Presurgical Infant Orthopedics Research Articles

Nasoalveolar molding treatment in presurgical infant orthopedics in cleft lip and cleft palate patients

The nasoalveolar molding (NAM) technique is a new approach to presurgical infant orthopedics that reduces the severity of the initial cleft alveolar and nasal deformity. This technique facilitates the primary surgical repair of the nose and lip to heal under minimal tension, thereby reducing scar formation and improving the esthetic result. NAM technique is the nonsurgical, passive method of bringing the gum and lip together by redirecting the forces of natural growth. NAM has proved to be an effective adjunctive therapy for reducing hard and soft tissue cleft deformity before surgery. This paper reviews the basic principles of NAM therapy, various types of appliances used in this therapy, protocol followed, and a critical evaluation of the advantages and disadvantages of this technique. Universally authors have agreed the positive outcome of NAM for better esthetics after cleft lip and palate (CLP) repair, but the long-term effects of this therapy are yet to be substantiated. Despite a relative paucity of high-level evidence, NAM appears to be a promising technique that deserves further research.

Primary Repair of Cleft Lip and Nasal Deformity

After studying this article, the participant should be able to: 1. Describe the relevant anatomy and embryology that contribute to the cleft lip and nasal deformity. 2. Differentiate among the various forms of cleft lip, including microform, minor form, incomplete, complete, and bilateral. 3. List the options for presurgical infant orthopedics. 4. Describe the techniques and the expected outcomes of primary cleft lip and nasal repair. The authors describe cleft lip and its surgical management. They address the anatomy, forms, techniques, and outcomes of this complex and challenging deformity.

편측성 구순구개열 신생아에 대한 술전비치조정형장치의 효과

구순구개열은 얼굴에 발생하는 다양한 종류의 기형 중 빈번히 발생하는 기형으로, 발생 빈도는 일반적으로 1000명당 0.28~3.74명으로 알려져 있으나 파열의 종류, 인종 및 성별에 따라 큰 차이를 보인다. 구순구개열의 치료는 수술영역에서 많은 발전이 있었지만 수술만으로는 문제점을 해결하기는 어렵다. 파열부 간격을 줄이고 구순열 수술을 용이하게 하기 위한 술전 신생아 정형술의 개념이 1950년 McNeil에 의해 개발되었으며, 최근에는 술전 비치조 정형장치(presurgical nasoalveolar molding appliance, PNAM)를 사용하여 치조골뿐만 아니라 코의 모양을 정상화하려는 시도가 이루어지고 있다. 세 명의 환자가 편측성 구순구개열로 진단받은 후 술전비치조정형장치 장착을 위해 의뢰되었다. 레진과 교정용와이어를 이용하여 제작한 K-NAM 장치물을 입술 성형 수술을 시행하기 전까지 장착하였다. 첫 내원시와 nasal molding을 시행하여 입술 성형 수술을 하기 직전, 입술 성형 수술 이후 콧구멍의 높이, 너비, 비주의 각도를 측정하여 비교한 결과 세 증례에서 모두 코의 대칭성이 증가하며 술 후 심미개선에 효과적임을 알 수 있었다. K-NAM 장치물은 장치의 장착, 유지, 조절이 용이하고 장착한 상태에서 수유가 가능하기 때문에 장착시간을 증가시킬 수 있다. 따라서 nasal molding이 가능한 한정된 기간 안에 최대의 효과를 기대할 수 있다. 그리고 젖병을 빠는 행위가 가능해짐으로써 동시에 구강조직의 발달에도 도움을 줄 수 있을 것이라 생각한다. Cleft lip and palate, the most common craniofacial anomalies, are severe congenital defects that have an incidence of 0.28 to 3.74 per 1000 live births. Although there has been great improvement in the field of cleft surgery, surgical approach cannot be the single solution to resolve the various problems encountered in patients with cleft lip and palate. The concept of presurgical infant orthopedics (PSIO) for gradual closure of the cleft gap and simplified surgical performance was first introduced by McNeil in 1950. Recently, there are many attempts not only to approximate the alveolar segments but also to reshape the nasal cartilage. Three infants with unilateral cleft lip and palate were referred from the department of Plastic Surgery for presurgical nasoalveolar molding (PNAM). Maxillary appliances using resin with orthodontic wire were fabricated. Then these appliance was applied until patients underwent lip surgery. In all cases, the patients could wear the appliance all day since they were able to eat even with the appliance on, This resulted in significant improvements in the nasal symmetry were found. Our appliance, namely K-NAM, extends the wearing time within the limited period and as a result it is expected to maximize the treatment effects. Used properly, this appliance would play a major role in enhancing nasal symmetry with satisfactory results.

