical preparations can all leave clearly identifiable traces on human skeletal remains. Several studies on skeletons from archeological contexts have identified traces of these practices. However, the distinction between medical/forensic autopsy and anatomical dissections for scientific research can be challenging. We report the case of a middle-aged female skeleton from the cemetery of the church of San Biagio (Ravenna, Italy), dating back to the 17th-19th centuries, that shows signs of a complete craniotomy. In an attempt to clarify the reason for this practice, we analyzed all pathological and non-pathological markers on the skeleton. We carried out anthropological analyses and osteometric measurements to determine the biological profile and the cranial capacity of the individual. Paleopathological investigation and analyses of traumatic injury patterns were carried out using both a morphological and a microscopic approach. While we observed that the craniotomy was performed with a rip saw, we identified perimortem blunt force trauma to the frontal bone and an osteolytic lesion on the inner surface of the frontal bone. No other pathology was recognizable on the skeleton. Our differential diagnosis confidently proved that the craniotomy was due to an autoptsy procedure and was not the result of an anatomical dissection. We believe that, among other possible reasons, failed surgery could likely be the motive behind the ordering of the autopsy.

Background: The purpose of this study was to assess the incidence, cause, characteristics, presentation, and management of pediatric frontal bone fractures., Methods: A retrospective cohort review was performed on all patients younger than 15 years with frontal fractures that presented to a single institution from 1998 to 2010. Charts and computed tomographic images were reviewed, and frontal bone fractures were classified into three types based on anatomical fracture characteristics. Fracture cause, patient demographics, management, concomitant injuries, and complications were recorded. Primary outcomes were defined by fracture type and predictors of operative management and length of stay., Results: A total of 174 patients with frontal bone fractures met the authors' inclusion criteria. The mean age of the patient sample was 7.19 ± 4.27 years. Among these patients, 52, 47, and 75 patients were classified as having type I, II, and III fractures, respectively. A total of 14, 9, and 24 patients with type I, II, and III fractures underwent operative management, respectively. All children with evidence of nasofrontal outflow tract involvement and obstruction underwent cranialization (n = 11)., Conclusions: The authors recommend that type I fractures be managed according to the usual neurosurgical guidelines. Type II fractures can be managed operatively according to the usual pediatric orbital roof and frontal sinus fracture indications (e.g., significantly displaced posterior table fractures with associated neurologic indications). Lastly, type III fractures can be managed operatively as for type I and II indications and for evidence of nasofrontal outflow tract involvement. The authors recommend cranialization in children with nasofrontal outflow tract involvement., Clinical Question/level of Evidence: Risk, II.

Several resorbable fixation systems are used for osteosynthesis in craniofacial surgery. Recently, ultrasonic-assisted pinned resorbable systems have been introduced; however, few studies have described the associated complications during the long-term follow-up until complete resorption. In this study, we investigated the complications of craniofacial surgery using the ultrasonic-assisted pinned resorbable system with a follow-up of at least 30 months. Among patients who underwent craniofacial surgery using a commercially available ultrasonic-assisted pinned resorbable system between 2014 and 2016, those with follow-up visits for at least 30 months were included in this study. We investigated the development of complications such as local infection, exposure of the device, and reoperation related to the implant. Twenty-four patients aged 6 months to 69.4 years (median: 3.5 years) were followed up for more than 30 months. None of the patients required reoperation regardless of implants. Further, no infection or device exposure was seen among all patients. However, two patients aged 6 and 22 months who underwent cranioplasty for craniosynostosis and another patient aged 148 months who underwent cranioplasty for cranial defect exhibited plate-related bulging in the scalp during the course of resorption between 7 and 12 months of follow-up. The bulges were characterized by swelling without pain or redness and resolved spontaneously within 18 months of follow-up, which was considered to occur after complete absorption of the plate. In conclusion, subcutaneous swelling is related to resorbable plates and has a benign clinical course. We recommend that patients be informed of this phenomenon preoperatively to relieve their anxiety., Competing Interests: Declaration of Competing Interest None., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

In this paper we present the study of a skull belonging to a young male from the Italian Bronze Age showing three perimortem injuries on the frontal and parietal bones; the peculiarity of the frontal injury is represented by its singular shape, which may be indicative of the weapon that caused the lesion. The aim of the present study is to examine the traumatic evidence in relation to possible etiological factors, in order to attempt to establish if the lesion occurred peri or post-mortem, and to evaluate if these traumatic injuries could be interpreted as an evidence of interpersonal violence, by combining anthropological, taphonomic and ESEM investigations. The combination of multidisciplinary methods of study can provide important new insights into inter-personal violence.

Background: In automotive events, head injuries (skull fractures and/or brain injuries) are associated with head contact loading. While the widely-used head injury criterion is based on frontal bone fracture and linear accelerations, injury risk curves were not developed from original datasets., Objectives: Develop skull fracture-based risk curves for using previously published data and apply resampling techniques to assess their qualities., Methods: Force, deflection, energy, and stiffness data from thirteen human cadaver head impact tests were used to develop risk curves using parametric survival analysis. Injuries occurred to all specimens. Data points were treated as uncensored. Variables were ranked, and the variable best explaining the underlying fracture response was determined using the Brier Score Metric (BSM). The qualities of the risk curves were determined using normalized confidence interval sizes. Statistical resampling methods were used to assess the quality of the risk curves and the impact of the sample size by conducting 2000 simulations. Sample sizes ranged from 13 to 26., Findings: The Weibull distribution was optimal for all the response variables, except deflection (log-logistic). The quality of the risk curves was the highest for deflection. This variable best explained the underlying head injury response, based on BSM. Improvements in the quality of the risk curves were achieved with additional samples of force and deflection (<13), while energy and stiffness variables required more size. Individual risk curves are given., Interpretation: These probability curves from head contact loading add to the understanding skull fractures and can be used to improve safety in injury producing environments., (Published by Elsevier Ltd.)

