Nasoalveolar Molding Research Articles

Correction of Unilateral Cleft Lip, Palate and Alveolus by Presurgical Nasoalveolar Molding using Modified Nasal Stent- A Case Report

Cleft deformities may lead to psychological problems, dental problems, and aesthetic problems, if left untreated. Hence the management of cleft patients is quite challenging and controversial which involves a multidisciplinary approach including members of various specialties. The Presurgical Nasoalveolar Molding (PNAM) method is an innovative therapy for mitigating the impact of craniofacial deformities. The use of PNAM therapy in a newborn infant is described in this case report. Impressions were taken during the first visit and on the same day lip tape therapy (lip taping) was started using 3M™ Steri Strip™. The Nasoalveolar Molding (NAM) plate was delivered to approximate the cleft alveolus. A modified nasal stent appliance was administered until the cleft gap was decreased to around 4 mm and the cleft lip was repaired through surgery. The use of PNAM with the modified nasal stent appliance showed promise in lowering the amount of the cleft deformity of the lip, palate, and alveolus, with improving nasal aesthetics. When comparing pre-NAM to post-NAM, there was also a considerable reduction in the alveolar defect. In cleft patients, the PNAM-assisted primary reconstruction employing a nasal stent appliance resulted in an overall improvement of the nasolabial complex, enhanced aesthetics, and a reduction in the extent of surgery and surgical operations.

Rethinking the Rule of 10s: Early Cleft Lip Repair Improves Weight Gain.

This study compares patients undergoing early cleft lip repair (ECLR) (<3-months) and traditional lip repair (TLR) (3-6 months) with/without nasoalveolar molding (NAM) to evaluate the effects of surgical timing on weight gain in hopes of guiding future treatment paradigms. Retrospective review. Children's Hospital of Los Angeles, California. A retrospective chart review evaluated patients who underwent ECLR or TLR ± NAM from November 2009 through January 2020. No intervention was performed. Patient demographics, birth and medical history, perioperative variables, and complications were collected. Infant weights and age-based percentiles were recorded at birth, surgery, 8-weeks, 6-months, 12-months, and 24-months postoperatively. The main outcomes were weight change and weight percentile amongst ECLR and TLR ± NAM groups. 107 patients met inclusion criteria: ECLR, n = 51 (47.6%); TLR + NAM, n = 35 (32.7%); and TLR-NAM, n = 21 (19.6%). ECLR patients had significantly greater changes in weight from surgery to 8-weeks and from surgery to 24-months postoperatively compared with both TLR ± NAM (P < .05). Age-matched weights in the ECLR group were significantly greater than TLR ± NAM at multiple time points postoperatively (P < .05). ECLR significantly increased patient weights 24-months postoperatively when compared to TLR ± NAM. Specifically compared to TLR-NAM, ECLR weights were significantly greater at all time points past 6-months postoperatively. The results of this study demonstrate that ECLR can mitigate feeding difficulties and malnutrition traditionally seen in patients with cleft lip.

Recent Advances in Nasoalveolar Molding Therapy Using 3D Technology.

Presurgical Nasoalveolar Molding (NAM) is an adjunctive treatment modality designed to reorient misaligned tissue structures and nasal cartilage in cleft lip and/or palate (CL/P) patients. Recent advances in NAM therapy focus on modifications to the intraoral molding plate or nasal stent intended to improve treatment outcomes, ease of use, compliance, and cost-effectiveness. Notably, 3D technological advancements have been employed to design NAM devices more efficiently and create objective, standardized means of measuring progressive morphological changes during therapy. These advances are designed to incorporate 3D technology in the treatment of cleft lip and/or palate to render it more precise, accurate, and time-efficient.

