Craniofacial Program in Austin Craniofacial Orthodontics At Texas Children’s North Austin Campus
The Craniofacial Orthodontics program at Texas Children’s North Austin Campus, part of the Division of Plastic and Craniofacial Surgery, is one of the few programs in the country to offer highly specialized, comprehensive care in this area. As a subspecialty of orthodontics, craniofacial orthodontics is designed to address facial and jaw differences, particularly in children with cleft lip and palate, craniofacial microsomia (parts of the face are underdeveloped), craniosynostosis (bones in a baby’s skull fuse early) and craniofacial syndromes.
We know that children with facial differences can encounter many challenges. We are here for your entire family, every step of the way. We can do this by offering highly individualized treatment plans and supporting children and their families through various stages from early infancy into adulthood. Bringing together a team of experts we offer some treatments and services that other programs might not have.
Nasoalveolar molding (NAM) in infants with cleft lip and palate
At Texas Children’s Hospital North Austin Campus, we typically repair alveolar clefts between 6 and 8 years of age, when your child’s permanent teeth are beginning to come in to the mouth. An alveolar cleft is the gap in the gum line and bone and was visible at birth. For the teeth to come into bone, an alveolar bone graft is needed to create a bridge across the cleft/gap. If a graft is not done before the tooth adjacent to the cleft begins to erupt, the tooth can be unstable and possibly lost.
Timing of the alveolar graft will be determined by a dental x-ray taken when your child is around 5-6 years old. Our craniofacial orthodontist and craniofacial surgeon will examine this x-ray to see which adult tooth is going to erupt first. In 9 out of 10 kids with cleft lip and alveolus, the tooth next to the front tooth (lateral incisor) is not well formed and will not be part of their adult teeth. If this is the case, the first adult tooth to erupt is the canine (“dog” or sharp tooth) and the alveolar grafting will take place around 8 years of age. If the lateral incisor is present (1 in 10 kids) then we will recommend earlier bone grafting at 6-7 years of age.
Alveolar cleft repair may require orthodontic preparation to bring the gums on each side of the cleft into better alignment and create space for the permanent teeth to erupt. Your orthodontist will work closely with your child’s craniofacial plastic surgeon to prepare for the alveolar bone graft (ABG), a procedure in which the surgeon takes bone from the hip and brings it into any area of the alveolus where the bone is deficient. This surgery can often be performed as a day surgery.
Orthodontic preparation for alveolar bone graft often includes palatal expansion. Using an orthodontic appliance that is fixed to the upper back teeth, our orthodontic team will expand and align the two parts of the palate to prepare an optimal bone graft site and to start to make the two jaws fit together better. Usually, these expanders use springs that do the expansion automatically, but sometimes a child will need a special expander that you adjust yourself each day using a small key. The expansion is very slow and is not painful.
After expansion is complete, the expansion appliance is removed in the dental chair, we make a thin splint to be worn by your child before they have their surgery. This splint needs to be worn 24 hours a day and is only removed for cleaning. It helps keep the gums in their new expanded position until after the bone graft has been placed and has fully healed into stable bone.
- Typically for children aged 6 to 9, in the mixed dentition phase when baby teeth begin to fall out and permanent teeth come in.
- Focuses on identifying and addressing jaw growth or tooth development issues early. For patients with craniofacial differences, including cleft lip and palate, there are often misaligned teeth or disruption in tooth and/or jaw development, which are best addressed at this time.
- Treatment may include headgear, functional appliances, braces on selected teeth, retainers, expansion appliances and space maintainers.
- Duration: 9 to 12 months
- Begins during early adolescence and focuses on straightening teeth for esthetic, functional and stable outcomes. This can include
- Replacement of missing teeth for functional and esthetic reasons
- Guiding teeth into the arch which are not in an ideal position or which cannot otherwise come into the mouth
- In cases where there are concerns with jaw development, a combination of orthodontics and orthognathic (jaw) surgery may be needed
- Duration: 12 to 30 months, depending on severity and surgery needs. Multiple phases may be necessary, especially if jaw surgery becomes necessary
Common findings in craniofacial differences include missing teeth, extra teeth, teeth which do not come in at the right time or erupt in the wrong position, missing or not enough bone after grafting procedures, and altered patterns of jaw growth. Using the most advanced technology, our team can take low-dose radiation 3D X-rays and 3D surface scans of the teeth; they allow us to carefully assess your child’s needs and plan treatment in these complex situations.
It is possible that orthodontic treatment alone will not be sufficient to correct your child’s bite. The most common reason for this is that one or both jaws have not developed properly. For example, the upper and lower jaws may each be too large, too small or have developed asymmetrically. Patients with cleft lip and palate, craniofacial microsomia, craniosynostosis, Treacher Collins syndrome, and ectodermal dysplasia may all show these altered growth patterns. These jaw development issues may also occur independent of any syndrome or medical diagnosis.