Appropriate medical care for a patient with a facial fracture can not only optimize aesthetic outcomes but also prevent the potential morbidity and mortality of delayed treatment. In this article, we focus on the clinical presentations, physical examination findings, diagnostic imaging, consultations, and follow-up that patients with facial fractures need related to their emergency department management. Specifically, we address the nuances of evaluating frontal, orbital, nasal, maxillofacial, and mandibular fractures., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Objective: Introduction: At present biocomposite materials are used in the surgical treatment of frontal bone fracture. They improve osteogenesis, reduce the number of complications. Immunologic aspects of application of these materials are studied insufficiently, therefore this report presents the results of immunoassay of patients with frontal bone fracture in the proximate posttraumatic period before implanting preparation "Syntekost". The aim: To define the role of immune mechanisms in the realization of the biocomposite material's positive influence on the development of effective posstraumatic rehabilitation schemes., Patients and Methods: Materials and methods: 16 patients with frontal bone fracture (FBF) were examined on admission to the Otolaryngology Clinics of Vinnitsa Region Hospital. Additionally, 10 patients of the similar age were examined as a control group. The content of cells with markers of surface antigens-CD3,14,16,20,25, concentration of immunoglobulins of classes M,G,A,E, С4 complement component and lactoferrin was determined in blood. Immunoenzyme methods were applied. Nonparametric Wilcoxon - Mann - Whitney test, computer programme WIN Pepi were used for statistical measurements., Results: Results: A decrease in the level of IgM in comparison with practically healthy donors and an increase in the concentration of lactoferrin were identified as humoral immunity factors of patients with frontal basilar trauma. The most significant deviation in the peripheral blood cellular makeup in CD-markers was an increase in cells with markers CD14 and CD16., Conclusion: Conclusions: The level of cells and prodefensin-lactoferrin that maintain inborn immunity increases and the concentration of coarse defensive protein decreases in the initial period after frontal bone fracture, which must be taken into consideration during post-surgical treatment.

Background: To approach isolated anterior frontal bone fracture, coronal incision is the common surgical access of choice. This approach has complications such as aesthetically undesirable scarring and alopecia along the incision line. An alternative approach to these fractures is through a supratarsal incision. The aim of the present study was to correct the frontal bone fracture, through supratarsal approach., Methods: Six consecutive patients with frontal bone fracture were operated through supratarsal incision and evaluated regarding: patient cosmetic satisfaction, forehead contour, scarring, sensibility and motility in forehead and upper eyelids., Results: Seven months (6-12) postoperatively, all the patients had normal mobility in the forehead and the upper eyelids and 17% (n = 1) had hypoesthesia of superior orbital nerve. The forehead contour was excellent in all patients. About 83% (n = 5) of the patients were very satisfied and 17% (n = 1) were satisfied with the surgical result., Conclusion: Correction of anterior frontal bone fracture through a supratarsal approach appears to be safe and offers a sufficient exposure to the frontal bone fracture correction with excellent contouring results and no noticeable scarring.

Purpose: Fracture of the frontal bone can be accompanied by damage to the optic canal. The present study uses finite element analysis to identify fracture patterns, suggesting the involvement of the optic canal., Methods: Ten finite-element skull models were generated from computer tomography data of 10 persons. Then, dynamic analyses simulating collision of a 2-cm-radius brass ball to 6 regions on the frontal bone in the 10 models were performed. Fracture patterns presented by the frontal bone in the 60 experiments were observed, and all those involving the optic canal were selected. Commonalities of the selected fracture patterns were identified., Results: Fracture of the optic canal was observed in 9 of the 60 patients. In all 9 patients, fracture existed on the anterior and posterior walls of the frontal sinus and on the superior orbital wall., Conclusion: When the anterior and posterior walls of the frontal sinus and the superior orbital wall are all broken, the optic canal is highly likely to be involved in the damage. When this pattern is observed in emergency examination, preventive decompression of the optic nerve should be considered to avoid potential occurrence of blindness.