Effect of Nasoalveolar Molding in Infants with Cleft Lip & Palate

In the 19 th century McNeil (prosthodontist) used an oral prosthesis to approximate the cleft alveolar segments and thus initiating the concept of modern presurgical infant orthopedics. More recently (1994) Barry Grayson developed a new technique that not only it approximates the alveolar segments, but it also reshapes the nose in order to perform primary nose surgery, this technique is called Nasoalveolar molding (NAM). Patients with nonsyndromic complete unilateral cleft lip and palate. Nasoalveolar molding was performed for each patient and treatment time took 8-12 weeks. A serial of standard basilar view 1:1 photographs were taken for each patient. Each patient was photographed at the initial visit and after the nasoalveolar molding. Digital caliper was used to measure the cleft size on the study model at the initial visit and after nasoalveolar molding. Patients expressed good improvement. The cleft size was reduced significantly. Improved both the columella deviation and length as well as the nostril width and height in the cleft side. NAM is an effective procedure in reducing the alveolar cleft size and it also improves the nasal architecture. This will facilitate the work of the plastic surgeon during the lip adhesion and primary nose surgery and consequently with better aesthetic outcome.

Comparative evaluation of nasal and alveolar changes in complete unilateral cleft lip and palate patients using intraoral and extraoral nasoalveolar molding techniques: randomized controlled trial.

ObjectivesCleft lip and palate is a common congenital anomaly that impairs the aesthetics, speech, hearing, and psychological and social life of an individual. To achieve good aesthetic outcomes, presurgical nasoalveolar molding (NAM) has become important. Currently, the intraoral NAM technique is widely practiced. Numerous modifications have been made to intraoral NAM techniques, but the original problem of compliance leading to discontinuation of treatment remains unsolved. Therefore, the present study compared an extraoral NAM technique with the intraoral NAM technique.Materials and MethodsTwenty infants with complete unilateral cleft lip and palate were included and divided into two equal groups. Group A received the intraoral NAM technique, and Group B received the extraoral NAM technique. Pre- and postoperative extraoral and intraoral measurements were recorded.ResultsGroups A and B did not differ significantly in any extraoral or intraoral parameter.ConclusionThe extraoral NAM technique is as effective as the intraoral NAM technique in achieving significant nasal and alveolar changes in complete unilateral cleft lip and palate patients. Additionally, it reduces the need for frequent hospital visits for activation and the stress associated with the insertion and removal of the intraoral NAM plate, thereby improving compliance.

English

BACKGROUND Cleft individuals have a significant altered growth of the craniofacial structures since birth. The treatments available for infants are mostly associated with controversies regarding timing of initiation, types &amp; timing in surgery, grafting etc. Maxilla is affected in all three dimensions; due to surgery alone or in conjugation with the infant orthopaedics, intrinsic growth retardation or combination of all. Considering the current conflict over the use of pre-surgical nasoalveolar molding (PNAM) and to evaluate the efficacy of PNAM technique, this postdoctoral research was done to compare the maxillary palatal volume in unilateral cleft lip and palate (UCLP) cases treated with and without PNAM as compared to non-cleft individuals. METHODS This is an observational cross-sectional study. The palate alveolar volume was assessed and analysed using 3D-DVT angiography machine. RESULTS There was significant difference between cleft group and non-cleft individuals. The cases treated with PNAM had lesser palatal volume. CONCLUSIONS Restrictive effect on maxilla was evident in PNAM cases, but this altered growth could also be an amalgamation of numerous factors like surgery, infant orthopaedics, and intrinsic growth. Therefore, judicious use, current concepts, and biomechanics of PNAM is the need of an hour. KEY WORDS Maxillary Palatal Volume, Unilateral Cleft Cases, Presurgical Naso-Alveolar Molding, 3D-DVT

Effect of Cleft Width on the Outcome of Presurgical Nasoalveolar Molding in Patients With Unilateral Cleft Lip and Palate.

The purpose of this study was to investigate the short-term effects of presurgical nasoalveolar molding (PNAM) according to cleft width (CW) in patients with unilateral cleft lip and palate (UCLP). In this retrospective study, 32 newborns with nonsyndromic UCLP treated with PNAM were allocated to 2 groups based on CW (group A, CW ≤5 mm; and group B, CW >5 mm). The following measurements were carried out using standardized photographs taken before and after PNAM therapy (before primary lip surgery): nostril axis inclination of healthy (NAI-NC) and cleft sides (NAI-C), columellar angle (CA), nasal base inclination (NBI), nasal floor width ratio (NFWR), alar base height ratio (ABHR), and columellar length ratio. Before PNAM therapy, there were significant differences between the 2 groups with respect to NAI-C, NBI, NFWR, and ABHR, indicating greater deformation of the nose in group B. After PNAM therapy, CA, NAI-C, NAI-NC, NFWR, and columellar length ratio were significantly improved in both the groups, whereas NBI and ABHR significantly worsened in group B. The improvement in CA, NAI-C, and NFWR was significantly greater in group B. Although a larger CW had some negative effects on the outcome of PNAM, it was found to be advantageous for nasal symmetry, if initiated as early as possible. Nevertheless, it is important to consider those aspects of the nasolabial area that are involved in the perception of symmetry when evaluating the effect of CW on PNAM outcomes in UCLP.

