Case Report - Trauma

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

Abstract
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

Introduction with a laceration wound measuring approximately

5 cm × 3 cm in the left forehead region running parallel to
The frontal bone is the most frequently fractured cranial
the eyebrow [Figure 1], which was debrided immediately
bone in craniofacial trauma patients and accounts for 37%
and sutured to control bleeding. Diffuse edema of the left
of cranial fractures. In maxillary fractures, isolated Le Fort
upper and middle third of the face was evident along with
I fractures have significant association with frontal bone
circumorbital edema and subconjunctival hemorrhage of
fracture.[1] The frontal bone consists of three parts, the
the left eye. The patient’s mouth opening was adequate
squamous part which is the largest and forms majority of the
with bilaterally stable occlusion. Assessment of the
forehead, supraorbital margins and the superciliary arch.
computed tomography [Figure 2] revealed an incomplete
The frontal bone is more protected from traumatic events
and undisplaced Le Fort I fracture and a left frontal bone
due to the prominence of the nasal pyramid which protects
fracture which was approximately 3 cm × 2.5 cm × 1 cm.
the naso‑orbital region as well. The frontal bone also has a
The frontal bone fracture involved both the cortices without
higher resistance to mechanical impacts. The frontal bone
involvement of the frontal sinus, and there was no evidence
can withstand 800–1600 pounds of force,[2] thus conferring
of dural tear as discussed with the neurosurgical team. The
resistance against most forms of traumatic injury. Motor
patient was observed for any neurosurgical deficit and
vehicle accidents are the most common cause followed by
was found to be devoid of the same. Since the patient’s
assaults and sports‑related injuries.
mouth opening was adequate, occlusion was stable with

Case Report Address for correspondence: Dr. Jessica Yolanda Jeevitha,

A 25‑year‑old male reported to the hospital with an Department of Oral and Maxillofacial Surgery, Chettinad Dental
alleged history of road traffic accident and history of College and Research Institute, Kancheepuram, Tamil Nadu, India.
loss of consciousness and nasal bleed. The patient was E‑mail: jessicayolandaa@gmail.com
conscious, stable, and oriented. The patient presented
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DOI: How to cite this article: Meyyappan A, Jagdish E, Jeevitha JY. Bone
10.4103/ams.ams_155_19 cements in depressed frontal bone fractures. Ann Maxillofac Surg
2019;9:407-10.

© 2019 Annals of Maxillofacial Surgery | Published by Wolters Kluwer - Medknow 407

 Meyyappan, et al.: Bone cements in frontal bone fractures
Figure 1: Preoperative presentation of the patient
a b
c 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
a b
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
408
Figure 2: Computed tomography revealing left frontal bone fracture and
Lefort I fracture
Figure 4: Postoperative frontal view of the patient depicting bilateral
symmetry of the frontal bone
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.
The existing laceration was utilized to approach the fracture
site [Figure 3a]. The fracture site was exposed [Figure 3b] and
isolated. A calcium phosphate‑based cement[3] (HydroSet™)
which is a synthetic bone graft substitute was used in the
reconstruction of the depressed frontal bone fracture. The
bone cement [Figure 3c] 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 3d].
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
Annals of Maxillofacial Surgery  ¦  Volume 9  ¦  Issue 2  ¦  July-December 2019
 Meyyappan, et al.: Bone cements in frontal bone fractures
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)
adaptation and contour of the bone cement placed over the
defect.
Discussion
The frontal bone fracture is classified as follows[4] [Figure 6]:
• 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]:
• 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
Annals of Maxillofacial Surgery  ¦  Volume 9 ¦ Issue 2 ¦ July-December 2019
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)
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,[5] subbrow approach,[6]
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.[7]
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 [8] . 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.[9]
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.[10]
An alternative to autogenous grafts and methyl methacrylate
is the hydroxyapatite, which is of two generations: the ceramic
409
 Meyyappan, et al.: Bone cements in frontal bone fractures
and nonceramic.[11] 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.[9] 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.[3]
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
410 Annals of Maxillofacial Surgery  ¦  Volume 9  ¦  Issue 2  ¦  July-December 2019
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
Nil.
Conflicts of interest
There are no conflicts of interest.
References
1. Pappachan B, Alexander M. Correlating facial fractures and cranial
injuries. J Oral Maxillofac Surg 2006;64:1023‑9.
2. Jing XL, Luce E. Frontal sinus fractures: Management and complications.
Craniomaxillofac Trauma Reconstr 2019;12:241‑8.
3. Hannink G, Wolke JG, Schreurs BW, Buma P. In vivo behavior of a
novel injectable calcium phosphate cement compared with two other
commercially available calcium phosphate cements. J Biomed Mater
Res B Appl Biomater 2008;85:478‑88.
4. Garg  RK, Afifi AM, Gassner  J, Hartman  MJ, Leverson  G, King  TW,
et al. A  novel classification of frontal bone fractures: The prognostic
significance of vertical fracture trajectory and skull base extension.
J Plast Reconstr Aesthet Surg 2015;68:645‑53.
5. Gullane PJ, Gilbert RW. Approach to naso-frontal-ethmoidal complex
fractures. The Journal of Otolaryngology 1985;14:132-5.
6. Lee Y, Choi HG, Shin DH, Uhm KI, Kim SH, Kim CK, et al. Subbrow
approach as a minimally invasive reduction technique in the management
of frontal sinus fractures. Arch Plast Surg 2014;41:679‑85.
7. Edwards  MS, Ousterhout  DK. Autogeneic skull bone grafts to
reconstruct large or complex skull defects in children and adolescents.
Neurosurgery 1987;20:273‑80.
8. Nickell WB, Jurkiewicz MJ, Salyer KE. Repair of skull defects with
autogenous bone. Arch Surg 1972;105:431‑3.
9. Chen TM, Wang HJ, Chen SL, Lin FH. Reconstruction of post‑traumatic
frontal‑bone depression using hydroxyapatite cement. Ann Plast Surg
2004;52:303‑8.
10. Greene AK, Warren SM, McCarthy JG. Onlay frontal cranioplasty
using wire reinforced methyl methacrylate. J Craniomaxillofac Surg
2008;36:138‑42.
11. Schmitz JP, Hollinger JO, Milam SB. Reconstruction of bone using
calcium phosphate bone cements: A critical review. J Oral Maxillofac
Surg 1999;57:1122‑6.