Craniofacial Microsomia

Babies with very small jaws may have breathing problems. If this is the case for your baby, your doctors will discuss the options to manage and correct the cause.

Examples are:

• Ways to help position your baby so they can breathe more easily
• Surgery to lengthen the jaw and move it forward
• For severe breathing problems, placing a breathing tube in the windpipe (tracheostomy

Sometimes children have trouble breathing while they sleep (obstructive sleep apnea). Over time, this may lead to problems with how the heart and lungs work. It also can contribute to problems with learning and behavior.

We will ask questions during clinic visits to assess if breathing is a problem for your child. To better understand their breathing patterns, we may monitor your child overnight in our sleep lab (PDF) (Arabic) (Simplified Chinese) (Somali) (Spanish) (Vietnamese).

The treatment options and timing will depend on your child.

Some babies with CFM have 1 of these conditions, which may affect their feeding:

• Small jaw
• Cleft lip
• An opening in the roof of their mouth (cleft palate)
• Cleft in the side of the mouth (macrostomia)

Your baby may not be able to breastfeed or use regular bottles. We help you with feeding techniques during infancy.

We will check regularly to make sure that your baby is gaining weight. A dietitian may see you in the clinic to help with your child’s diet.

If your baby has a cleft lip or palate, our surgeon will talk with you about repairing it.

• Cleft lip surgery usually takes place when a baby is 3 to 4 months old.
• Cleft palate surgery usually happens at about 1 year.

See Cleft Lip and Palate Treatments.

At least half of children with craniofacial microsomia have hearing loss. There may be:

• Ear canals that are missing or very narrow
• Problems with the 3 bones in the middle ear that transmit sound
• Problems with the inner ear
• Nerve or brain processing delays related to hearing

Most often, your baby’s hearing is screened in the hospital soon after birth or within a few days.

If problems are found, we do further testing. A specialist trained to test hearing in infants and children (audiologist) will perform the tests.

As your child grows, they will have a variety of hearing tests based on their hearing status and ear health.

Our ear, nose and throat specialist (otolaryngologist) and audiologist will talk with you and your child about hearing management. This includes:

• Whether hearing aids are needed
• How to prevent further hearing loss
• The best place to sit in the classroom when your child reaches school age

The small size of the outer ear may make it hard for your child to wear hearing aids. One option might be bone-anchored hearing aids that are attached with a tiny screw.

Your child may need a CT (computed tomography) scan to examine their middle and inner ear. We do this when your child is about 5 years old. At that age, the ear is almost fully grown. CT scans help doctors decide if surgery to restore hearing is likely to be successful.

Many children with craniofacial microsomia have ears that are small, unusually shaped or missing. This is called microtia. Our Otolaryngology programis 1of the few in the country to offer comprehensive treatmentfor microtia. Our team is skilled at rebuilding ears using manmade (alloplastic) materials or cartilage from the ribs (autologous).Our options also include a removable prosthetic ear. Read more about microtia treatment.

With CFM, facial differences range from mild to severe. We tailor treatment to your child’s and family’s needs.

Surgery to repair a cleft of the mouth

Some children with CFM have a cleft along the corner of the mouth. Muscles around their mouth are separated. This causes an abnormally wide mouth (macrostomia) that can make it hard to feed and form sounds for speech.

This can be fixed by surgery that makes a complete ring of muscle around your child’s mouth.

• Surgeons carefully cut into the skin, the muscle and the tissue inside the mouth.
• They use a small zigzag incision. This helps to hide any scars.
• Surgeons use nearby muscles to form a complete ring of muscle around your child’s mouth.
• They also bring the corners of the mouth closer together. This gives the mouth a more normal shape and function.

Facial reanimation for palsy

Some children with CFM have weakness or trouble with movement in the face. This is called facial palsy. It happens because the nerves in the face are not working right.

Often, facial palsy improves in the first few years of life.