Role of presurgical nasoalveolar molding in the repair of unilateral cleft lip

Aim: A study aims to reappraise the merits of nasoalveolar molding before the repair of unilateral cleft lip. Materials and Methods: A prospective study was conducted with 20 cases of the unilateral complete cleft lip for 3 years. We counseled the parents, offered them to choose the surgical procedure with/without preoperative nasoalveolar molding (NAM), and obtained consent from them. The nasolabial closure was done either after aligning the cleft segments with NAM or without preoperative NAM. The patients were followed up for 1 year and assessed. Both groups are then compared with normal healthy individuals of the same age group. Results: Depending on preoperative NAM, the patients were divided into Groups A (without NAM) and B (with NAM). All the facial proportions and angles (except oral commissural width: facial width and nasal tip angle) of Group B are much closer to the values of normal age-controlled individuals. However, a significant difference existed between the Group A values and normal individuals. Group B showed better nasal symmetry and restoration of normal proportions. The quality of scar produced was significantly superior in Group B when compared to Group A. Body weight change was also significantly different in the two groups. Group B seemed to catch the 15th percentile while Group A stayed at the 3rd percentile in the postoperative period. Conclusion: Presurgical NAM helps to restore the normal facial proportions and produces a healthier scar. Furthermore, the bodyweight of patients seems to improve as the NAM plate acts as a feeding plate.

Multidisciplinary treatment from infancy to adolescence of a patient with a unilateral cleft lip and palate: a 16-year follow-up case report

Abstract Cleft lip and palate (CLP) are conditions that require long-term management and review from infancy to adolescence. Surgical procedures become easier when nasoalveolar moulding (NAM) measures are applied during the neonatal period. Orthodontic treatment provided for these patients during the progressive dentition developmental periods can achieve positive aesthetic and functional results. In patients affected by a CLP, the lateral incisor in the cleft region is usually missing and multidisciplinary prosthodontic rehabilitation of the edentulous space is often required. In the present case report, positive results of NAM, coupled with orthodontic and prosthodontic treatment are presented for a CLP patient who began management during the neonatal period. In addition, a minimally invasive aesthetic restoration is presented as a solution for the prosthodontic rehabilitation of a missing lateral incisor.

Effectiveness of Presurgical Nasoalveolar Molding Appliance in Infants With Complete Unilateral Cleft Lip and Palate.

To assess the effectiveness of the presurgical nasoalveolar molding appliance among infants with unilateral cleft lip and palate. In this prospective study, 95 pairs of casts of infants with unilateral cleft lip and palate treated by presurgical nasoalveolar molding were selected at the Children's Hospital 1 at Ho Chi Minh City, Vietnam. The average time of treatment was 3 months. All casts were scanned and measured using 3-dimensional technology before and after treatment. Paired t tests were applied for comparisons. There was a statistically significant increase in the nostril height in cleft side (P < .001), decrease in the nostril width and columella angle (P < .001), and decrease in cleft width and midline deviation (P < .001) after treatment with presurgical nasoalveolar molding appliance. Nasoalveolar molding appliance is effective in improving the morphology of nostril and maxillary alveolar. Understanding this helps orthodontists and surgeons in treatment outcome expectations.

Photometric Evaluation of Adult Patients With Bilateral Cleft Lip and Palate Treated With Nasoalveolar Molding and Primary Columella Lengthening.

