MANAGEMENT OF FRONTAL BONE FRACTURE USING CORONAL ACCESS

: Introduction: Fractures of the frontal bone originate from minor or high-intensity accidents. Various treatment modalities have been described, such as conservative treatment or osteosynthesis of the fracture. Objective: The objective of the present work is to report a surgical approach to a reduction and fixation of a panfacial fracture involving the frontal bone. In this work, coronal access was used for anatomical repositioning and reestablishment of the contour in the frontal region. No complications or sequelae were observed at approximately three months follow-up. Report: Female patient, 22 years old, was evaluated by the Oral and Maxillofacial Surgery and Traumatology team, in a reference hospital, with a history of an automobile accident, with multiple facial fractures. At the initial examination, the patient was conscious, hemodynamically stable and with all vital signs within normal limits. Computed tomography was performed, which indicated multiple fractures in the face, including in the frontal bone. In view of this, we opted for surgical treatment, which was performed through a bicoronal access, with reduction and rigid internal fixation of the multiple fractures on the face, including the frontal region, under general anesthesia, without intercurrences. Result: The aesthetic and functional reestablishment of the frontal region was obtained, maintaining the integrity of the anterior wall of the frontal sinus. Currently, the patient is four months after the operation, with resolution of the complaints, and the access site completely healed. Final considerations: Coronal access is a viable option for the aesthetic restoration of frontal sinus fractures, providing excellent intraoperative visibility and adequate healing.

Master's student in Dentistry with Concentration Area in Oral and Maxillofacial Surgery and Traumatology -São Paulo State University Júlio de Mesquita Filho -Brazil. 2 Oral and maxillofacial surgeon, Doctoral student in Dentistry with Concentration Area in Oral and Maxillofacial Surgery and Traumatology -São Paulo State University Júlio de Mesquita Filho -Brazil. 3Dental Surgeon from Universidade Brasil, Fernandópolis/SP -Brazil. 4Master's student in Dentistry with Concentration Area in Oral and Maxillofacial Surgery and Traumatology -São Paulo State University Júlio de Mesquita Filho -Brazil. 5 ABSTRACT: Introduction: Fractures of the frontal bone originate from minor or highintensity accidents.Various treatment modalities have been described, such as conservative treatment or osteosynthesis of the fracture.Objective: The objective of the present work is to report a surgical approach to a reduction and fixation of a panfacial fracture involving the frontal bone.In this work, coronal access was used for anatomical repositioning and reestablishment of the contour in the frontal region.No complications or sequelae were observed at approximately three months follow-up.Report: Female patient, 22 years old, was evaluated by the Oral and Maxillofacial Surgery and Traumatology team, in a reference hospital, with a history of an automobile accident, with multiple facial fractures.At the initial examination, the patient was conscious, hemodynamically stable and with all vital signs within normal limits.Computed tomography was performed, which indicated multiple fractures in the face, including in the frontal bone.In view of this, we opted for surgical treatment, which was performed through a bicoronal access, with reduction and rigid internal fixation of the multiple fractures on the face, including the frontal region, under general anesthesia, without intercurrences.Result: The aesthetic and functional reestablishment of the frontal region was obtained, maintaining the integrity of the anterior wall of the frontal sinus.Currently, the patient is four months after the operation, with resolution of the complaints, and the access site completely healed.Final considerations: Coronal access is a viable option for the aesthetic restoration of frontal sinus fractures, providing excellent intraoperative visibility and adequate healing.

INTRODUCTION
Le Fort III, panfacial, orbitoethmoid, and frontal sinus fractures have a 50% or greater risk of being associated with head injury, probably because they involve a wall of the cranial fossa.Depending on the intensity of the trauma, there may be injuries to the anterior and posterior wall of the frontal bone.As such, there is a frequent association with injuries in the orbit, in the central nervous system and in the frontal sinus (MORH et al., 1994).
Fractures of the frontal bone correspond to between 3-5% of facial fractures.
The frontal sinuses may be associated with these fractures, due to their thin thickness and because they are located between the internal and external laminae of the frontal bone and may involve the nasofrontal duct.(Alinasab et.Al., 2018).
The etiology of this fracture is varied and may result mainly from physical aggression and car accidents, where the average age of cases ranges from 29.1 years, with 92.3% male patients.Some complications may be associated and are easily diagnosed in the initial clinical examination, such as frontal depression, epistaxis, nasal obstruction and possible neurological alterations (Marinheiro et.Al., 2014).
Treatment ranges from conservative to surgical, depending on the displacement, patient choice and degree of functional and aesthetic impairment.Surgical treatment, when indicated, consists of fracture reduction followed by internal fixation.Due to the surgical access used, the importance of disclosing fracture treatment in this region was raised in order to disseminate a viable and safe possibility that guarantees less scarring damage to the patient.

OBJECTIVE
The objective of this work is to present a surgical approach as a way of treating fractures of the frontal bone using the coronal access.Its presentation is justified by the possibility of demonstrating the performance of this surgical intervention in this type of fracture.