Background: To date, calvarial defects in dogs have traditionally been addressed with different types of implants including bone allograft, polymethylmethacrylate and titanium mesh secured with conventional metallic fixation methods. This report describes the use of an absorbable and non absorbable novel polymer fixation method, Bonewelding® technology, in combination with titanium mesh for the repair of calvarial defects in two dogs. The clinical outcomes and comparative complication using resorbable and non-resorbable thermoplastic pins were compared., Case Presentation: This report of two cases documents the repair of a traumatic calvarial fracture in an adult male Greyhound and a cranioplasty following frontal bone tumor resection in an adult female Cavalier King Charles Spaniel with the use of a commercially available titanium mesh secured with an innovative thermoplastic polymer screw system (Bonewelding®). The treatment combination aimed to restore cranial structure, sinus integrity and cosmetic appearance. A mouldable titanium mesh was cut to fit the bone defect of the frontal bone and secured with either resorbable or non-resorbable polymer pins using Bonewelding® technology. Gentamycin-impregnated collagen sponge was used intraoperatively to assist with sealing of the frontal sinuses. Calvarial fracture and post-operative implant positioning were advised using computed tomography. A satisfactory restoration of skull integrity and cosmetic result was achieved, and long term clinical outcome was deemed clinically adequate with good patient quality of life. Postoperative complications including rostral mesh uplift with minor associated clinical signs were encountered when resorbable pins were used. No postoperative complications were experienced in non-resorbable pins at 7 months follow-up, by contrast mesh uplift was noted 3 weeks post-procedure in the case treated using absorbable pins., Conclusions: The report demonstrates the innovative use of sonic-activated polymer pins (Bonewelding® technology) alongside titanium mesh is a suitable alternative technique for skull defect repair in dogs. The use of Bonewelding® may offer advantages in reduction of surgical time. Further, ultrasonic pin application may be less invasive than alternative metallic fixation and potentially reduces bone trauma. Polymer systems may offer enhanced mesh-bone integration when compared to traditional metallic implants. The use of polymer pins demonstrates initial potential as a fixation method in cranioplasty. Initial findings in a single case comparison indicate a possible advantage in the use of non-absorbable over the absorbable systems to circumvent complications associated with variable polymer degradation, further long term studies with higher patient numbers are required before reliable conclusions can be made.

The frontal bone fractures occur very often in service units in oral and maxillofacial surgery. Bicoronal access is the most common for the surgical treatment of frontal bone fractures. However, patients are surprised when they receive notice that such invasive access will be made. This approach allows adequate visualization of the fracture site, but may be associated with complications, which can be avoided by the use of less invasive techniques. We describe an alternative approach that aims to minimize the complications of a coronal incision.

Background: The goal of cranioplasty is to achieve a lifelong, stable and structural reconstruction of the cranium covered by a healthy skin and scalp flap. We present two cases of large frontal bone defect following a accident., Cases: We describe the utilization of autogenous local split calvarial graft and titanium mesh for the reconstruction of the post trauma frontal bone defect., Conclusion: Cranioplasty using split calvarial bone grafting for restoring large cranial defects resulting from a trauma is a useful technique, and allows the surgeon to reconstruct a moderate to large cranial defect without rifting the inner cortical plate.

Introduction: Reconstruction of craniofacial defects due to traumatic injuries is a challenge for a reconstructive surgeon, given the functional impact, the aesthetic impact and the geometric complexity of the craniofacial skeleton. The use of cutting and repositioning guides enables a new approach from the craniofacial reconstruction with bone grafts on measure. We are presented to illustrate this technique the case of a patient., Observation: The patient was 50 years old, he presented a traumatic facial sequelar: a left frontal craniofacial deformation, an enlarged left orbit with enophthalmos and valgus left zygoma. The patient had a permanent diplopia, an important aesthetic and social gene impeding daily life. Surgical planning was performed for optimal care. We performed a cranioplasty frontotemporal by bone parietal duplication, osteotomy of zygoma and intra-orbital bone graft customized using cutting guides. The bone pieces were positioned with the repositioning books., Discussion: This presentation illustrates a novel application of cutting guides. This technique has the advantage of using customized autologous bone. This is the gold standard, it requires surgical experience., (Copyright © 2017 Elsevier Masson SAS. All rights reserved.)

Competing Interests: Disclosure The authors report no conflicts of interest in this work.

A 34-year-old woman with severe craniofacial trauma, which included eversion of the entire frontal bone, survived with high-quality functional and cosmetic results as a consequence of efficient and aggressive action by emergency technicians and physicians. Early preliminary steps of craniofacial reconstruction provided a structural foundation that facilitated this outcome.

The growing demand for various kinds of bone regeneration material has in turn increased the desire to find materials with optimal physical, chemical, and biological properties. The objective of the present study was to identify the proportions of ceramic and polylactide components in a bone substitute material prepared in collaboration with the Crystal Chemistry of Drugs Team of the Faculty of Chemistry at the Jagiellonian University, which would be optimal for bone regeneration processes. Another goal was to provide a histological analysis of the influence of a ceramic-polylactide composite on the healing of osseous defects in rabbits. The study was performed on laboratory animals (18 New Zealand White rabbits). The following study groups were formed: - group A (study group, 9 animals) - in this group we performed a histological analysis of healing with a ceramic-polylactide composite based on an 80/20 mix of hydroxyapatite and polylactide; - group B (study group, 9 animals) - in this group we performed a histological analysis of healing with a ceramic-polylactide composite with a reduced amount of hydroxyapatite compared to the previous group, i.e. in a ratio of 61/39; - group K (control, 18 animals) - the control group comprised self-healing, standardised osseous defects prepared in the calvarial bone of the rabbits on the contralateral side. In the assessment of histological samples, we were also able to eliminate individual influences that might have led to differentiation in wound healing. The material used in the histological analysis took the form of rabbit bone tissue samples, containing both defects, with margins of around 0.5 cm, taken 1, 3, and 6 months after the experiment. The osseous defects from groups A and B filled with ceramic-polylactide material healed with less inflammatory infiltration than was the case with control group K. They were also characterised by faster regression, and no resorption or osteonecrosis, which allowed for better regeneration of the bone tissue. A statistical analysis of the study results revealed the increased resorptive activity of the composite in group B, which may have been due to its higher polylactide content. Simultaneously, we observed that healing of osseous defects filled with ceramic-polylactide composites in 80/20 and 61/39 ratios was comparable.