Simplifying cleft surgery by presurgical nasoalveolar molding (PNAM) for infant born with unilateral cleft lip, alveolus, and palate: A clinical report

PatientA 2-day-old female infant with complete unilateral cleft lip, alveolus, and palate (left side) was presented to the Department of Prosthodontics, Government Dental College and Hospital, Nagpur for evaluation and treatment with presurgical nasoalveolar molding (PNAM) prior to surgical intervention. DiscussionThe alignment of the alveolar segments creates the foundation upon which excellent results of primary lip and nasal surgery are dependent in the repair of the cleft lip, alveolus, and palate patient. Presurgical infant orthopedics has been employed since the 1950s as an adjunctive neonatal therapy for the correction of cleft lip and palate. One of the problems that the traditional approach failed to address was the deformity of the nasal cartilages and the deficiency of columella tissue in infants with unilateral and bilateral cleft lip and palate. The purpose of this article is to illustrate the step-by-step fabrication process of the PNAM prosthesis used to direct growth of the alveolar segments, lips, and nose in the presurgical treatment of cleft lip and palate. ConclusionAs a result, the primary surgical repair of the lip and nose heals under minimal tension, thereby reducing scar formation and improving the esthetic result. Frequent surgical intervention to achieve the desired esthetic results can be avoided by PNAM.

A new approach in Presurgical Infant Orthopedics using an Active Alveolar Molding Appliance in the management of bilateral cleft lip and palate patient: A Case Report

Cleft lip and palate can arise with considerable variation in severity and form. Generally, the wider, more extensive clefts are associated with more significant nasolabial deformity. These clefts, deficient in hard and soft tissue elements, present a significant surgical challenge to achieve a functional and cosmetic outcome. A finer scar forms when a surgical incision heals under less rather than more tension. The principal objective of presurgical nasoalveolar molding (NAM) is to reduce the severity of the initial cleft deformity. The nasoalveolar molding appliance is a modern presurgical orthopedic device that allows for a positive growth of the alveolar ridges into an improved arch form as well as reshaping of the flattened nose into a more symmetrical shape. As a result of the presurgical appliance, the nose and lip are allowed to heal under minimal tension, thereby reducing scar formation and improving the esthetic result. This case report describes the management of a bilateral cleft lip and palate case with the use of an active alveolar molding appliance which retracts the forwardly placed premaxilla into a more esthetic position prior to the primary surgical repair.

Short-term Evaluation on Skeletal Pattern and Dental Arch of Five Unilateral Cleft Lip and Palate Patients who underwent Presurgical Infant Orthopedics, Gingivoperiosteoplasty, Surgical Lip Closure, and Furlow Palatoplasty

Short-term Evaluation on Skeletal Pattern and Dental Arch of Five Unilateral Cleft Lip and Palate Patients who underwent Presurgical Infant Orthopedics, Gingivoperiosteoplasty, Surgical Lip Closure, and Furlow Palatoplasty

Residents' journal review

Achieving an esthetic outcome from surgical procedures in cleft patients is a common concern for all treating clinicians, parents, and patients. Many cleft teams include presurgical infant orthopedics in their treatment protocols before initial lip repair. Infant orthopedics is described in this article as an oral plate with lip taping with or without nasoalveolar molding. Nasoalveolar molding is becoming more popular with these teams that include infant orthopedics, although it remains controversial.

Effectiveness of pre‐surgical infant orthopedic treatment for cleft lip and palate patients: a systematic review and meta‐analysis

The objective of the study was to systematically summarize current evidence on the effectiveness of pre-surgical infant orthopedics (PSIO) in cleft lip and palate (CLP) patients. Electronic and manual searches were conducted, and using specific inclusion and exclusion criteria, data extraction and analysis was performed by two independent investigators. When possible, overall pooled estimates with 95% confidence intervals were obtained using the random-effects model. Twenty-four of 885 original studies met the inclusion criteria and were included in the qualitative synthesis, whereas 10 of them were included in the quantitative synthesis (meta-analysis). Except for the variable M-T-C(5) assessing maxillary arch form, which presented an increase at 48 months of follow-up, all other variables concerning craniofacial and dentoalveolar changes demonstrated no significant differences, indicating that PSIO treatment has no effect on CLP patients. The limited evidence derived from this study does not seem to support the short- or long-term effectiveness of PSIO in CLP patients.