The aim of this study was to assess the nasal shape of young adults with BCLP treated with primary surgical columella lengthening and nasoalveolar molding (NAM). A group of 28 young adult patients with BCLP (mean age: 19.1±1.4 years) was compared through normalized photogrammetry to a control of 28 age- and sex-matched noncleft young adults. Nasal protrusion and length of the columella were not different from noncleft young adults. On the other hand, nasolabial angle, columellar width, interalar, and nasal tip width were significantly wider than the noncleft controls. Thus, 27% of the patients have requested at this time secondary correction of the excessive nasal width. Both NAM and primary rhinoplasty in patients with BCLP resulted in a near normal length of the columella and nasal projection until young adulthood. Nevertheless, width of all nasal features was significantly wider than the noncleft population and required secondary nasal correction in one-third of the sample.

Alveolar bone grafting and gingivoperiosteoplasty in bilateral cleft lip and palate.

Gingivoperiosteoplasty (GPP) and alveolar bone grafting (ABG) procedures have a vast history. There have been many publications regarding ABG and secondary ABG, with and without presurgical infant orthopedics (PSIO), in bilateral cleft lip and palate patients. There is little long-term data available describing results of both techniques. The interdisciplinary approach to primary and secondary surgical procedures has proven to be beneficial for patients with bilateral cleft lip and palate. In the neonates, naso-alveolar molding (NAM) has been found to optimize the aesthetic outcome as well as re-approximating the arches to facilitate GPP. During the mixed dentition stage, arch preparation/expansion before the secondary ABG procedure improves arch morphology, restores the functional interarch relationship, and facilitates surgery. This review aims to highlight the key points of both the procedures and why combining both procedures along with PSIO procedures such as NAM might be helpful for the patients in the long term.

Three-Dimensional Nasolabial Changes After Nasoalveolar Molding and Primary Lip/Nose Surgery in Infants With Bilateral Cleft Lip and Palate.

Utilize 3-dimensional (3D) photography to evaluate the nasolabial changes in infants with bilateral cleft lip and palate (BCLP) who underwent nasoalveolar molding (NAM) and primary reconstructive surgery. This is a retrospective serial longitudinal study of consecutively enrolled infants from September 2012 to July 2016 with BCLP who underwent NAM before primary lip and nose reconstructive surgery. It included infants who had digital 3dMD stereophotogrammetry records at initial presentation (T1), completion of NAM (T2), and 3 weeks following primary repair (T3). Twelve infants fulfilled the inclusion criteria. 3dMD Vultus software was used to orient images and plot 16 nasolabial points with x, y, z coordinates to obtain the linear and angular measurements. Nasal form changes were measured and analyzed between T1 (0.5 months old), T2 (5 months old), and T3 (6 months old). Intraclass correlation coefficient was performed for intrarater reliability. Averaged data from the 3D images was statistically analyzed from T1 to T2 and T2 to T3 with Wilcoxon tests. Unaffected infant norms from the Farkas publication were used as a control sample. After NAM therapy, statistically significant changes in the position of subnasale and labius superius improved nasolabial symmetry. Both retruded after NAM were displaced downward after NAM and surgical correction with respect to soft tissue nasion. The nasal tip's projection was maintained with NAM and surgical correction. The columella lengthened from 1.4 to 4.71 mm following NAM. There was a significant improvement in the nasolabial anatomy after NAM, and this was further enhanced after primary reconstructive surgery.

Knowledge and Attitude Among Various Dental Specialities Regarding Nasoalveolar Molding Procedure in Cleft Patients-A Cross-Sectional Study.

Nasoalveolar molding (NAM) is a presurgical orthopedic procedure, mainly focusing upon the aesthetic outcome of the treatment goal by reducing the number of reconstructive surgeries performed later for the purpose of esthetics. It was reported a very small proportion of pediatric dentists are providing presurgical intervention and the practice of NAM still side stepping among various dental practitioners. The study was aimed to assess the knowledge and attitude among various dental specialties regarding NAM procedure in cleft patients. A questionnaire-based cross-sectional survey was carried out among 180 dental professionals (pedodontists, orthodontists, prosthodontists, oral surgeons). A total of 180 questionnaires were prepared, out of which 98 were filled through direct personal interview and 82 were circulated via Google forms. Results were analyzed using chi-square test, Mann-Whitney U test, and Kruskal-Wallis test. There was statistically significant difference in the cumulative knowledge scores between specialty with P < .001; 99% of the participants think one should opt for NAM before cleft lip and palate surgery and 39% participants prefer pedodontists to carry out NAM procedure. Dental specialists in India have a positive attitude toward presurgical orthopedics. Majority of them agreed that there is great improvement in the aesthetic outcomes of surgeries after NAM intervention.