Background: Vertebrobasilar artery entrapment resulting from a clivus fracture is rare. The entrapped lesions are not radiographically depicted precisely because they are only identified by autopsy or completely occluded. In addition, no changes in the features have been revealed clearly because radiologic examinations were performed only in the acute stage., Case Description: We report a case of traumatic entrapment of the vertebral artery depicted precisely by a three-dimensional angiographic study in the subacute stage, presenting the serial changes in the morphologic features and a review of the published cases., Conclusion: It is necessary to manage vertebrobasilar artery entrapment cautiously because it is suggested that the entrapped lesion is accompanied by arterial dissection., (Copyright © 2016 Elsevier Inc. All rights reserved.)

The deep layers of the nasoethmoid region comprise a thin-walled lacrimal bone, a paper-thin ethmoid plate, and ethmoidal cells, forming an extremely fragile and easily crushed structure. In a nasoethmoid complex fracture where the support structure itself is destroyed, epithesis and immobilization are difficult and can lead to residual saddle nose deformities. Therefore, bone grafts are often necessary at a later date. Recently, the authors occasionally see reports of nasoethmoid complex fractures that are treated with Halo distraction devices. Advantages of this device are that it applies constant traction to maintain the shape of the structures until the ruptured nasoethmoid bone and mucosa are repaired, thus minimizing relapse. There is no need for rigid fixation with a plate, no limitations on how much distraction is possible, and no major skin incisions are required for the approach. The authors treated a 30-year-old man who suffered a severe and widespread depressed facial deformation due to a nasoethmoid fracture that included a midface comminuted fracture using a Halo-type distraction device. A gentle traction was maintained on the nasoethmoid bone and part of the maxilla pulling it forward, and resulted in an extremely good outcome both esthetically and functionally. This method is believed to be extremely useful and effective, requiring only minimally invasive surgery for comminuted midface fractures involving a nasoethmoid fracture with a depressed frontal process of the maxilla. Below, the authors provide a detailed description of their experience with this device.

Post-traumatic deformity of frontal sinus anterior table can be treated in various ways. Usage of a certain type of an implant is a common method. We performed an osteotomy and subsequent reduction of the fragments to reconstruct their anatomical position. Titanium miniplates and screws were used for fixation. This case report suggests a possible use of this method in patients with more extensive frontal sinus and distinct post-traumatic deformity. No similar case manages as described in our case report was found in the literature.

Background: Studies in tissue engineering about mesenchymal stem cells (MSCs) provide promising results for bone regeneration. The aim of this study was to evaluate the effects of rat bone marrow-derived MSCs (rMSCs) alone and when combined with demineralized bone matrix (DBM) on critical-sized cranial defects of rats., Methods: Ten rats were used to obtain allogeneic rMSCs. Forty rats were separated equally into 4 groups. A full-thickness circular bone defect was created in the frontal bone of the rats. Group 1 was an operative control group. In group 2 DBM, in group 3 rMSCs, and in group 4 DBM combined with rMSCs were applied into the defects. Bone regeneration was evaluated by computed tomographic analysis and immunohistochemistry., Results: In radiological evaluation, the percentage of area healed in group 3 at the 12th week was statistically significantly greater than in group 1. In group 3 and group 4, distributed healing patterns were observed more than in group 2 and in group 1. Immunohistochemical evaluation revealed that group 4 had the best osteoinductive potential. Osteoinductive potential of group 3 was similar to group 2 and was better than group 1., Conclusions: Allogeneic rMSC applications have created a statistically significant radiologic reduction of the bone defect areas at the end of the 12 weeks. The MSC applications have also increased the bone density and changed the healing patterns. Combined use of the DBM and rMSCs has created more osteoinductive responses. This combination can provide better results in craniofacial bone reconstruction.

The skull base is uniquely positioned to absorb force imparted to the craniofacial skeleton, thereby reducing brain injury. Less well understood is the effect of the direction of force imparted to the craniofacial skeleton on the severity of brain injury. Eighty-one patients from two UK major trauma centres who sustained a fronto-basal fracture were divided into two groups: those struck with predominantly anterior force and those by predominantly lateral force. The first recorded Glasgow Coma Score (GCS), requirement for intubation, and requirement for decompressive craniectomy were used as markers of the severity of brain injury. An average GCS of 5 was found in the lateral group and 14 in the anterior group; this difference was statistically significant (P<0.001). There was an increased need for both intubation and decompressive craniectomy in the lateral group compared to the anterior group (absolute risk difference 46.6% and 15.8%, respectively). These results suggest that the skeletal anatomy of the fronto-basal region influences the severity of head injury. The delicate lattice-like structure in the central anterior cranial fossa can act as a crumple zone, absorbing force. Conversely in the lateral aspect of the anterior cranial fossa, there is a lack of collapsible interface, resulting in an increased energy transfer to the brain., (Copyright © 2016 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.)