Presurgical Nasoalveolar Molding (PNAM) for a Unilateral Cleft Lip and Palate: A Clinical Report

Cleft lip and palate deformity is a congenital defect of the middle third of the face. Incidence varies from 1:500 to 1:2500 live births. Etiology depends upon hereditary and environmental factors. Restoration of these defects is important not only for functional and esthetic reasons, but also because there may be a positive psychological impact for the patient and parents. The goal of primary closure of the lip for unilateral cleft lip is to ensure a normal and symmetrical lip and nose. Presurgical infant orthopedics has been employed since the 1950s as an adjunctive neonatal therapy for the correction of cleft lip and palate. Presurgical nasoalveolar molding (PNAM) represents a paradigm shift from the traditional methods of presurgical infant orthopedics. PNAM consists of active molding of the alveolar segments as well as the surrounding soft tissues. This clinical report describes a new approach of PNAM therapy for an infant with complete unilateral cleft lip and palate showing significant reduction in cleft defect size and improved contour and topography of deformed surrounding soft tissues.

Preliminary study of Korean orthodontic residents' current concepts and knowledge of cleft lip and palate management.

ObjectiveA national survey was conducted to assess orthodontic residents' current concepts and knowledge of cleft lip and palate (CLP) management in Korea.MethodsA questionnaire consisting of 7 categories and 36 question items was distributed to 16 senior chief residents of orthodontic department at 11 dental university hospitals and 5 medical university hospitals in Korea. All respondents completed the questionnaires and returned them.ResultsAll of the respondents reported that they belonged to an interdisciplinary team. Nineteen percent indicated that they use presurgical infant orthopedic (PSIO) appliances. The percentage of respondents who reported they were 'unsure' about the methods about for cleft repair operation method was relatively high. Eighty-six percent reported that the orthodontic treatment was started at the deciduous or mixed dentition. Various answers were given regarding the amount of maxillary expansion for alveolar bone graft and the estimates of spontaneous or forced eruption of the upper canine. Sixty-seven percent reported use of a rapid maxillary expansion appliance as an anchorage device for maxillary protraction with a facemask. There was consensus among respondents regarding daily wearing time, duration of treatment, and amount of orthopedic force. Various estimates were given for the relapse percentage after maxillary advancement distraction osteogenesis (MADO). Most respondents did not have sufficient experience with MADO.ConclusionsThese findings suggest that education about the concepts and methods of PSIO and surgical repair, consensus regarding orthodontic management protocols, and additional MADO experience are needed in order to improve the quality of CLP management in Korean orthodontic residents.

Presurgical Infant Orthopedics

This article focuses on current practices and controversy in the area of presurgical infant orthopedics in patients born with cleft lip and palate.

Long-Term Effects of Presurgical Infant Orthopedics in Patients with Cleft Lip and Palate: A Systematic Review

This study aimed to assess the scientific evidence on the efficiency of presurgical infant orthopedic appliances in patients with cleft lip and palate to shed light on a specific, contemporary discussion of whether the appliances have long-term advantages with respect to treatment outcomes. A systematic review. Two literature surveys from the five electronic databases were performed with a 1-month interval. Randomized controlled trials and controlled clinical trials (controls had no presurgical infant orthopedics) that had follow-up periods of a minimum of 6 years were included in the study. The exceptions to the follow-up limit were studies related to feeding and parent satisfaction. Of the 319 articles retrieved in the literature surveys, 12 were qualified for the final analysis. The level of evidence of these articles ranged from 1b to 4. Eight randomized controlled trials and four controlled clinical trials were available on eight treatment outcomes. The longest follow-up period of the randomized controlled trials was 6 years. No randomized controlled trials were found on active presurgical infant orthopedic appliances and on nasoalveolar molding appliances. Based on the results, presurgical infant orthopedic appliances have no long-term positive effects on seven of the eight studied treatment outcomes in patients with cleft lip and palate. More randomized controlled trials need to be done to have evidence regarding the effects of presurgical infant orthopedics in different surgical protocols. Also, the encouraging results about the effect of nasolaveolar molding appliances on nasal symmetry have to be supported by future randomized controlled trials.

