Early cleft management: the case for nasoalveolar molding

Three-dimensional analysis of presurgical nasoalveolar molding outcomes in patients with unilateral cleft lip and palate: A preliminary study using LED surface scanning technology

OBJECTIVES

Presurgical infant orthopedic appliances, such as presurgical nasoalveolar molding (PNAM) devices, are used to attain optimal conditions for primary repair of the lip and nose (PRoLN) in patients with cleft lip. We aimed to analyze the three-dimensional (3D) outcomes of PNAM using an LED surface scanner.

METHODS

Fifteen patients with unilateral cleft lip and palate (CLP) were included in this study and treated using a PNAM device. The patients' faces were digitized pre- and post-PNAM using an Artec Space Spider scanner, and the scanned data were analyzed using 3D software (Geomagic Control X and ANSYS SpaceClaim). The columellar angle (CA), nostril curvature (NC) on the affected (NC_A) and unaffected (NC_U) sides, gap of cleft lip (GCL), alar width (AW), and nasal tip angle (NTA) were measured.

RESULTS

CA increased significantly by 10.00° and NC_A by 0.030 mm-1 (p < 0.001). GCL decreased by 4.98 mm2 on average and NC_U by 0.015 mm-1 (p = 0.029 and 0.046, respectively). AW also decreased by approximately 1.22 mm pre- and post-treatment (p = 0.002), and NTA, which shows a lateral profile, decreased by approximately 3.32° (p = 0.002).

CONCLUSIONS

This study confirmed the orthopedic benefits of PNAMd treatment through 3D analysis using an LED surface scanner. Further studies involving a larger number of participants are warranted to study the effects of PNAM and analyze longitudinal changes in patients with CLP.

CLINICAL SIGNIFICANCE

This study shows that PNAM effectively corrects columellar deviation and nostril shape in patients with unilateral cleft lip, with 3D scanners enhancing primary lip and nose repair outcomes.

Treatment outcomes of digital nasoalveolar moulding in infants with cleft lip and palate: A systematic review with meta-analysis

The aim of this systematic review was to compare the treatment outcomes of digital nasoalveolar moulding (dNAM) technique with conventional nasoalveolar moulding (cNAM) or non-presurgical intervention protocol in infants with unilateral (UCLP) or bilateral (BCLP) cleft lip and palate. A bibliometric search by MEDLINE (via Ovid), Embase, Cochrane Library, grey literature and manual method was conducted without language restriction until November 2023. Literature screening and data extraction were undertaken in Covidence. The risk of bias was evaluated using the Newcastle-Ottawa Scale and RoB-2. Pooled effect sizes were determined through random-effects statistical model using R-Software, and the certainty of evidence was assessed using the GRADE approach. Among 775 retrieved articles, nine studies were included for qualitative synthesis (6-UCLP, 3-BCLP), with only three eligible UCLP studies for meta-analysis. In the UCLP group, very low certainty of evidence indicated no difference in alveolar cleft width (SMD, 0.13 mm; 95% CI, -0.31 to 0.57; I2, 0%), soft tissue (lip) cleft gap, nasal width, nasal height, and columellar deviation angle changes between dNAM and cNAM. In the BCLP group, qualitative synthesis suggested similar changes in alveolar, lip, and nasal dimensions with dNAM and cNAM. In both cleft groups (UCLP, BCLP), reduced alveolar cleft width was observed in the dNAM group compared to the non-presurgical intervention protocol, along with fewer clinical visits and reduced chairside time for dNAM compared to cNAM. It can be concluded that the treatment outcomes with dNAM were comparable to cNAM in reducing malformation severity and were advantageous in terms of chairside time and clinical visit frequency. However, the overall quality of evidence is very low and standardization is needed for the virtual workflow regarding the alveolar movements and growth factor algorithms. Registration: PROSPERO-database (CRD42020186452).

A cross-sectional analysis of the content and quality of presurgical infant orthopedics videos on YouTube

BACKGROUND

Caregivers seeking additional information about Presurgical Infant Orthopedics (PSIO) may turn to online sources, but the quality of information on platforms like YouTube is uncertain.

AIM

To investigate the content and quality of PSIO videos on YouTube.

DESIGN

YouTube videos were searched using keywords related to PSIO appliances. Videos that met the eligibility criteria (n = 52) were categorized as care provider or caregiver-based. Engagement metrics were analyzed and quality assessments were performed by two raters using the Global Quality Score (GQS), Video Information and Quality Index (VIQI), and Medical Quality Video Evaluation Tool (MQ-VET).