Introduction: There is still no consensus on the ideal material to be used in craniofacial defects. Autogenous bone grafts are mostly preferred owing to their use with fewer complications. The aim of this study was to evaluate whether the scapular bone graft can be used with equal or more advantages to other bone graft resources in orbital, maxillary sinus front wall, and frontal bone defects., Patients and Methods: Twenty-four orbital, maxillary sinus front wall, and frontal bone defects were reconstructed with scapular bone grafts. Sixteen patients presented with complicated orbital fractures, 5 patients presented with isolated orbital floor fractures, and 3 patients presented with frontal bone fractures. The grafts were radiologically evaluated 1 day, 6 months, and 12 months postoperatively by 3-dimensional computed tomography scan., Results: All orbital, maxillary sinus front wall, and frontal bone defects were reconstructed successfully with scapular bone grafts. Clinical evaluation of the patients at 6 to 24 months of follow-up was considered satisfactory. Minimal donor site morbidity was observed. Scapular bone grafts adapted nicely to the recipient area, and bony union was complete as demonstrated by 3-dimensional computed tomography scans., Conclusions: Reconstruction of orbital, maxillary sinus front wall, and frontal bone defects with scapular bone grafts is an easy and safe procedure with minimal donor site morbidity. Scapular bone graft is a good reconstructive option for orbital, maxillary sinus front wall, and frontal bone defects.

An anterolateral thigh myo-adipofascial flap was used in the definitive management of a patient presented with chronic infective process associated with a large fronto-nasal defect. Unfortunately, the risk of free flap transfer failure emerged when intraoperative dissection showed absence of a reliable ipsilateral superficial temporal artery as the recipient artery. This rare incident happened at the stage whereby the anterolateral thigh flap was nearly completely raised with a distal perforator in situ. In this article, the authors presented an innovative strategy to salvage the flap by transforming the flap into a modified composite flap based on the retrograde blood flow principle. To the best of our knowledge, this is the first report of using such a technique in reconstructive microsurgery. This successful salvage strategy has clinical application and could potentially minimize free flap transfer failure.

The skull defect model is the existing representative osteogenesis model. The skull defect model involves monitoring osteogenesis patterns at the site of a skull defect, which has the advantages that identical defects can be induced across individual experimental animals and the results can be quantitatively evaluated. However, it can damage the cerebrum because it requires a complex surgery performed on the parietal bone. This study aims to develop a new osteogenesis model that compensates for the weak points of the existing model. Male 8-week-old imprinting control region mice were put under inhalational anesthesia, and the surgery area was disinfected with 70% ethanol prior to the creation of a 5-mm incision along the sagittal line between the glabella with a pair of scissors. The incised area was opened and, after we checked the positions of the inferior cerebral vein and the sagittal suture, a 21-gauge needle was used to make two symmetrical holes with respect to the sagittal suture 3 mm below the inferior cerebral vein and 2 mm on either side of the sagittal suture. After images were obtained using micro-computed tomography, the degree of osteogenesis was quantitatively analyzed. In addition, mRNA extracted from the site of the defect confirmed a significant increase in mRNA levels of collagen 1a, alkaline phosphatase, bone sialoprotein, osteocalcin, and Runx2, known markers for osteoblasts. The promotion of osteogenesis could be observed at the site of the defect, by histological analysis., (© 2015 Wiley Periodicals, Inc.)

Longitudinal clivus fractures are rare in children, with only 5 cases published in the English literature to date. Clivus fractures, particularly longitudinal type, are associated with high mortality and morbidity. We report a case of longitudinal clivus fracture in a teenager with survival and complete neurological recovery. Our case is the first pediatric case of longitudinal clivus fracture caused by frontal impact and the first described pediatric case associated with transient diabetes insipidus (DI)., (© The Author(s) 2014.)

Background: Pediatric cranial vault fractures are a unique subset of injuries that pose distinct management and treatment challenges. They are anatomically distinct from their adult counterparts with potential implications on the development of the brain and craniofacial skeleton, and require unique considerations for management and treatment outcomes.A detailed analysis of the characteristics and outcomes of pediatric cranial vault fractures remains understudied in this population. Thus, the aim of this study was to characterize the demographics, injury patterns, operative interventions, concomitant injuries, and factors predictive of mortality in pediatric patients sustaining cranial vault fractures., Methods: A retrospective review of patients less than 18 years of age presenting to the emergency department of a pediatric level I trauma center between 2000 and 2005 with skull fractures was performed. All patients were included regardless of treating specialty, treatment modality, or inpatient status. Patients were stratified into 3 groups (age < = 5 yrs, 5.1-11 yrs, and >11 yrs). ZIP codes were mapped using ArcGIS 10.2 Software (ESRI Inc, Redlands, CA) with ZIP code shapefiles from ESRI's ArcGIS Online. Socioeconomic and demographic variables at the ZIP code level were linked to each geocoded location using the United States Census Bureau summary files, and spatial clusters of injury were performed using GeoDa to conduct a test of local indicator of spatial autocorrelation. Statistical analysis was performed using the SPSS version 17 (SPSS Inc, Chicago, IL)., Results: A total of 923 consecutive patients met the inclusion criteria for the study. Caucasian (P < 0.001) males (P = 0.055) were most likely to sustain cranial vault fractures. The average age at injury was 5.97 years. Falls (53.7%) were the most common cause of injury across all age groups, followed by collisions (20.8%), with falls being more common in the youngest age group (< = 5 yrs), and collisions being more common in the older age groups. Direct objects to the head had the highest rate of surgical intervention (P < 0.001). Parietal bone fractures were more frequent in the youngest age group, while frontal and temporal bone fractures were more common in the older age groups. Increasing age was an independent predictor of the need for surgical intervention (P < 0.0001). The overall incidence of blindness and hearing loss was low, and increased with increasing age. Patients with fractures as a result of violent mechanisms were more likely to come from highly impoverished zip codes, compared with patients with nonviolent mechanisms of injury (19.6% versus 8%). Overall mortality was low (2.9%). Temporal bone fractures had the greatest risk of mortality (P < 0.001) with age > = 5 years being an independent predictor of mortality (P < 0.001). Victims of falls, and patients with associated gastrointestinal or musculoskeletal injuries, had a statistically significant increased chance of survival, whereas victims of collisions and patients with concomitant cervical spine, cardiothoracic, or respiratory injuries had a significantly increased risk of death., Conclusions: Pediatric cranial vault fracture injury patterns are significantly correlated with demographics, mechanisms of injury, presence and type of concomitant injuries, need for surgical intervention, and mortality. Although the need for operative intervention and overall mortality is low, these variables play significant roles in portending prognosis, and an understanding of the metrics presented herein will enable practitioners optimize management and treatment in this unique patient population.

