Presurgical Nasoalveolar Molding Research Articles

3D nasoalveolar moulding: A complete digital workflow model

Nasoalveolar moulding (NAM) is a paradigm shift from the presurgical orthopaedics used extensively over the past 20 years in infants with cleft lip and palate. It has been proposed that the gap between the clefted segments be filled up before surgical repair via presurgical nasoalveolar moulding. To attain the best practical and aesthetic results, it is a straightforward yet effective treatment that must be started at the appropriate age and time. In order to enhance treatment outcomes, convenience of use, compliance, and cost-effectiveness, recent developments in NAM therapy have focused on implementing changes to the nasal stent or intraoral moulding plate. Specifically, 3D technology has been used to improve the efficiency of NAM device design and develop standardised, objective methods of determining progressive morphological changes during therapy. The article discusses various methods that use 3D printing technology to produce tangible components from a virtual therapeutic strategy. It also looks at how developments in computational methods and printing materials could open up novel opportunities for computer-assisted NAM therapy.

3-Dimensional Evaluation of Two PNAM Techniques (Modified Grayson & AlignerNAM) on Facial Soft Tissue Morphology: A Randomised Clinical Trial.

Evaluate facial changes after Presurgical Naso-Alveolar Molding (PNAM) in unilateral cleft lip and palate (UCLP) patients treated with Modified Grayson Technique and AlignerNAM (with DynaCleft nasal elevator) using a 3D facial scan. Randomised clinical trial. Institutional study. Participants: 20 UCLP patients allocated to two groups (10 patients each). Group A patients underwent PNAM with Modified Grayson Technique and Group B patients underwent AlignerNAM (with DynaCleft nasal elevator). Their 3D facial scans were obtained by using an iOSbased application (Bellus3D FaceApp) mounted on a novel frame. These .stl files were analysed using 3D software (GOM INSPECT) at three-time intervals; before intervention (T0), after intervention (T1) and one month after lip repair surgery (T2). Changes in facial and nasolabial morphology. Both techniques brought significant improvement in the columellar length, nasal tip projection, columella angle, nasal tip angle and a significant reduction in cleft width. At T1, a statistically significant difference in angular and linear measurements was present in both groups. At T2, no statistically significant difference in linear parameters was observed between the two groups except for the outer lateral height of the non-cleft side, basal lateral height of the non-cleft side, and philtrum width. Similar pattern was observed in angular measurements with no statistically significant difference between the two groups except in nasolabial angle, anterior nasal base triangle III, and anterior nasal root triangle. Aligner NAM and Modified Grayson technique are equally effective PNAM methods with similar clinical results in nasolabial morphology after lip repair surgery.

A Bibliographic Analysis of Indian Contribution in Application of Presurgical Naso-Alveolar Molding in Cleft Lip/Palate Infants

Background: Pre-surgical nasoalveolar molding is a novel treatment modality applied in cleft lip/palate infants prior to surgery. Numerous articles have been published in the literature. Using Bibliographic analysis tt is essential to know the nation wise contribution of total research output towards PSNAM. Aim: To evaluate Indian contribution globally on the domain ‘application of presurgical naso-alveolar molding in cleft lip/palate infants’ by analysing all the studies published till date. Materials and Methods: A detailed bibliographic database search was carried out using PUBMED for a period of two months from September to October 2023. Different Mesh keywords in several combinations were used to obtain the articles. All types of published articles from inception till October 2023 and were published in English language were considered for this bibliographic analysis. The selected published articles pertaining to Indian Institutions, researchers or authors and specialties were tabulated and evaluated to obtain the overall bibliographic details. Results: India’s global contribution was 6.65% (total 31 articles). More number of case reports (n=15) were published followed by case control studies (n=5). Highest publication credit was conquered by author Thakur S (n=5) and Journal of Indian Prosthodontic Society and Contemporary clinical dentistry journals shared maximum articles published (n=5 each) having impact factor of 0.265 and 1.2 respectively. South zone contribution was highest (n=12) in that Karnataka state bagged with highest contribution. H.P. Government Dental College and Hospital and regarding specialty, Pediatric and Preventive Dentistry contributed more research work towards PSNAM. Conclusion: From the present bibliographic review, it was concluded that there is a growing demand and increasing trend in the application of PSNAM in cleft lip/palate infants. The current review provides insight into the current literature on PSNAM and paves for further research and its application in clinical practice

Outcomes of Presurgical Nasoalveolar Molding using Modified Nostril Retainers in Patients with Unilateral Cleft Lip and Palate at an Average Follow-up of 2 Years.

