NYU Nasoalveolar Molding Protocol: From Birth to Adulthood

Abstract

INTRODUCTION: One of the most actively debated therapies for patients with a cleft is nasoalveolar molding (NAM). Although supporters cite improvements in nasal symmetry, nasal aesthetics, columellar length, cost benefit, and nasal revision rates, one of the most convincing criticisms of NAM is the absence of reports on its effects at facial maturity, the target timepoint of assessment for cleft care interventions. This study reports clinical outcomes of NAM to facial maturity including rates of revision surgery to the lip and nose, incidence of secondary alveolar bone graft (ABG), and orthognathic surgery (OGS), and effects on facial growth. METHODS: A single-institution retrospective review of patients all with a cleft who underwent NAM protocol from 1990 to 2000. Patients were included in the study if they had a diagnosis of unilateral or bilateral cleft lip and alveolus, with or without cleft palate. Patients were excluded if they had a syndromic diagnosis or if medical and/or dental records were incomplete. Lateral cephalogram measurements of patients with unilateral cleft lip and palate was obtained at 17 years or older and before OGS, if patients received OGS. These measurements were then compared with published Eurocleft cephalometric data. RESULTS: One hundred eighty-nine patients were identified, of which 100 met inclusion criteria. Eighteen patients had cleft lip and alveolus only. The average age at last follow-up visit was 20 years (15–26 years). Average age at time of unilateral cleft lip repair was 4 months (3–7 months), bilateral cleft lip repair 6 months (3–10 months), unilateral palate repair 13 months (4–27 months), and bilateral palate repair 13 months (6–17 months). Gingivoperiosteoplasty (GPP) was performed in 86% (86/100) of patients. ABG was performed in 52% (52/100). Of those who underwent GPP, ABG was avoided in 56% (48/86). A total of 23% (19/82) of patients with both cleft lip and palate required secondary surgery for velopharyngeal insufficiency (VPI), and 8% (4/48) of patients who underwent LeFort I advancement also required surgery for VPI. OGS was performed in 49% (49/100), and revisions to lip and/or nose prior to facial maturity were performed in 49% (49/100). At the time of lip and/or nose revision, 74% (36/49) were older than 14 years. Overall, 17% (17/100) required neither ABG, OGS, nor nose or lip revision. Thirty-four patients with unilateral cleft lip had lateral cephalograms available for analysis. There were no significant differences in SNA (P = 0.44), s-n-pg (P = 0.78), NSL/NL (P = 0.76), NSL/ML (P = 0.61), or n-sp/n-gn × 100 (P = 0.79) when compared with data from Eurocleft centers that used presurgical orthopedics. DISCUSSION: Cleft lip and palate reconstruction were not delayed because of NAM. Surgery for VPI and OGS rates were comparable to those reported in the literature. Facial growth analysis at facial maturity revealed no significant difference when compared with Eurocleft centers other than ANB (P = 0.005). These data suggest that NAM does not inhibit midface growth. Furthermore, ABG was avoided in 56% of patients who underwent GPP; lip and nose revision was avoided in 51%; and ABG, OGS, and any soft tissue revision surgery was avoided in 17%.