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.

Purpose: The broad spectrum of frontal bone fractures, including those with orbital and skull base extension, is poorly understood. We propose a novel classification scheme for frontal bone fractures., Methods: Maxillofacial CT scans of trauma patients were reviewed over a five year period, and frontal bone fractures were classified: Type 1: Frontal sinus fracture without vertical extension. Type 2: Vertical fracture through the orbit without frontal sinus involvement. Type 3: Vertical fracture through the frontal sinus without orbit involvement. Type 4: Vertical fracture through the frontal sinus and ipsilateral orbit. Type 5: Vertical fracture through the frontal sinus and contralateral or bilateral orbits. We also identified the depth of skull base extension, and performed a chart review to identify associated complications., Results: 149 frontal bone fractures, including 51 non-vertical frontal sinus (Type 1, 34.2%) and 98 vertical (Types 2-5, 65.8%) fractures were identified. Vertical fractures penetrated the middle or posterior cranial fossa significantly more often than non-vertical fractures (62.2 v. 15.7%, p = 0.0001) and had a significantly higher mortality rate (18.4 v. 0%, p < 0.05). Vertical fractures with frontal sinus and orbital extension, and fractures that penetrated the middle or posterior cranial fossa had the strongest association with intracranial injuries, optic neuropathy, disability, and death (p < 0.05)., Conclusions: Vertical frontal bone fractures carry a worse prognosis than frontal bone fractures without a vertical pattern. In addition, vertical fractures with extension into the frontal sinus and orbit, or with extension into the middle or posterior cranial fossa have the highest complication rate and mortality., (Copyright © 2015 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Aneurysmal bone cysts (ABCs) rarely occur in the cranial bone. Surgical resection can lead to bone defects, deformities, functional abnormalities, and so on. This article describes a frontal ABC in a 73-year-old man who has a rapidly increasing swelling in the frontal bone preceded by an accidental trauma. In this case, we use percutaneous sclerotherapy with absolute alcohol under the guidance of fluoroscopy to treat the ABC instead of traditional surgical resection. When analyzed the follow-up imaging, bone reconstruction happened after using absolute alcohol. It is a feasible alternative treatment for ABC arising from the cranial bone.

Additive manufacturing (AM) technology from engineering has helped to achieve several advances in the medical field, particularly as far as fabrication of implants is concerned. The use of AM has made it possible to carry out surgical planning and simulation using a three-dimensional physical model which accurately represents the patient's anatomy. AM technology enables the production of models and implants directly from a 3D virtual model, facilitating surgical procedures and reducing risks. Furthermore, AM has been used to produce implants designed for individual patients in areas of medicine such as craniomaxillofacial surgery, with optimal size, shape and mechanical properties. This work presents AM technologies which were applied to design and fabricate a biomodel and customized implant for the surgical reconstruction of a large cranial defect. A series of computed tomography data was obtained and software was used to extract the cranial geometry. The protocol presented was used to create an anatomic biomodel of the bone defect for surgical planning and, finally, the design and manufacture of the patient-specific implant., (Copyright © 2014 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

The objective of this study was to investigate the diagnosis and surgical treatment of central brain herniations caused by traumatic bifrontal contusions. A total of 63 patients (45 men and 18 women; mean age of 43 years with a range from 20 to 72 years) who suffered from traumatic bifrontal contusions between January 2007 and December 2012 were inspected. The clinical and imaging results were studied for all patients, and we found that swelling of the mesencephalon and a downward shift of the bilateral red nucleus were significant signs of central brain herniation in the image of magnetic resonance imaging. All patients were given a simultaneous bilateral craniotomy for balanced decompressive surgery. The Glasgow Outcome Scale was used to monitor the patients during the follow-up period, which lasted from 6 to 52 months with a mean of 22 months. At the termination of the follow-up period, the following Glasgow Outcome Scale scores were obtained: 14 patients scored 5 points, 22 patients scored 4 points, 7 patients scored 3 points, 13 patients scored 2 points, and 7 patients scored 1 point. Therefore, our study suggested that an early magnetic resonance imaging scan could result in a more timely diagnosis of central brain herniation, and simultaneous bilateral craniotomy was found to be one of the best treatments for central brain herniation to improve patient outcomes.