Presurgical nasoalveolar molding (PNAM) using a modified nostril retainer is a new treatment approach. This study aimed to evaluate the outcomes of early nasal molding using this approach with an average follow-up of 2 years in patients with severe unilateral cleft lip and palate. This retrospective study included 18 patients with unilateral cleft lip and palate without genetic syndromes who underwent PNAM with modified nostril retainers. The Grayson technique was employed with an intraoral plate to approximate cleft segments. Nasal molding was initiated before reducing the cleft width to 5 mm. Measurements, including alar base height ratio (ABHR), nasal floor width ratio (NFWR), columellar length ratio (CLR), columellar angle (CA), and nostril axis inclination on the cleft and non-cleft sides (NAI-C and NAI-NC, respectively), were calculated from standard photographs taken before PNAM (T1), after PNAM (T2), after an average of 1.81 months post-surgery (T3), and after an average of 2.2 years after T3 (T4). Pairwise comparisons of values at the four time points were conducted. NFWR, CLR, CA, NAI-C and NAI-NC significantly increased after PNAM (p<0.05). However, no significant change was observed in ABHR (p>0.05) from T1 to T2. These outcomes were maintained at T4, and no patient developed a mega nostril. The use of a modified nostril retainer for nasal molding appears to provide stability during the high probability of relapse reported in the literature.

Post-cheilorhinoplasty esthetic evaluation of unilateral cleft lip and palate infants treated with and without pre-surgical nasoalveolar molding

Objectives: Unilateral cleft lip and palate sets many challenges both functional and esthetic. Cleft patients are at an elevated risk for developing psychosocial problems. The objective of this study was to assess any difference in esthetics post-cheilorhinoplasty in unilateral cleft lip and palate (UCLP) infants treated with and without nasoalveolar molding. Materials and Methods: Esthetic evaluation of nasolabial appearance and comparative analysis of photographic records collected post-cheilorhinoplasty for presurgical nasoalveolar molding (PNAM), lip-tape (LPTP), no pre-treatment (NoPreTx), and control (CTRL) groups were done using 5 point scale. There were six evaluators, two orthodontists, and one maxillofacial surgeon each from the two participating institutions. Paired “t”-test for nasolabial score comparison between groups, Cronbach’s alpha for reliability analysis, and Fleiss Kappa for interevaluator agreement were used for statistics. All statistical analysis was done at confidence level of 95% and 0.05 as level of significance. Results: Significant difference was found between nasolabial esthetic scores for PNAM group when compared to LPTP (P = 0.000) and NoPreTx (P = 0.001) groups. Infants who underwent PNAM had better nasolabial esthetic scores in all categories compared to infants who underwent LPTP or NoPreTx. The scale of measurement and the nasolabial esthetic evaluation scores were coherent and reliable as shown by Crohnbach’s alpha (&lt;0.9) both for individual components and for overall score. Conclusion: UCLP infants who were brought by their parents to the craniofacial center early within 1 month of their birth and who underwent nasoalveolar molding therapy before cheilorhinoplasty had significantly better nasolabial esthetics post-surgery.

The Effect of Presurgical Nasoalveolar Molding on Oronasal Fistula Following Primary Palatoplasty

Objective: Presurgical nasoalveolar molding (PNAM) is widely used in cleft care protocol. This study investigated the correlation between PNAM and oronasal fistula after primary palatoplasty. Methods: A case-controlled study of 80 unilateral and bilateral complete cleft palate patients who underwent cleft palate repair were enrolled. Patients were divided into 2 groups: (1) no PNAM use and (2) PNAM use. The incidence of oronasal fistula and postoperative complications were compared between groups. Results: Forty patients in each group demonstrated the same baseline characteristics. The PNAM group showed a significantly lower postoperative oronasal fistula rate (15% versus 50%, P=0.003). Palatal cleft width wider than 12.5 mm increases the odds ratio of fistula formation by 1.19-fold (P=0.037), and the PNAM protected against postoperative palatal fistula formation (odds ratio 0.20, P=0.003). Conclusion: Presurgical nasoalveolar molding can reduce postoperative oronasal fistula in wide-gap Veau type III and IV cleft palate.

