The fracture must be irrigated to eliminate debris and possible foreign material. The brain may be exposed with a frontal sinus fracture. Therefore irrigation should be performed away from the brain.
When a fracture is depressed, one or two periosteal elevators are placed underneath the fragment and the whole fracture complex is elevated to restore the normal anatomical contour.
If a bone fragment is dislodged into the frontal sinus or devitalized, it should be removed to avoid the formation of a sequestrum.
Plate selection and preparation
One or more low-profile titanium 2mm non-locking miniplates are contoured using specially designed miniplate bending pliers, and adapted to the desired anatomical site. This allows for accurate repositioning and reconstruction of the frontonasal area. The length of the plate should allow for at least two screws on each side of the fracture. Three screws per fracture fragment (six cortices) are ideal.
The plates are applied spanning the frontonasal fracture margins. An adequate number of plates should be applied to provide stability to the fractured segment.
The length of the screws is determined by using CT measurements of the bone thickness...
… and a depth gauge.
As a general guide, the sequence of plate placement is initiated from reconstruction and fixation of the facial region buttresses to serve as a base for other fragments to be secured. If a buttress is unavailable, the fragments are fixed to any surrounding stable bone. For more information see "General considerations".
The soft tissues are closed routinely in two layers. A Stent bandage is secured in place for 72 hours in order to minimize postoperative swelling and emphysema.
7. Case example
8-month old Golden Retriever with a comminuted frontonasal fracture in addition to multiple maxillofacial fractures and TMJ luxation, from falling from a moving vehicle.
The dorsal midline approach was used to expos the fractures; loose and devitalized bone was removed from the frontal sinus.
The fractures were anatomically reduced and stabilized with four 2.0mm non-locking titanium miniplates.
Following routine closure, a Stent bandage was applied for 72 hours.
A composite temporization material was applied covering the canine teeth forming two pillars for the maxillofacial and TMJ injuries.
The dog should be kept on soft food for one or two weeks after surgery.
Intraoperative intravenous administration and then oral antibiotics for one to two weeks is recommended. Antibiotics used should have an excellent oral cavity penetration and spectrum. Example: ampicillin at 20 mg/kg intravenous antibiotics followed by oral antibiotics amoxicillin/clavulanic acid at 15-20 mg/kg orally twice daily.
Pain medication, such as opioids and non-steroidal anti-inflammatory medications, are used for 7-14 days.
If the fracture involved the oral cavity, oral rinse with 0.05-0.12% chlorhexidine gluconate solution is recommended (not for maxillomandibular fixation).
Recheck is recommended in 10-14 days and at three and six months post-surgery.
If there are any signs of complications (i.e. purulent nasal discharge), CT and rhinoscopy are indicated.
Typically, titanium miniplates and screws are osseointegrated. If there is no implant failure or infection, there is no need for implant removal.