The reconstruction of calvarial defect is a challenging treat for any craniofacial surgeon. The split calvarial bone graft reconstruction is a well-described method of reconstruction and gives very good results. Here, we present a 14-year-old girl who presented with a frontal cranial bone defect with a size of 5 × 3 cm for which the reconstruction was done with a split calvarial bone graft taken from the parietal bone. The method of reconstruction resembled keeping a lid of a jar, and we named this procedure lid cranioplasty. We were able to come out with very good cosmetic and functional outcome.

The aim of this retrospective study was to evaluate the epidemiology, treatment, and complications of frontal bone fractures associated, or not, with other facial fractures. This evaluation also sought to minimize the influence of the surgeon's skills and the preference for any rigid internal fixation system. The files from 3758 patients who attended the Oral and Maxillofacial Surgery Department of the School of Dentistry of Ribeirao Preto, University of Sao Paulo, from March 2004 to November 2011 and presented with facial trauma were scanned, and 52 files were chosen for the review. Eleven (21.15%) of these patients had pure fractures of the frontal bone, and trauma incidence was more prevalent in men (92.3%), whites (61.53%), and adults (50%). Despite the use of helmets at the moment of the trauma, motorcycle crashes were the most common etiological factor (32.69%). Fracture of the anterior wall of the frontal sinus with displacement was the main injury observed (54.9%), and the most common treatment was internal fixation with a plate and screws (45.09%). Postoperative complications were observed in 35.29% of the cases. The therapy applied was effective in handling this type of fracture, and the success rate was comparable to that reported in other published studies.

Object: Head trauma is a common cause of morbidity and mortality in the pediatric population and often results in a skull fracture. Pediatric skull fractures are distinct from adult fractures. Pediatric fractures have a greater capacity to remodel, but the pediatric brain and craniofacial skeleton are still developing. Although pediatric head trauma has been extensively studied, there is sparse literature regarding skull fractures. The authors' aim was to investigate the characteristics, injuries, complications, and outcomes of the patients in whom surgical intervention was needed for skull fractures., Methods: The authors performed a retrospective review of patients presenting to the emergency department of a pediatric Level I trauma center between 2000 and 2005 with skull fractures. Patient demographics, mechanism of injury, associated injuries, fracture bone involvement, surgical intervention, complications, and outcomes were analyzed. Groups treated nonoperatively, for skull fracture repair, and for traumatic brain injury were compared., Results: A total of 897 patients with a skull fracture were analyzed. Most patients (n = 772, 86.1%) were treated nonoperatively (Non-Op group). Fifty-eight patients (6.5%) underwent repair of the fracture (Repair group) and 67 (7.5%) required intervention for treatment of traumatic brain injury (TBI group). The Non-Op group was significantly younger, and the TBI group had a lower initial Glasgow Coma Scale (GCS) score. A fall (51.2%) was the most common mechanism of injury in the Non-Op group, whereas a motor vehicle crash (23.9%) and being hit in the head with an object (48.2%) were most prevalent in the TBI and Repair groups, respectively. Associated injuries were seen in all 3 groups, with brain injury (hematoma) being the most common. Frontal bone fracture was seen most in the Repair and TBI groups, and the parietal bone was the most frequent bone fractured in the Non-Op group. Patients in the TBI group were much more likely to have 2 or 3 skull bones fractured. In the Repair group, 36.2% had a complication (38.0% intervention related and 62.0% trauma related), but no patient had a worsening of their neurological status. In the TBI group, 48.7% of the patients suffered a complication, the vast majority (90.6%) of which were related to the trauma., Conclusions: The majority of pediatric skull fractures can be managed conservatively. Of those requiring surgical intervention, fewer than half of the surgeries are performed solely for skull fracture repair only. Patients hit in the head with an object or involved in a motor vehicle crash are more likely to need surgical intervention either to repair the skull fracture or for TBI management, respectively. Frontal bone fractures are more likely to necessitate repair, and those patients treated for TBI have a greater incidence of 2 or 3 bones involved in the fracture. Complications occurred but most were related to underlying trauma, not the surgery. No patients who underwent intervention for repair of their skull fracture only had a worsening of their neurological status.

The management of frontal bone injury is an important issue, and inappropriate management of such injuries may give rise to serious complications. Piezosurgery is a technique used to perform safe and effective osteotomies using piezoelectric ultrasonic vibrations. This instrument allows a safe method for osteotomy of the cranial vault in close proximity to extremely injury-sensitive tissue such as the brain. After a wide review of the literature, the authors present this technical report, introduce the use of piezosurgery to perform a safe "slim-osteotomies" for treatment of posttraumatic frontal bone deformities, and suggest the use of this instrument for aesthetic recontouring of the craniofacial skeleton.

A 13-year-old cob mare was presented with exophthalmos and periocular swelling of the left eye. The diagnostic work-up included ocular ultrasound, sonographic examination through the thinned frontal bone, radiography, standing computed tomography of the skull and exploratory osteoplastic surgery. Histopathology was consistent with an organized hematoma. An intradiploic hematoma of the frontal bone was diagnosed 5 years after head trauma, with progressive expansion and deformation of the skull resulting in exophthalmos. Exophthalmos with facial bone deformation was the only clinical finding of intradiploic hematoma. Standing computed tomography (CT) aided the diagnosis to differentiate intradiploic hematoma from other, more common causes of facial bone distortion associated with paranasal sinus diseases. Intradiploic hematoma of possible traumatic origin is a differential diagnosis for sinonasal disease and exophthalmos in the horse., (© 2013 American College of Veterinary Ophthalmologists.)