Establishment of a novel classification system for alveolar morphology in infants with unilateral complete cleft lip and palate

ObjectivesUnilateral complete cleft lip and palate (UCCLP) is one of the most severe clinical subtypes among cleft lip and palate (CLP), making repair surgery and subsequent orthodontic treatment particularly challenging. Presurgical nasoalveolar molding (PNAM) has shown conflicting and heterogeneous results in the treatment of UCCLP patients, raising questions about whether the diversity in alveolar anatomical morphology among these patients plays a role in the effectiveness of PNAM treatment.Materials and methodsWe collected 90 digital maxillary models of infants with UCCLP and performed mathematical clustering analysis, including principal component analysis (PCA), decision tree modeling, and area under the ROC Curve (AUC) analysis, to classify alveolar morphology and identify key measurements. We also conducted clinical evaluations to assess the association between the alveolar morphology and CLP treatment outcomes.ResultsUsing mathematical clustering analysis, we classified the alveolar morphology into three distinct types: average form, horizontal form, and longitudinal form. The decision tree model, AUC analysis, and comparison analysis revealed that four measurements (Trans ACG-ACL, ML length, MG length and Inc length) were essential for clustering the alveolar morphology of infants with UCCLP. Furthermore, the blinded clinical evaluation indicated that UCCLP patients with alveolar segments of horizontal form had the lowest treatment outcomes.ConclusionOverall, our findings establish a novel quantitative classification system for the morphology of alveolar bone in infants with UCCLP and suggest that this classification may be associated with the outcomes of CLP treatment.Clinical relevanceThe multidisciplinary CLP team should thoroughly evaluate and classify the specific alveolar morphology when administering PNAM to infants with UCCLP.

Perception and Attitude of Parents of Children With Orofacial Clefts Regarding the Use of Presurgical Orthopedics and Feeding Obturators.

This study aims to evaluate the parents' attitude and their perception regarding the management of orofacial cleft (OFC) children with presurgical nasoalveolar molding (PNAM), DynaCleft and/or feeding obturators. A cross-sectional, descriptiveand observational retrospective survey-based study was conducted among parents of OFC children treated with PNAM, DynaCleft and/or feeding obturators who attended a primary dental health care center in Al-Madinah, Saudi Arabia, from 2019 to 2023. A validated questionnaire was used after translating it from English to Arabic. The questionnaire consisted of 32 questions divided into two sections. The first section covers parents' sociodemographic data and OFC risk factors. The second section evaluates the parents' perception regarding the use of presurgical orthopedics (PSO) for OFC repair. The questionnaire was completed through telephone interviews carried out by two investigators with the parents of OFC children. Out of 142 parents of OFC children, only 40 parents and their children met the inclusion criteria of the study. Most parents (95%) reported their satisfaction with the treatment and stated that they would encourage other parents of OFC children to use PSO. This study concluded that parents of OFC children had a positive attitude towardPSO treatment. Based on the positive outcomes of PSO treatment reported in the current study and previous literature, PSO should be considered as a routine treatment in the early management of orofacial clefts.

Schematic Treatment Tree for the Presurgical Nasoalveolar Moulding of Patients with Cleft Lip and Palate.

Cleft lip and palate is the most common and unfortunate congenital defect that is debilitating for both the patients and their parents. Such complex condition demands for a precise and judicious management, as its outcome can drastically influence the quality of life of the child. To provide a concise treatment algorithm or tree which might guide the clinicians and make it easier for them to opt for a better treatment option when confronting different severities and types of this defect. The clinical experience at our center alongwith review of current literature is used to propose a decision making treatment tree. For the better aesthetics, function and ease of cosmetic surgery, several presurgical procedures have been introduced including the nasoalveolar moulding (NAM) appliance, adhesive tapes with nasal elevators, Figueroa's appliance, Hotz appliance, etc. The schematic decision-making tree may prove beneficial to the healthcare providers specially pedodontists who frequently come across such situations to choose the best treatment option for their patients.