RESULTS

Inter-rater and intra-rater correlations were high (r ≥0.9; p < 0.01), indicating excellent reliability. Strong correlations were observed between the GQS, VIQI, and MQ-VET scores (r: 0.86-0.91; p < 0.01). Mean GQS (2.7 ± 1.1), VIQI (13.0 ± 4.1), and MQ-VET (42.6 ± 12.4) scores indicated poor to moderate video quality. Most videos (73.1%) were in the care provider category and rated significantly higher (p < 0.05) in quality than the caregiver category for all three indices, but not for video engagement metrics.

CONCLUSION

YouTube PSIO videos are not comprehensive and lack quality. Caregivers of infants undertaking PSIO should seek advice from care providers and not rely solely on YouTube videos.

Assessment of knowledge, awareness, and attitude about the current treatment protocols for newborns with cleft lip and palate among obstetrician-gynecologists and radiologists – A questionnaire survey

This study aimed to assess the knowledge, awareness, and attitudes of Obstetricians-gynaecologists and radiologists regarding current treatment regimens for CLP and their perspectives on elective termination of pregnancy for the same cause.

A 15-question survey was conducted among 68 gynaecologists and 52 radiologists who were registered with the Medical Council of India. The questionnaire, distributed via social network, contained 19 questions, including knowledge, awareness, and attitude regarding CLP, presurgical orthopaedics, and pregnancy termination. Spearman rank correlation was used to assess construct validity, and a Chi-square test with a significance level of 0.05 was used to compare the responses between both groups.

The study showed that about 89% of gynaecologists and 92.3% of radiologists can identify CLP during the initial assessment of the foetus using ultrasound technique, whereas 30.90% of gynaecologists and 36.50% of radiologists have encountered elective termination of pregnancy due to CLP. While 89.70% of gynaecologists and 88.50% of radiologists do not know pre-surgical orthopaedic procedures for CLP. No statistically significant difference existed in the knowledge level about CLP and its treatment regimens among both groups.

The awareness and attitude among the OB-GYNs, and radiologists on prenatal detection of CLP was found to be highly significant. At the same time, there was limited knowledge among these specialists about CLP and its management.

Comparative Study of Maxillary Growth in Patients With Unilateral Cleft Treated With and Without Pre-Surgical Orthopedics

Compare the maxillary growth of patients with Unilateral Cleft treated with pre-surgical Functional Maxillary Orthopedic (FMO) and that of who underwent a surgical procedure with no previous use of appliances.

Prospective study, the patients were divided into 2 groups. G1, was composed of 12 patients who received no pre-surgical intervention and cheilorhinoplasty at 6 months of age and G2, included 12 patients treated using Pre-Surgical Funtional Maxilary Orthopedic; they underwent no surgery during the study. Measurements were taken at three times: before the first month of life, at 6 months and between 9-12 months of age. Cleft distance (anterior, medium and posterior), maxillary width (anterior, medium and posterior) and minor and major segment width were analyzed.

Alveolar Cleft decrease was 79.82% in G1 and 52% in G2. Posterior Cleft decrease was 24.1% in G1 and 41.77% in G2. Greater Segment Width increase was 24.53% for the patients in G1, and 37.47% for the patients in G2. As for Inter Canine Width, a decrease of 5.16% in G1 and an increase of 9.19% in G2 were found. Medium Arch Width only increased in a statistically significant manner in G2 9.02%.

Surgery allowed for the closure of the alveolar cleft. FMO made it possible to close the anterior and the posterior clefts through the growth of the maxillary segments, increased the transverse growth of the maxilla and could prevent maxillary collapse. Each team must individually evaluate whether to indicate or not the use of preoperative orthopedics.

The Burden of Care of Nasoalveolar Molding: An Institutional Experience

Nasoalveolar molding (NAM) is an early presurgical intervention to facilitate primary cleft lip repair by reducing cleft severity and improving labial and nasal form. However, it continues to be associated with the burden of care that influences access and completion of therapy. The authors, therefore, aim to determine the burden of care of NAM therapy for families seeking treatment at a high-volume urban cleft center. A retrospective study of all patients undergoing primary cleft repair between 2012 and 2020 was performed. Patients were grouped based on whether or not NAM therapy was offered. Variables including physical, psychosocial, and financial factors were assessed. Two hundred and thirty patients underwent primary cleft repair between 2012 and 2020. Of these, 176 patients were indicated for NAM, with 4% discontinuing, and 54 patients did not undergo NAM. The 169 patients who completed NAM had a mean duration of treatment of 13.6±8.8 wks consisting of 15±6 scheduled NAM adjustment visits and 1±1 unscheduled visit made urgently to assess caregiver concerns. The mean travel distance was 28.6±37.1 miles. Eighty-four percent of caregivers were married, and 16% did not have English as a primary language. Though 57% had private insurance, 43% of patients received charity support for their treatment. NAM is a finite presurgical intervention that requires caregivers to participate in patient care for approximately three months of their early life. The decision to pursue NAM should be considered alongside the burden of care for caregivers to complete treatment.

