**8. Anterior table fracture**

A displaced fracture of the anterior table is the most common type of frontal sinus injury [15] which leaves a contour deformity of the forehead. Anterior table fractures involving the nasalorbital-ethmoidal area or supraorbital rim have a 25% to 50% incidence of nasofrontal duct involvement [16-19]. In general, operative exposure of an anterior table fracture should also include an intraoperative examination of the nasofrontal duct to evaluate for injury. Exposure is best achieved by using a bicoronal incision (Figure 3).

Once the coronal incision has been made and the anterior table exposed, sinusotomy must be planned. One prong of a bayonet forceps is placed inside the sinus to the maximum peripheral extent. The corresponding prong then reflects its position on the external surface of the outer table. A number 701 burr in a high-speed drill marks the perimeter adjacent to the bayonet forceps. After sinus marking is complete, the osteotomy is accomplished using either a drill or oscillating saw [20]. Once the frontal sinus has been entered, cultures are taken of any fluids encountered. At this point, nasofrontal duct patency can be evaluated with the placement of either fluorescein or methylene blue proximally at the ostium located medially at the sinus floor. If there is no evidence of nasofrontal duct obstruction, the fracture fragments should be reduced and fixated (Figure 4).

The severely comminuted anterior table is best repaired with a precontoured plate (Figure 5). If there is significant comminution of the anterior table with bone loss, split calvarial graft is the material of choice to address defects of the anterior table (Figure 6).The use of synthetic

**Figure 3.** The frontal sinus fracture is approached via bicoronal incision 

**Right: The fracture fragments are reduced and fixated by plates. Below: The postoperative radiograph of the patient. Figure 4.** Left: Depressed fracture of the anterior table of the frontal sinus. Right: The fracture fragments are reduced and fixated by plates. Below: The postoperative radiograph of the patient.

The severely comminuted anterior table is best repaired with a precontoured plate (**Figure 5**). If there is significant comminution of the anterior table with bone loss, split calvarial graft is the material of choice to address defects of the anterior table (**Figure 6**).The use of synthetic materials, such as methyl methacrylate or even hydroxyapatite cements, is to be discouraged because of the risk of infection

**Figure 4. Left: Depressed fracture of the anterior table of the frontal sinus.**

secondary to communication with the sinus floor [21].

materials, such as methyl methacrylate or even hydroxyapatite cements, is to be discouraged because of the risk of infection secondary to communication with the sinus floor [21].

**Figure 5.** The severely comminuted anterior table is repaired with a titanium mesh

**Figure 3.** The frontal sinus fracture is approached via bicoronal incision 

476 A Textbook of Advanced Oral and Maxillofacial Surgery Volume 2

**Figure 4. Left: Depressed fracture of the anterior table of the frontal sinus. Right: The fracture fragments are reduced and fixated by plates. Below: The postoperative radiograph of the patient.**

secondary to communication with the sinus floor [21].

and fixated by plates. Below: The postoperative radiograph of the patient.

The severely comminuted anterior table is best repaired with a precontoured plate (**Figure 5**). If there is significant comminution of the anterior table with bone loss, split calvarial graft is the material of choice to address defects of the anterior table (**Figure 6**).The use of synthetic materials, such as methyl methacrylate or even hydroxyapatite cements, is to be discouraged because of the risk of infection

**Figure 4.** Left: Depressed fracture of the anterior table of the frontal sinus. Right: The fracture fragments are reduced

**Figure 6.** Split calvarial graft can be used for the repair of the severely comminuted anterior table