Presurgical Nasoalveolar Molding Modified Technique in Complete Bilateral Cleft Lip and Palate Infant: A Case Report

Through this research, we have presented a modified presurgical nasoalveolar molding (PNAM) device, protocol, and equipment of preoperative nasal alveolar formation techniques to improve lip, nose, alveolar, and palatal deformity in the Department of Orthodontics and Maxillo-Facial Department at the University of Prishtina. A two-week-old boy was brought to our Department of Orthodontics. The baby was diagnosed with non-syndrome bilateral complete cleft of the primary and secondary palate. After a complete examination and orthodontic therapeutic planning, precaution was taken for creating a PNAM appliance and sent to the laboratory. An intraoral molding plate was established on both sides of the separate segments of the maxilla and fixed with a mini screw to approximate the maxillary segments. Parts of the strings built in the front side activated (please check) and, together with the nasal stent, were added to correct the nose deformity. By using modified NAM to close the cleft segments, both the ones of the upper lip and the ones of the palate, we achieved the same results and reduced possible tissue damage by maintaining the conventional NAM apparatus. We used an alveolar formation plate with traction stainless steel to reduce the separate parts. Under this presurgical treatment, the cleft alveolus and palatal segments were reduced considerably. Also, the parts of the flatting nasals of the nose were set up. Through interdisciplinary work, we created a new modified NAM appliance to avoid the obstacles of the traditional NAM devices and to improve the presurgical treatment by using the benefits of the postnatal period of the child to have a more effective treatment. Despite the inability of previous studies to decide on the degree of efficacy of PNAM and the fact that scientific data is limited, we consider that our research can contribute to a better understanding of why it is essential to use PNAM and of the need to enhance the apparatus.

Design of Unilateral Complete Presurgical Nasoalveolar Molding (PNAM) Corrector Based on Feature Points Extraction of Complex 3D Surface

Cleft lip and palate is a congenital maxillofacial deformity. Unilateral complete cleft lip and palate is one of the most common clinical types. Nasal alveolar molding (PNAM) is a recognized strategy for the treatment of cleft lip and palate. However, the current design of PNAM devices mainly relies on the subjective experience of doctors. The purpose of this paper is to describe the design and manufacture of a new computer-aided design appliance, which can be applied to the presurgical nasoalveolar molding of unilateral complete cleft lip and palate, eliminate individual differences, and improve production efficiency. In this paper, seven feature points on the healthy side and the affected side are extracted by the method of Gaussian curvature and ridge line extraction, and the healthy side rotation and built-in model are designed by using these seven feature points, which can quickly generate eight treatment stages of PNAM. The correction effects of the PNAM appliance designed in this paper were compared with the original maxillary model and the clinical PNAM appliance (hand-made by subjective experience) from the aspects of alveolar fissure width and symmetry. The PNAM appliance designed in this paper can effectively improve the symmetry of patients with unilateral complete cleft lip and palate (morphological similarity: t = 3.250, p ≤ 0.01; length similarity: t = 1.559, p = 0.150) and reduce the width of alveolar cleft (t = 8.330, p &lt; 0.01). This can fully achieve the therapeutic effect of PNAM appliances prepared by experienced doctors and is more efficient. The method based on complex 3D surface feature point extraction can provide the basis for the design and evaluation of a unilateral complete PNAM correction model, improve the design and production efficiency of unilateral complete cleft lip and palate appliance, eliminate the design problems caused by individual differences, and reduce the burden of doctors.

PREDICTABLE FACIAL ESTHETICS BY PRESURGICAL NASOALVEOLAR MOULDING IN NEONATES - A CASE REPORT

A Cleft is a congenital abnormal space or gap in the upper lip and palate. Although plastic surgery has made great advances in the area of cleft surgery, aesthetical corrections of the decient columella and nasal cartilages were difcult. presurgical naso-alveolar molding (PNAM) at an early stage is used to reduce soft tissue and cartilaginous deformity. This article presents a case report of a 6-day-old baby boy with a left-sided unilateral incomplete cleft lip and palate, with no signicant medical history or any associated systemic illness. He was referred with the primary need for a feeder plate. The width of the cleft was measured from the base of the alveolus on one side to the other and was approximately 7 mm. The nal impression was made with a custom tray. NAM appliance was fabricated and inserted in the patient's mouth. Orthodontic wire of 21 gauzes was used for wire bending to support the acrylic forming a nasal bulb. In 2 months, the followup patient was recalled at each 15 days intervals for 1 and a half months for activation and modication of the plate to gradually approximate the alveolar segments. After 2 months of follow-up, it was shown that the cleft palate gap was reduced to 3mm from 7mm. PNAM allows overall improvement in the aesthetics of nasolabial complex in cleft conditions and minimizes the extent and the numbers of surgery. The cleft deformity was signicantly reduced in size with the NAM therapy in the present case

Comparison of Facial Growth Between Two Nasoalveolar Molding Techniques in Unilateral Complete Cleft Lip Patients: A Randomized, Prospective, Single-blind Trial.

