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British Journal of Oral and Maxillofacial Surgery xxx (2020) xxx–xxx

Technical note
Reverse umbrella technique – percutaneous reduction of
frontal bone fracture using an intermaxillary fixation screw
device
K. Maharaj ∗ , W. Wakeford, A. Majumdar
Luton and Dunstable University Hospital, United Kingdom

Accepted 21 July 2020

Keywords: Frontal bone; Percutaneous reduction; IMF screw

Fractures of the frontal sinus account for approximately

5%–15% of all maxillofacial fractures with a slight male
preponderance.1 The standard management involves an
access coronal flap for open reduction and internal fixation,
but this has some unwanted risks such as scar, alopecia,
paraesthesia, and facial nerve weakness.2 We report a safe
and effective percutaneous technique for closed reduction
of a non-comminuted isolated anterior table fracture of the
frontal sinus with the use of intermaxillary fixation (IMF)
screws under image intensifier guidance.
An image intensifier, if available in theatre, helps with
safe placement of the IMF screw and evaluating the satisfac-
tory reduction of the fracture. At the start of the operation
with the patient under general anaesthesia, the surface defect
is marked along with the proposed site for insertion of the
IMF screw. A combination of 2% lignocaine and 1:80,000
adrenaline is infiltrated at the proposed insertion site. A small
stab incision approximately 2 mm in length is made on the
skin, over the point of introduction of the IMF screw, with
minimal soft tissue stripping. A 1.2 craniofacial drill is used
to drill a hole for introducing the IMF screw. Although the
IMF screw is self-tapping we recommend using the twist drill
as it allows insertion of the IMF screw with minimal force. Fig. 1. Image intensifier view in theatre with IMF screw confirming satis-
factory reduction.

The IMF screw is then inserted into position, perpen-

∗ Corresponding author at: Oral and Maxillofacial Surgery Department,
dicular to the bony fragment. The screw is assessed with
Luton and Dunstable University Hospital, Lewsey Rd, Luton LU4 0DZ,
the image intensifier to make sure the position is satisfac-
United Kingdom. Tel.: +44 7958156125. tory, and then a wire is threaded through the holes in the
E-mail address: k.maharaj@nhs.net (K. Maharaj). screw head, twisted, and secured. A gentle outward traction
https://doi.org/10.1016/j.bjoms.2020.07.023
0266-4356/Crown Copyright © 2020 Published by Elsevier Ltd on behalf of The British Association of Oral and Maxillofacial Surgeons. All rights reserved.

Please cite this article in press as: Maharaj K, et al. Reverse umbrella technique – percutaneous reduction of frontal bone fracture using
an intermaxillary fixation screw device. Br J Oral Maxillofac Surg (2020), https://doi.org/10.1016/j.bjoms.2020.07.023
YBJOM-6132; No. of Pages 2
ARTICLE IN PRESS
2 K. Maharaj et al. / British Journal of Oral and Maxillofacial Surgery xxx (2020) xxx–xxx

Fig. 2. Preoperative and postoperative lateral frontal bone views showing reduction.

is applied on the wire with a pair of wire twisting forceps,
on a trajectory that is perpendicular to the fragments. The
surgeon will feel the fragments elevating and the fracture
reducing from the periphery of the defect, at which time the
contour is re-established, which is confirmed by the image
intensifier (Fig. 1). This is similar to the closing action of an
upside-down umbrella, allowing the fracture to be splinted by
periosteum and soft tissue (Fig. 2). Once satisfactory reduc-
tion is confirmed, the IMF screw is removed in the usual
manner and the stab incision is closed.
Although this technique has been described before, via
a transcutaneous approach using titanium bone screws,2–4
this is to our knowledge the first reported use of stainless
steel IMF screws and an image intensifier intraoperatively.
The choice of IMF screws depends upon their design and
easy availability. IMF screws are self-tapping, self-drilling,
tapered, and have a pitch distance of 0.7 mm,5 which allows
them to engage the bone and secure their position without
slipping. The head has holes that will allow wires to be passed
through to prevent slippage during traction forces, which also
allows a greater degree of control during elevation.
We have used this technique successfully in young
patients within 10 days of them sustaining a localised non-
comminuted fracture of the anterior table of the frontal sinus
from a low impact injury. We do, however, always discuss and
consent for open approaches with the patient or guardians in
cases of failed reduction.
Conflict of interests
We have no conflicts of interest.
Ethics statement/confirmation of patients’ permission
Ethics approval was not required. We have obtained the
patient’s permission to publish the radiographic images.
References
1. Gerbino G, Roccia F, Benech A, et al. Analysis of 158 frontal sinus frac-
tures: current surgical management and complications. J Craniomaxillofac
Surg 2000;28:133–9.
2. Yoo A, Eun SC, Baek RM. Transcutaneous reduction of frontal sinus
fracture using bony tapper device. J Craniofac Surg 2012;23:1835–7.
3. Mavili ME, Canter HI. Closed treatment of frontal sinus fracture with
percutaneous screw reduction. J Craniofac Surg 2007;18:415–9.
4. Spinelli G, Lazzeri D, Arcuri F, et al. Closed reduction of the isolated
anterior frontal sinus fracture via percutaneous screw placement. Int J Oral
Maxillofac Surg 2015;44:79–82.
5. Cornelius CP, Ehrenfeld M. The use of MMF screws: surgical technique,
indications, contraindications, and common problems in review of the
literature. Craniomaxillofac Trauma Reconstr 2010;3:55–80.

Please cite this article in press as: Maharaj K, et al. Reverse umbrella technique – percutaneous reduction of frontal bone fracture using
an intermaxillary fixation screw device. Br J Oral Maxillofac Surg (2020), https://doi.org/10.1016/j.bjoms.2020.07.023