Fractures of the orbitozygomatic complex are one of the most common facial fractures encountered by plastic surgeons. Many would consider this to be primarily a cosmetic deformity; however, these injuries can be associated with acute life-threatening complications. Intracranial pseudoaneurysm, although rare, is a well-documented complication of blunt facial trauma, which most plastic surgeons are unaware of. We present the case of a 20-year-old woman who developed an intracranial pseudoaneurysm after blunt facial trauma to illustrate the importance of (1) understanding this rare but highly morbid complication, (2) assessing high-risk patients for pseudoaneurysm, and (3) delaying reconstruction in high-risk patients.

Object: Promising clinical results were reported in watertight closure of anterior skull base defects (ASBDs) with bisphenol-a-glycidyl-dimethacrylate (bis-GMA)-based materials to prevent the cerebrospinal fluid leaks. However, interrelation of these materials with surrounding bones in histologic level, referred to as the osteointegration, has not been reported in the anterior skull base. In addition, an illustrative case with an ASBD that was repaired using a bis-GMA composite has been presented., Methods: Twenty New Zealand rabbits were divided into 4 groups: control and sham groups consisted of 2 and 6 rabbits, respectively. The "skull base defect" group (n = 6) underwent a unifrontal craniectomy and an iatrogenic ASBD followed by creating a dural defect to obtain a cerebrospinal fluid leak. Similar bony and dural defects were acquired in the "repair with bis-GMA based allograft" group (n = 6), but the bony defect was closed with bis-GMA-based allograft., Results: All animals in the "skull base defect" group died in 3 weeks after surgery. There were no animal losses in the "repair with bis-GMA based allograft" group at the sixth month. Histologic evaluation revealed complete osteointegration of bis-GMA composite with surrounding bones., Conclusions: bis-GMA based allograft achieved a watertight repair of the ASBD. Histologic findings of this study showed that bis-GMA composite is a reliable material to be used in the closure of anterior skull base bony defects.

Objective: The aim of this study was to develop and test the utility of a novel systematic protocol to analyze CT images of patients with trauma in the anterior cranial base and upper midface., Material and Methods: The radiological data and primary reports of 27 consecutive patients with a frontal skull base fracture treated in two tertiary care hospitals from 2007 to 2011 were scrutinized. A novel algorithm for systematic image reviewing was used to assess the CT images and the findings were compared with the primary radiological reports., Results: The systematic review detected a substantial number of fractures and defects in anatomical structures that had not been systematically reported in the primary, on-call reports. Anterior skull base fracture was not initially reported in 32% of the patients; however, the algorithm detected this in 93% of them. The corresponding rates for fracture through cribriform plate were 28% and 72% and for fracture through the sella or hypophyseal area 22% and 78%. There were two fractures of the clivus and these were initially missed., Conclusions: Despite the failure to identify these fractures radiologically in the primary setting, all patients were still considered to have received appropriate treatment, but, the use of an image-reviewing algorithm will enhance the specificity of CT in the diagnosis of frontobasilar fractures., (Copyright © 2013 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

Reconstruction of craniofacial defects in children presents several challenges that are not encountered in the adult population. Autologous bone grafts have long been the criterion standard for repairing these defects. Recently, several new materials and techniques have expanded our arsenal of reconstructive options. In this clinical report, we describe the use of both particulate bone grafting and demineralized bone matrix together to repair craniofacial defects encountered in pediatric patients.

Temporal hollowing is most frequently an acquired defect and can be caused by a volumetric deficiency of bone, soft tissue, or both. Given high-density porous polyethylene's ease of use, customizability, long-term strength and resiliency, and successful application in other areas of the craniofacial skeleton, the authors have used it as the first-line material for reconstruction of temporal hollowing. Herein, we present 4 illustrative cases demonstrating this technique and further describe subtypes of the temporal defect with appropriate means of reconstruction. The cases were reviewed for comorbidities, intraoperative details, and the postoperative course. There were no complications, and all patients were pleased with their final result. High-density porous polyethylene is a safe, well-studied, and easily handled biomaterial that is useful for the treatment of temporal hollowing.

The purpose of this study was to compare the osteogenic potential of a synthetic and a demineralized bone matrix (DBM) putty using a cranial defect model in New Zealand white rabbits. Paired, bilateral critical-size defects (10 mm) were prepared in the frontal bones of 12 rabbits and filled with either OsteoSelect DBM Putty or NovaBone calcium-phosphosilicate putty. At days 43 and 91, 6 rabbits were killed and examined via semiquantitative histology and quantitative histomorphometry. Defects filled with the DBM putty were histologically associated with less inflammation and fibrous tissue in the defect and more new bone than the synthetic counterpart at both time points. Histomorphometric analysis revealed that the defects filled with DBM putty were associated with significantly more bone formation at day 43 (70.7% vs 40.7%, P = 0.043) and at day 91 (70.4% vs 39.9%, P = 0.0044). The amount of residual implant was similar for both test groups at each time point.