In these cases, a combination of orthodontics and orthognathic (jaw) surgery may be the ideal treatment. If so, phase 2 orthodontics may be limited so that the teeth are straightened, but the bite is not fully corrected. Final orthodontic treatment and full alignment of the bite will be postponed until your child has finished growing and is a candidate for definitive jaw surgery.
Phase 2 orthodontic treatment lasts approximately 12 to 30 months, depending on the severity of the problem and whether your child is a candidate for jaw surgery.
The craniofacial orthodontist at Texas Children’s Hospital North Austin Campus is one of a select group of specialists in the country who have completed a craniofacial orthodontic fellowship recognized by the American Dental Association. This training allows our orthodontic team to not only prepare your child for corrective jaw surgery using braces, but to also be a very important part of planning the details of the surgery itself. This close partnership between our orthodontist and surgeons is not common but is needed for the best surgical results. Your child may have their braces applied and adjusted at our craniofacial clinic, or we are also happy to partner with your local orthodontist in preparing for surgery if you live a distance from the hospital.
Patients with cleft lip and palate, craniofacial microsomia, craniosynostosis, Apert syndrome, Crouzon syndrome, Pfeiffer syndrome and Treacher Collins syndrome may all have altered growth of their face, which result in differences of the jaw shape and position. This creates a poor bite, making biting and chewing difficult. In addition, the size and position of the jaws can have a negative effect on the airway, resulting in obstructive sleep apnea (decreased oxygen levels due to difficulty breathing while sleeping). These issues cannot be addressed by orthodontics alone and as a result, an orthognathic (jaw) surgical-orthodontic treatment plan is the ideal treatment. In some instances, the upper and/or lower jaws may be too large, too small or have developed differently from each other.
If we recommend jaw surgery our orthodontists work with your child’s surgeon to plan the surgical movements and prepare the teeth to fit together well after jaw surgery. At Texas Children's Hospital North Austin Campus, orthognathic surgical planning is often done with the aid of special 3D X-rays and computer software to give the most precise surgical plan. We plan the surgery virtually on the computer with high precision so that the actual surgery is quicker and more accurate. The jaw surgery is usually recommended to take place when your child is done growing to ensure that they do not outgrow the correction. This is usually around 16-17 years old for females, and 18-19 years old for males. We often take an x-ray of the wrist growth plate to confirm that it is closed, and your child has stopped growing before we clear them for surgery.
The overall orthodontic treatment time can vary, depending on the complexity of the jaw and bite difference. At minimum, 6 to 12 months of braces is needed to prepare for jaw surgery. Once surgery is completed, another 6 to 12 months of braces are needed to fine-tune the bite. During this time, orthodontic elastics may be used to maintain or improve the bite during healing.
Our surgical team at Texas Children’s North Austin Campus has an international reputation of excellence in using a powerful technique known as Distraction osteogenesis to treat craniofacial conditions. Distraction osteogenesis uses specialized devices placed during surgery to either makes bones longer, such as lengthening the lower jaw, or to move the position of a bone, such as bringing the upper jaw and cheekbones into a better position. Our craniofacial orthodontic team is a vital part of these treatments before and after surgery.
Before a distraction osteogenesis surgery, your craniofacial orthodontist and craniofacial surgeon will meet with you and your child to discuss the treatment plan and goals. Some distraction osteogenesis surgeries need a specialized plastic and metal splint made that is attached to the upper teeth at the time of surgery. To prepare this splint, the orthodontist will take a surface scan of your child’s upper teeth using a light-emitting wand and use this 3D photo of the teeth to make the specialized splint. This scan is typically done 3-5 weeks before the surgery. Your surgeon will also use this scan to combine with your child’s CT scan image so they can make a virtual surgical plan specific to your child’s teeth and bones.
In the 2-4 weeks after a distraction surgery, you will be turning the distraction devices placed at surgery every day. This “activation phase” is the time that the distraction devices slowly bring your child’s bones into their new position. During the activation phase, your child will be seen in clinic once a week by both the craniofacial orthodontist and your surgeon. During these visits the two specialists will examine the progress of your child’s treatment using dental x-rays. Once the bones are in the new position, the team will ask you to stop turning the devices and your child will enter the healing phase, or “consolidation phase”, which last 2-3 months. We will stay in touch with you during this healing phase but we do not need to see you as often.
After the consolidation phase is over your child will return to the operating room for a brief surgery to remove the distraction devices. After the devices are removed, your craniofacial orthodontist will continue to follow you to monitor your child in clinic. They may recommend using elastics that are attached to braces or small hooks to guide your child’s jaws as they grow.