Pre-directional appliance: A new approach to correct shifted premaxilla in bilateral cleft cases

Management of bilateral cleft lip and palate cases is a challenging task, and if the premaxilla is shifted to either side, it poses a problem for the surgeon to operate and also for the orthodontist to do the orthodontic alignment. The aim of this study was to reposition the shifted premaxilla for better retraction with presurgical infant orthopedics, thus reducing the tissue tension and further scarring which have detrimental effects on maxillary growth. The innovative technique with pre-directional (PD) appliance is easy to fabricate and use and works in this direction. Acrylic, springs, permasoft liner, elastics, retentive tapes. Previous approach for the shifted premaxilla was more focused on the surgical correction. In adults, surgery with osteotomy is the only option, with its own limitations and disadvantages, in repositioning the shifted premaxilla. Thus, PD appliance aids to correct the shifted premaxilla in presurgical molding stage. The premaxilla was thus shifted 5.5 mm to the left side, with premaxilla in facial symmetry, with the PD appliance. Presurgical orthopedics with PD appliance is worth in infants with shifted premaxilla in bilateral clefts cases.

Presurgical nasoalveolar moulding treatment in cleft lip and palate patients

ABSTRACTPresurgical infant orthopedics has been employed since 1950 as an adjunctive neonatal therapy for the correction of cleft lip and palate. Most of these therapies did not address deformity of the nasal cartilage in unilateral and bilateral cleft lip and palate as well as the deficiency of the columella tissue in infants with bilateral cleft. The nasolaveolar molding (NAM) technique a new approach to presurgical infant orthopedics developed by Grayson reduces the severity of the initial cleft alveolar and nasal deformity. This enables the surgeon and the patient to enjoy the benefits associated with repair of a cleft deformity that is minimal in severity. This paper will discuss the appliance design, clinical management and biomechanical principles of nasolaveolar molding therapy. Long term studies on NAM therapy indicate better lip and nasal form, reduced oronasal fistula and labial deformities, 60 % reduction in the need for secondary alveolar bone grafting. No effect on growth of midface in sagittal and vertical plane has been recorded up to the age of 18 yrs. With proper training and clinical skills NAM has demonstrated tremendous benefit to the cleft patients as well as to the surgeon performing the repair.

Presurgical nasoalveolar moulding treatment in cleft lip and palate patients

Presurgical infant orthopedics has been employed since 1950 as an adjunctive neonatal therapy for the correction of cleft lip and palate. Most of these therapies did not address deformity of the nasal cartilage in unilateral and bilateral cleft lip and palate as well as the deficiency of the columella tissue in infants with bilateral cleft. The nasolaveolar molding (NAM) technique a new approach to presurgical infant orthopedics developed by Grayson reduces the severity of the initial cleft alveolar and nasal deformity. This enables the surgeon and the patient to enjoy the benefits associated with repair of a cleft deformity that is minimal in severity. This paper will discuss the appliance design, clinical management and biomechanical principles of nasolaveolar molding therapy. Long term studies on NAM therapy indicate better lip and nasal form, reduced oronasal fistula and labial deformities, 60 % reduction in the need for secondary alveolar bone grafting. No effect on growth of midface in sagittal and vertical plane has been recorded up to the age of 18 yrs. With proper training and clinical skills NAM has demonstrated tremendous benefit to the cleft patients as well as to the surgeon performing the repair.