Nasoalveolar molding (NAM) has become standard treatment in our Craniofacial Center. Two types of pre-surgical NAM, Grayson technique and Figueroa technique, co-exist. We previously found no differences in number of clinic visits, cost and 6 months post-operative outcome between the two techniques. Since Figueroa's method involves passive, whilst Grayson's method involves active, alveolar molding, we extended the previous study to evaluate facial growth between these two groups. This randomized, prospective, single-blind study, conducted between May 2010 and March 2013, recruited 30 patients with unilateral complete cleft lip and palate patients and randomized them for Grayson or Figueroa pre-surgical NAM. Their standard lateral cephalometric measurements at 5 years were used to determine facial growth. Twenty-nine patients completed 5 years of follow-up. There were no statistical differences in facial cephalometric measurements between the two groups. Pre-surgical NAM using either passive or active NAM technique produced similar facial growth patterns after unilateral cleft lip and palate repair.

Presurgical naso alveolar moulding in a bilateral cleft lip and palate patient- A case report

One third of all craniofacial anamolies of head and neck region are of cleft lip and palate with an incidence of 1 in 700 worldwide. In Asian population the reported incidence is 2.0 per 1000 live births or higher. This case report presents the treatment of a 1-month old bilateral cleft lip and palate baby with Presurgical Nasoalveolar Molding, which was followed by chelioplasty.

PNAM (Presurgical Nasoalveolar Molding) therapy-first step in preparation of infant for cleft lip and palate repair

PNAM (Presurgical Nasoalveolar Molding) therapy-first step in preparation of infant for cleft lip and palate repair

Presurgical Nasoalveolar Molding—Efficacy and Biomechanics in Management of Cleft Lip and Palate: A Review of the Literature

AbstractPresurgical infant orthopaedics (PSIO) appliances are used in the management of cleft lip and palate. Frequently, among all PSIO appliances utilized is presurgical nasoalveolar molding (NAM) appliance. In this review, we looked for the application of the NAM appliance, its efficacy, and biomechanics. A comprehensive search strategy was performed in two databases (Google Scholar and PubMed) for articles using NAM in the treatment plan of patients with cleft lip and palate. Six articles were included in this study with one randomized control trial, two retrospective, and three case reports studies. The studies reveal the NAM is efficient as a presurgical modality treatment for complete cleft lip and palate with multiple benefits, including reducing surgical scars and alveolar gap, used as feeding plate, improve nasal contour, and decreased the number of rectifying surgical procedure.

Effect of NAM on Nasal Symmetry and Proportions in Patients with UCLP: A Systematic Review

Introduction : Nasal reconstruction presents a challenge in case of patients with unilateral cleft lip and palate (UCLP). Correction of the nasal deformity to achieve a symmetrical nose from the deficient columella and malformed nasal cartilage in cleft patients presents a great challenge. Nasoalveolar molding (NAM) was developed as a neoadjuvant therapy for patients with cleft lip and palate to improve nasal deformity before surgical intervention. The aim of this systematic review was to understand more about the effect of NAM on nasal symmetry and proportions in patients with UCLP. Method : We searched for manuscripts involving patients with UCLP who received NAM prior to cleft lip repair. Electronic literature searching of the PubMed, Scopus, Cochrane and Google scholar databases was conducted for the studies that had been published up to December 2021. Result : Presurgical NAM demonstrated benefits in nasolabial form when compared with patients who did not receive any presurgical infant orthopaedic appliances (PSIO). The use of presurgical NAM helps to achieve favourable reshaping of the nose and decrease the severity of the initial cleft deformity, resulting in improvement on nasolabial form. These changes lead to improved nasal symmetry and proportions in UCLP patients. Conclusion: The preponderance of evidence in this review suggests that presurgical NAM is a beneficial adjuvant therapy for nasal deformity correction and helps achieve nasal symmetry in patients with UCLP. However, there is insufficient evidence to conclude whether presurgical NAM produces these benefits at the time of nasal maturity.