METHODOLOGY
The criterion used for the bibliographical research for the construction of the text was the selection of articles from the sites of PubMed

CLINICAL CASE
A 22-year-old female patient entered the emergency department of the local hospital for evaluation by the Oral and Maxillofacial Surgery and Traumatology team after being the victim of a car accident with a collision with a fixed object.The patient was eupneic on room air, verbalizing and walking, performing normal physiological functions.On clinical examination of the face, the patient presented edema, abrasions, a step in the frontal region and no rhinolirrhea.Also, the presence of periorbital edema and ecchymosis, edema in the supraorbital and frontal regions, where during palpation despite the edema, a sinking of the area was noted, diagnosing a possible fracture.Furthermore, she confirmed the diagnosis with a face computed tomography scan, which showed, through axial, sagittal and coronal sections and three-dimensional reconstruction, the depression of the anterior wall of the frontal bone (Figure 1).Given the diagnosis, the surgical procedure was performed under general anesthesia with orotracheal intubation in a surgical center.The procedure began with trichotomy in the cranial scalp region, marking the surgical incision from the right pre-auricular region to the left pre-auricular region and degermation of the surgical area followed by local infiltrative anesthesia with 2% lidocaine and 1 epinephrine: 100,000 for hemostasis and analgesia.After fixing the field, the incision was made up to the pericranium, the flap was tensioned after using three traction points.(Figure 2) After accessing the fracture, the procedure for reducing and fixing the bone fragments with titanium plates and screws was initiated, anatomically reestablishing the region, followed by the installation of a suction drain in the frontal region (Figure 3, Figure 4).reductions and fixations of the other facial fractures, completing the surgical procedure without intercurrences.Computed tomography of the face (Figure 5) showed correct fixation and stability of the fractured bone stumps.The patient was discharged 72 hours postoperatively, with normal physiological conditions, no pain complaints and returning to the outpatient clinic for postoperative follow-up in 07 days.In surgical treatment, the incision along the coronal plane is made to expose the area affected by the fracture and allow direct access to the fractured bones.Once exposed, the bones can be realigned and fixed with surgical plates and screws to allow for proper healing.Such a procedure is aesthetically favorable for the patient, having a good postoperative prognosis, being performed by the oral and maxillofacial surgeon or in conjunction with neurosurgery (Doonquah L, Brown P, Mullings W. 2012).
It is important to emphasize that the coronal access is an invasive surgical approach and that the decision to use it should be based on the clinical evaluation of the patient and the severity of the fracture.In the case reported in this paper, good repositioning and bone fixation were obtained.Furthermore, surgery involves risks and complications, and these aspects should be discussed in detail with the oral and maxillofacial surgeon before the procedure.Only an experienced and qualified surgeon should perform coronal access surgery in cases of frontal bone fractures (Steve Chukwulebe, Christopher Hogrefe 2019).

FINAL CONSIDERATIONS
The coronal access is a viable option for the aesthetic and functional reestablishment of fractures in frontal regions, providing excellent intraoperative Oral and maxillofacial surgeon, Doctoral student in Dentistry with Concentration Area in Oral and Maxillofacial Surgery and Traumatology -São Paulo State University Júlio de Mesquita Filho -Brazil 6 PhD in Dentistry with Concentration in Implant Dentistry, Doctoral student in Dentistry with Concentration Area in Oral and Maxillofacial Surgery and Traumatology -São Paulo State University Júlio de Mesquita Filho Brazil. 7Oral and Maxillofacial Surgeon, Professor of the Department of Surgery and Diagnosis São Paulo State University Júlio de Mesquita Filho -Brazil. 8Oral and Maxillofacial Surgeon, Professor of the Department of Surgery and Diagnosis São Paulo State University Júlio de Mesquita Filho -Brazil.
Fracture reduction consists of repositioning the bone stumps, restoring anatomical and functional integrity, and may use titanium plates/screws and/or titanium mesh and/or biomaterials for filling in cases of advanced bone loss to ensure fixation.In most cases, frontal bone fractures are accompanied by multiple fractures on the face from polytraumatized patients, where the multidisciplinary interaction between neurosurgery and buco-maxillofacial teams is paramount for better planning and surgical execution(Pires et.Al., 2018; Stevens M, Kline SN, 1995; Doonquah L, Brown P, Mullings W. 2012).

(
http://www.ncbi.nlm.nih.gov/pubmed),Revista decirurgia e Traumatologia Bucomaxilifacial, Journal of Oral and Maxillofacial Surgery, Archives of Otolaryngology Head and Neck Surgery and Journal of Neurosurgery.With the selection of articles, reading and analysis were carried out to assemble the work.The articles used were those that presented issues related to fractures of the frontal region, such as anatomy, etiology, signs and symptoms, imaging tests, surgical access, and complications.

Figure 1 -
Figure 1 -Computed tomography of the face in three-dimensional reconstruction showing multiple fractures, including a frontal bone fracture.

Figure 2 -
Figure 2 -Trichothymia, marking of the surgical incision from the right pre-auricular region to the left pre-auricular region, degermation of the surgical area.

Figure 3 -
Figure 3-Exposure of the frontal bone fracture.

Figure 4 -
Figure 4-Procedure for reduction and fixation of bone fragments with titanium plates and screws, anatomically restoring the region.

Figure 5 -
Figure 5-3D Reconstruction from Computed Tomography of the postoperative reduction and fixation of frontal bone fractures and other fractures in the maxillofacial region.