The Nasoalveolar Molding Cleft Protocol: Long-Term Treatment Outcomes from Birth to Facial Maturity.

The authors present outcomes analysis of the nasoalveolar molding treatment protocol in patients with a cleft followed from birth to facial maturity. A single-institution retrospective review was conducted of cleft patients who underwent nasoalveolar molding between 1990 and 2000. Collected data included surgical and orthodontic outcomes and incidence of gingivoperiosteoplasty, alveolar bone grafting, surgery for velopharyngeal insufficiency, palatal fistula repair, orthognathic surgery, nose and/or lip revision, and facial growth. One hundred seven patients met inclusion criteria (69 with unilateral and 38 with bilateral cleft lip and palate). Eighty-five percent (91 of 107) underwent gingivoperiosteoplasty (unilateral: 78 percent, 54 of 69; bilateral: 97 percent, 37 of 38). Of those patients, 57 percent (52 of 91) did not require alveolar bone grafting (unilateral: 59 percent, 32 of 54; bilateral: 54 percent, 20 of 37). Twelve percent (13 of 107) of all study patients underwent revision surgery to the lip and/or nose before facial maturity (unilateral: 9 percent, six of 69; bilateral: 18 percent, seven of 38). Nineteen percent (20 of 107) did not require a revision surgery, alveolar bone grafting, or orthognathic surgery (unilateral: 20 percent, 14 of 69; bilateral: 16 percent, six of 38). Cephalometric analysis was performed on all patients with unilateral cleft lip and palate. No significant statistical difference was found in maxillary position or facial proportion. Average age at last follow-up was 20 years (range, 15 years 4 months to 26 years 10 months). Nasoalveolar molding demonstrates a low rate of soft-tissue revision and alveolar bone grafting, and a low number of total operations per patient from birth to facial maturity. Facial growth analysis at facial maturity in patients who underwent gingivoperiosteoplasty and nasoalveolar molding suggests that this proposal may not hinder midface growth. Therapeutic, IV.

Nasal Aesthetic Evaluation Following Pre-Surgical Naso-Alveolar Molding Application: A Single-Blinded Cohort Retrospective Study in Indonesia

Introduction: As a major facial aesthetic unit, the nose is one of the significant features in cleft lip and palate repair. The use of a naso-alveolar molding (NAM) device was known to help narrow the cleft gap and improve nasal aesthetics. This study aims to evaluate post-operative nasal morphology in unilateral cleft lip and palate patients who had used presurgical NAM, particularly in an established craniofacial centre in one of developing countries. Methods: A cohort retrospective study was conducted at Cleft Craniofacial Centre, Cipto Mangunkusumo Hospital Indonesia, comparing the nasal symmetry in unilateral cleft lip patients with and without prior application of NAM (NAM and control group), twelve months following primary cheiloplasty. Differences between the cleft and normal side were assessed using standard basilar view photographs based on five points nasal measurements. Results: A total of twelve patients were enrolled, six with a history of NAM application and six without (control). Overall nasal measurements confirmed a lower mean of differences in the NAM group compared to the control, showing statistically significant results in nostril height, nasal dome height, and columellar height (p &lt;0.05). Conclusion: This study provides an insight that cleft lip patients with a history of NAM application had superior nasal symmetry compared to patients without presurgical NAM application 1-year post-cheiloplasty. Presurgical NAM application is recommended for patients with unilateral cleft lip and palate.

Long-Term Effects of Nasoalveolar Molding in Patients With Unilateral Cleft Lip and Palate: A Systematic Review and Meta-Analysis.