An investigation into nutritional methods at the fifth day after birth of infants in association with cleft type and laterality.

In patients with clefts, the affection of other congenital malformations on the feeding is unclear. We investigated the other congenital malformations and nutritional intake of neonates with cleft lip and/or palate and examined their relationships associated with cleft type and laterality. The participants included 126 infants under treatment with a presurgical naso-alveolar molding (PNAM) or a Hotz-type plate. The survey items were gender, cleft type and side, presence and nature of other congenital malformations, birth weight and nutritional method at age of the fifth day. The number of infants was 36 (28.6%) of cleft lip and alveolus, 82 (65.1%) of cleft lip and palate, and 8 (6.3%) of cleft palate only. Forty-three patients (34.1%) had other various congenital malformations. The nutritional method included oral intake in 78.6% (n=99) of cases and tube feeding with/without oral intake in 21.4% (n=27) of cases. The rate of tube feeding was higher for right-sided clefts than that for left-sided clefts. This observation was consistent with the fact that right-sided clefts were associated with more significant other congenital malformations than those on the left-side. The nutritional method for infants with cleft lip and/or palate was related to the presence of other congenital malformations, not to cleft laterality or oral cleft itself under early treatment with PNAM plate. These results proposed that screening the general condition is essential for neonates with right-sided cleft lip with/without cleft palate compared to left-sided clefts, which should be conducted immediately after birth for planning the appropriate nutritional method.

Influence of presurgical nasoalveolar molding (PNAM) treatment in maxillary dental arch width and nasolabial symmetry in patients with unilateral complete cleft lip and palate.

Unilateral complete cleft lip and palate (UCCLP) is one of the most severe clinical subphenotypes among nonsyndromic cleft lip and/or palate (NSCL/P), that complicates surgical repair operations. Presurgical nasoalveolar molding (PNAM) is a technique used to reshape the nose, lip and alveolar bone of infants with UCCLP before surgery (the modified Mohler rotation advancement cheiloplasty and two flap palatoplasty), with the potential to facilitate surgical repair. However, the effectiveness of PNAM treatment is still a matter of debate. In this paper, the 3Shape scanning system and 3dMD stereophotography were used to assess the short-term and long-term effects of PNAM treatment on the dental arch morphology and nasolabial features of patients with UCCLP, respectively. The findings indicated that PNAM treatment negatively affects both short-term and long-term dental arch shape compared to the treatment without PNAM, particularly in terms of limiting the transverse width of the maxillary canine-to-midline. Regarding the nasal and labial symmetry, PNAM improves the symmetry of the nasal alae in patients over 7 years old and the symmetry of the lip in patients under 7 years old. Moreover, UCCLP patients who received PNAM treatment exhibited a shorter and wider shape of the nostril on the cleft side compared to those without PNAM treatment. In clinical practice, the multidisciplinary team should carefully consider the advantages and disadvantages of the outcomes of PNAM treatment when treating infants with cleft lip and palate.

Knowledge, Attitude, and Perception among Dental Graduate Practitioners about Presurgical Naso-alveolar Molding Therapy in cleft lip/palate infants: A Questionnaire-based Survey

Aim: To explore or evaluate dentist’s (BDS graduate practitioners) knowledge and perception towards Presurgical Naso-alveolar molding (PNAM) in cleft lip/palate infants. Materials and methods: A questionnaire containing 10 validated questions (Google forms) was electronically distributed through E-mail and WhatsApp. A total of 144 BDS graduate practitioners were included in the study. The data obtained was subjected to statistical analysis. Results: The majority of BDS practitioners were not aware of PSNAM regarding many of its aspects like the time duration required for PSNAM treatment, the person who performs PSNAM, the design of the appliance, and the infant's age at which it is carried out. 91% of the practitioners showed interest in learning information about PSNAM and wished to attend workshops or courses about PSNAM. Conclusion: There is a necessity to enhance the level of awareness, perception, and knowledge of BDS graduate practitioners towards the PNAM treatment performed in cleft lip/palate infants.