Definition & Overview
Open and closed treatments of craniofacial separation refer to two methods used to treat severe fractures of the craniofacial bone, which usually occurs due to midface trauma or injury. Open treatment is performed through open surgery wherein the skin is incised to gain access to the fractured bone and repair it manually through internal fixation and bone grafting. Closed treatment, on the other hand, is a non-invasive alternative that repairs the fractures using a variety of techniques and devices. This option does not require an incision and is less risky than open surgery. Nevertheless, both procedures are still widely used today due to the individualised nature of craniofacial separation treatment.
Who Should Undergo and Expected Results
Open or closed treatment of craniofacial separation is necessary for patients who suffer from severe fractures of the craniofacial bone. The word “craniofacial” refers to the area encompassing the upper portion of the skull and the entire facial structure.
Craniofacial separation is another term that refers to a Le Fort III fracture, the third classification of facial fractures. The classifications, which were developed by Rene Le Fort in 1901, are as follows:
- Le Fort I – A fracture that runs across the maxilla or the upper jaw
- Le Fort II – A pyramid-shaped fracture that breaks through the cheekbone just below the eye socket and runs across the nasal bridge
- Le Fort III – A severe fracture wherein the frontal bone behind the forehead separates from the cheekbone. This kind of injury crosses the lateral and medial orbits and extends all the way to the nasofrontal junction, causing the nasal bridge to break.
A Le Fort III fracture is also called craniofacial separation because the craniofacial bone totally separates in a tripod pattern. This causes the nose and the dental arch to become mobile.
The treatment of craniofacial separation (and other craniofacial injuries) is an individualised process. The ideal treatment procedure depends on the extent and location of the injury. Thus, while some patients can be treated using closed or minimally invasive techniques, some patients require open surgery.
How is the Procedure Performed?
In many cases of craniofacial separation (and other craniofacial fractures), the treatment is delayed to get the patient out of immediate danger. Part of doing so is to ensure that the patient is able to breathe properly. Airway management is usually the first step since this type of injury usually also affects the nasal septum.
It is important to ensure that the patient is in stable condition before undergoing open/closed treatment with reconstruction as it is performed under general anaesthesia.
In open treatment of craniofacial separation, the surgeon first creates an incision to access the fractured bone. He then performs open reduction and internal fixation by suspending the facial bones from a frontal bar, or the thickened frontal bone above the frontonasal structures. The facial bones are fixed in place using titanium plates and screws. With the bones in full view, the surgeon then fixes each individual fracture. He begins with fractures relating to the frontal bar then moves on to the inferior fractures. He then works on the vertical and horizontal maxillary buttresses before moving to the orbital fractures. After the procedure, all incisions are closed.
In closed treatment of craniofacial separation, doctors use various devices to set the fractured bone right and manipulate it into its proper place so it can heal properly as it begins to regenerate. These devices include an interdental wiring and a splint.
Possible Risks and Complications
There are a lot of risks and potential complications involved in a craniofacial separation and its treatment, whether open or closed.
A large percentage of Le Fort III fractures affect the patient’s vision in some way. These fractures also cause airway obstruction. Also, impact or trauma that causes severe craniofacial separation are often accompanied by other injuries, which need to be treated first to make sure the patient is out of immediate danger.
Open treatment puts the patient at risk of common complications associated with open surgery. These include:
- Allergic reaction to anaesthesia
Closed treatment using interdental wiring puts the patient at risk of adverse effects on surrounding structures. These may include the jaw and teeth.
Studies show that interdental wiring can cause:
- Temporary increased mobility
- Progressive caries
- Loss of tooth sensitivity
These complications, however, are quite uncommon, and tend to go away once the interdental wiring is removed.
Ghabach MB, Rouphael MAA, Roumoulian CE, Helou MR. “Airway management in a patient with Le Fort III fracture.” Saudi J Anaesth. 2014 Jan-Mar; 8(1): 128-130. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3950437/
Thor A, Andersson L. “Interdental wiring in jaw fractures: effects on teeth and surrounding tissues after a one-year follow-up.” Br J Oral Maxillofac Surg. 2001 Oct; 39(5): 398-401. https://www.ncbi.nlm.nih.gov/pubmed/11601824