The aim of this systematic review and meta-analysis was to investigate long-term treatment effects of nasoalveolar molding (NAM) in patients with unilateral cleft lip and palate (UCLP). Included manuscripts met the following criteria: (1) involved patients with UCLP who received NAM; (2) included comparison group(s) who either received non-NAM passive presurgical infant orthopedic appliances (PSIO) or who did not receive any PSIO; (3) reported at least one objective or validated measure of nasolabial, craniofacial, or palatal form; and (4) had patient follow-up beyond 4 years of age. A total of 12 studies were included in this review. Meta-analyses were possible for Asher-McDade parameters and cephalometric measurements. Compared to patients who did not receive any PSIO, those who underwent NAM therapy were more likely to have good to excellent frontal nasal form (Risk ratio: 2.4, 95% CI: 1.24-3.68) and vermillion border (Risk ratio: 1.8, 95% CI: 1.19-2.71). However, there were no statistically significant differences in cephalometric measurements between these groups. Additionally, there were no statistically significant differences between patients receiving NAM versus non-NAM PSIO. There was insufficient evidence to determine the impact of NAM on dental arch development. The preponderance of evidence in this review suggests that NAM produces benefits in nasolabial aesthetic form when compared with no appliance-based presurgical treatment. However, there is insufficient evidence to conclude whether NAM produces such benefits when compared with other passive PSIOs.

A Staged Expansion Screw Protocol to Retract the Premaxilla In BCLP Infants with Delayed Nasoalveolar Molding.

Currently, the treatment protocol for cleft palate at several centers around the world involves primary lip repair around 3-4 months of age, using presurgical nasoalveolar molding, which is done soon after birth. Unfortunately, in cases where treatment is delayed, the potential for repositioning the nasoalveolar apparatus is severely limited. The purpose of this paper is to illustrate a novel use of an expansion screw appliance to aid in the faster and more efficient active molding of the premaxillary and lateral maxillary segments in infants for whom the start of PNAM therapy is delayed, without the side effects commonly seen with pin-retained active molding appliances.

Function of Nasoalveolar Molding Devices in Bilateral Complete Cleft Lip and Palate: A 3-Dimensional Maxillary Arch Analysis.

This study aimed to observe and analyze the effects of nasoalveolar molding (NAM) on maxillary arch dimensions in patients with bilateral complete cleft lip and palate (BCLP) using 3-dimensional analyses. Retrospective case series. Seventeen infants were treated using modified Khon Kaen University presurgical nasoalveolar molding devices (KKU-NAM). Dental casts were evaluated 3 dimensionally at 3 time points: pretreatment (T1), after using modified KKU-NAM for 2 weeks (T2), and before cheiloplasty (T3). Repeated-measures analysis of variance and Friedman test were used to compare the maxillary arch dimensions between time points. Both sides of the cleft width, premaxilla deviation, and premaxilla protrusion had significantly reduced with the use of KKU-NAM. Premaxillary rotation had significantly improved, whereas the arch depth did not change significantly. Premaxilla width, posterior arch width, alveolar length, and height had significantly increased. The anterior arch width, intercanine width, and lateral sulcus width showed no significant changes. The intraclass correlation coefficient used to test the measurements indicated substantial reliability. The modified KKU-NAM is an effective device for reducing the severity of bilateral cleft deformities, especially in the premaxilla area.

Interdisciplinary Considerations for Nasolabial Repair During a Global Pandemic.

At the declaration of the global pandemic on March 11, 2020, many hospitals and institutions developed a tiered framework for the stratification and prioritization of elective surgery. Cleft lip and palate repair was classified as low acuity, and nasoalveolar molding (NAM) clinics were closed. Anticipating the consequences of delayed cleft care and the additional burden this would cause families, we reassessed our risk-stratification and perioperative algorithms. We hypothesized we could safely optimize nasolabial repair without burdening our care systems and without increasing COVID-19-related morbidity/mortality. Our multidisciplinary cleft team reevaluated patient selection to maximize surgical impact. Perioperative protocols were adjusted, and COVID-19 preoperative testing was utilized before nasolabial repair and prior to suture removal under anesthesia. Early in the pandemic, unilateral cleft repair was prioritized and successfully completed on 9 patients. There were no complications related to COVID-19. Nasoalveolar molding clinic was reopened after total patient volume was significantly decreased. We offer an approach for surgical management of nasolabial clefts during a global pandemic. Although guidelines have suggested postponing all cleft care, we found that at our dedicated pediatric hospital with low burden of COVID-19 and adequate resources, we could follow a strategy to safely resume cleft care while decreasing burden on our patients' families and care delivery systems.