Nasoalveolar Molding for Infants Born with Clefts of the Lip, Alveolus, and Palate

Presurgical infant orthopedics has been employed since the 1950s as an adjunctive neonatal therapy for the correction of cleft lip and palate. Nasoalveolar molding represents a paradigm shift from the traditional methods of presurgical infant orthopedics. One of the problems that the traditional approach failed to address was the deformity of the nasal cartilages in unilateral, as well as bilateral, clefts of the lip and palate and the deficiency of columella tissue in infants with bilateral clefts. The Nasoalveolar Molding (NAM) technique utilizes wire and acrylic nasal stents attached to an intraoral denture. This appliance is used to mold the nasal cartilages, premaxilla, and alveolar ridges into normal form and position during the neonatal period. In effect, this presurgical management of the cleft infant is intended to reduce severity of the oronasal deformity prior to surgery. This technique takes advantage of the malleability of immature nasal cartilage and its ability to maintain a permanent correction of its form. In addition, we demonstrate the ability to nonsurgically elongate the columella in bilateral cleft lip and palate through the application of tissue expansion principles. This is performed by gradual elongation of the nasal stents and the application of forces that are applied to the lip and nose. Utilization of the NAM technique has eliminated surgical scars associated with traditional columella reconstruction, has reduced the number and cost of revision surgical procedures, and has become the standard of care in this Cleft Palate Center.

The orthodontist and complex craniofacial anomalies

The orthodontist and complex craniofacial anomalies

Current Trends in the Treatment of Bilateral Cleft Lip and Palate

Surgery alone in a primary synchronous repair is able to correct the nasal deformity in bilateral cleft lip and palate at 6 months of age. The patency of the nostrils and the elongation of the columella are and remain good when a nasal retainer is maintained during the first 3 to 4 months. There is no need for presurgical nasoalveolar molding or lip adhesion. I believe it is important to know that presurgical infant orthopedics are not necessary to lengthen the columella and that it is not a good argument to justify their use. Wealthy countries perhaps can bear the high cost of procedures such as presurgical nasoalveolar molding with the subsequent risk of a narrow anterior maxillary arch that increases orthodontic treatment time and cost and the probability of LeFort I osteotomy. In countries in which the cost must be reduced it is possible to correct the cleft lip-nose deformity in one operation with good results and to delay the first orthopedic treatment up to 4 years of age to perform the gingivoperiosteoplasty with a bone graft at approximately 5 years of age, so that the width and the relationships of the maxillary arch are normal at the time of the mixed dentition.

Presurgical nasoalveolar molding in infants with cleft lip and palate.

Presurgical infant orthopedics has been employed since the 1950s as an adjunctive neonatal therapy for the correction of cleft lip and palate. In this paper, we present a paradigm shift from the traditional methods of presurgical infant orthopedics. Some of the problems that the traditional approach failed to address include the deformity of the nasal cartilages in unilateral as well as bilateral clefts of the lip and palate and the deficiency of columella tissue in infants with bilateral clefts. The nasoalveolar molding (NAM) technique we describe uses acrylic nasal stents attached to the vestibular shield of an oral molding plate to mold the nasal alar cartilages into normal form and position during the neonatal period. This technique takes advantage of the malleability of immature cartilage and its ability to maintain a permanent correction of its form. In addition, we demonstrate the ability to nonsurgically construct the columella through the application of tissue expansion principles. This construction is performed by gradual elongation of the nasal stents and the application of tissue-expanding elastic forces that are applied to the prolabium. Use of the NAM technique has eliminated surgical columella reconstruction and the resultant scar tissue from the standard of care in this cleft palate center.

3-dimensional analysis of cleft palate casts

It is the aim of presurgical infant orthopedics (PSIO) to reduce the width of the cleft and to achieve optimal alignment of the cleft palate segments within the first few months of infancy prior to any surgical cleft closure. The question about the amount that PSIO can stimulate and steer the growth of the maxilla using a Hotz and Gnoinski passive appliance has not yet been satisfactorily answered. In this study, a 3-dimensional digital computer-aided procedure was developed to analyze metrically and to visualize the growth of the edentulous maxilla of cleft lip and palate in infants. In a pilot study, a series of digital scans of consecutive plaster casts was carried out. 5 infants with complete unilateral cleft lip and palate (UCLP), who had been treated with passive appliances were evaluated. Impressions were taken at the age of one week and after 3, 6 and 12 months. Following digitizing, the casts were computer-reconstructed and segmented perpendicular to the alveolar crest, the reference points being C1, C1', C2, C2' and I. The volume of the resulting segments was ascertained. Computer superimposition of reconstructed consecutive casts was employed to facilitate a visualization of the extent and direction of morphological changes. Our first results have shown that with our method it is possible to quantify the growth rate of defined segments of the maxilla. The 3-dimensional analysis presented here will be the basis for further studies to objectify PSIO.