If your child has severe problems with facial movement, your child’s team will include specialists from our Facial Reanimation Clinic. They will determine if surgery is likely to improve your child’s facial movement.

Options to improve facial symmetry

In about 65% of people with CFM there are differences in how the 2 sides of their face look (facial asymmetry).

The differences may be reduced by certain surgeries your child may have — such as those that correct problems with the mouth or jaw or improve movement in the face.

If you or your child has concerns about how their face looks, talk to your child’s team. The treatment options depend on your child’s age. They range from counseling to surgery.

Skin tags

Some children with CFM have skin tags, most often in front of their ears. Skin tags are tiny extra pieces of skin. They may have a small narrow stalk connecting the skin bump to the surface of the skin, or they may be attached deeper below the skin. They are painless.

If your child has skin tags, your team will talk with you about whether to remove them.

Many children with CFM have a small lower jawbone. This can cause problems with breathing.

Your child’s teeth may not fit together well. Some children also have an undersized upper jaw.

A dentist or orthodontist will look to see if your child’s teeth are too crowded or if they are missing some teeth. The orthodontist also checks how well the upper and lower jaws fit together.

Starting at about 6 years, we will talk with you about the best treatment and timing for your child.

• Some children may need a dental appliance or braces for the best dental function and appearance. Most often this happens when your child is a teenager. Some children may need this sooner.
• Orthodontics might be done alone or in combination with surgery, depending on your child’s needs.
• When facial and jaw growth is nearly complete (age 13 to 16 years), many children with CFM will need orthodontics to properly align their teeth.

Learn more about craniofacial orthodontics.

Enlarging the jaw

Many children with a small jaw benefit from jaw lengthening (orthognathic) surgery to correct their bite. Our craniofacial orthodontist and surgeon work together to plan the best treatment for your child.

Your doctor may recommend:

• A bone graft to lengthen the jaw or to make a new jaw joint. A graft uses bone or cartilage from another part of the body. We first consider this option when your child is 4 to 7 years old.
• Mandible distraction to increase the size of your child’s lower jaw. See a series of photos that demonstrate how this procedure was used for a child born with bilateral craniofacial microsomia.
• Le Fort I maxillary advancement if your child’s upper jaw needs to be larger and moved forward.

Some children with CFM have a cleft lip or palate. In others, the muscles in the back of the mouth don’t work right. This is a type of velopharyngeal dysfunction (VPD).

VPD and clefting can harm your child’s ability to make speech sounds.

If you or your doctors have concerns about your child’s speech, your child will see a speech and language pathologist (SLP).

Treatment options may include:

• Speech therapy to help develop more normal speech patterns.
• A custom-made speech appliance called an obturator.
• Surgery. This is likely if your child has a type of VPD called velopharyngeal insufficiency. Your surgeon and speech pathologist will work together to recommend what is best for your child.

Some children with CFM have a pinkish-white growth on the eye (epibulbar dermoid). If your child does, an eye doctor (ophthalmologist) on our team will check your child’s eyes for other differences.

The doctor monitors the growth on the eye to make sure it does not interfere with your child’s sight. If it is large or getting in the way of vision, the doctor may recommend surgery to remove it.

Some children with CFM have problems with the spine. Usually, the problem is in the top part, called the cervical spine.

Your child’s craniofacial pediatrician will order X-rays when the bones are well formed. This happens when your child is at least 3 years old.

If the X-rays show differences in the way your child’s bones fit together, your doctor will order more tests.

Children with CFM have an increased chance of kidney problems. We recommend that all children with CFM have an ultrasound of their kidneys when they begin treatment at Seattle Children’s.

We are looking to make sure that the kidneys were formed normally. If your child has a normal ultrasound, they will not need another one in the future.

This ultrasound usually takes less than 20 minutes. It does not require needle pokes or medicine.

It is rare for children with CFM to have problems with their heart. Your doctor may decide that your child needs an echocardiogram (ultrasound picture of the heart) to check for abnormalities. If you have concerns talk to your doctor.