The Life Cycle of Orofacial Cleft Operations

Patients with cleft lip and palate must undergo various surgical interventions at appropriate times to achieve optimal outcomes. While guidelines for the timing of these operations are well known, it has not yet been described if national surgical practice reflects these recommendations. This study evaluates whether orofacial operations are performed in time frames that align with advised timing. Time-to-event analyses were performed using the 2012-2020 Pediatric National Surgical Quality Improvement Program database on the ages at time of orofacial operations. Outliers with an absolute Z-score of 3.29 or greater were excluded. Cleft lip (N=9374) and palate (N=13,735) repairs occurred earliest at mean ages of 200.99±251.12 and 655.08±694.43 days, respectively. Both operations clustered along the later end of recommended timing. 69.0% of lip versus 65.1% of palate repairs were completed within the advised age periods. Cleft lip (N=2850) and palate (N=1641) revisions occurred at a mean age of 7.73±5.02 and 7.00±4.63 years, respectively. Velopharyngeal insufficiency operations (N=3026), not including palate revision, were performed at a delayed mean age of 7.58±3.98 years, with only 27.7% of operations occurring within the recommended time frame. Finally, 75.8% of alveolar bone grafting cases (N=5481) were found to happen within the advised time period, with a mean age of 10.23±2.63 years. This study suggests that, with the exception of VPI procedures, orofacial operations reliably cluster near their recommended age periods. Nevertheless, primary lip repair, palatoplasty, and velopharyngeal insufficiency procedures had a mean age that was delayed based on advised timing.

Prefabricated Trays Stock for Impression of Cleft lip and Palate Orthopedic Appliances: A Three-Dimensional Computational Analysis of Maxillary Jaws

OBJECTIVE

This study aimed to propose digitally designed impression trays, for newborns with cleft lip and palate (CLP) defects, using the computer-assisted design and manufacturing (CAD/CAM) technique, based on measurements of width, length, and height made on processed and scanned plaster models. Thus, we will describe the different software and concepts that can be used for the design of these impression trays.

DESIGN

A total of 59 plaster casts of newborn patients with CLP were collected and then scanned. After that, digital dental casts were three-dimensional (3D) evaluated, using precise anatomical landmarks.

SETTING

The Maxillofacial Prosthodontics Team at the Dental consultation and treatment center in Rabat, Morocco.

PATIENTS AND PARTICIPANTS

The study involved plaster casts of newborns with CLP, who had undergone presurgical neonatal treatment in the Maxillofacial Prosthodontics service in Rabat, Morocco.

INTERVENTIONS

None.

MAIN OUTCOME MEASURE(S)

3D evaluation of 59 scanned plaster casts of newborn patients with CLP.

RESULTS

This work allowed us to obtain digital impression trays for each anatomical variation of orofacial clefts. These trays will limit the problems linked to conventional techniques for making neonatal orthopedic plates. We also emphasized the importance of a multidisciplinary approach involving several professionals in Morocco from various fields and specialties.

CONCLUSION

This original technique is advantageous for the practitioner as well as for the patients and their parents. It allows for precise recording, better adaptation, time-saving, and parental comfort.

Pre-surgical Nasal Molding of a Two-Day-Old Neonate With Complete Unilateral Cleft Lip and Palate Using Passive Nasoalveolar Molding Technique: A Case Report

The occurrence of congenital deformities like cleft lip and palate is not uncommon and is often a traumatizing experience for families. The entire rehabilitation process includes frequent hospital visits and the brunt of numerous procedures. Early intervention with pre-surgical infant orthopedics facilitates better surgical outcomes and additional psychosocial benefits to the infant's family. The present clinical report addresses the pre-surgical management of a non-syndromic two-day-old female baby whose parents presented with the chief complaint of deformed lips, nose, and difficulty while feeding. The neonate had a complete left-sided cleft lip, alveolus, and cleft palate on examination. Early management with pre-surgical passive nasoalveolar molding (PNAM) has favorable outcomes, including desired upper lip, alveolus, and nose shape. Non-invasive pre-surgical intervention with PNAM reduces the severity of the deformities before the primary surgical repair, thus decreasing the overall cost of cleft care and the number of secondary revisions, thus increasing the probability of favorable outcomes.

Changes of Age-related Auricular Cartilage Plasticity and Biomechanical Property in a Rabbit Model

OBJECTIVES

Ear molding is an emerging technique that can correct auricular deformities. Treatment initiation time is the most important prognostic determinant of ear molding. Here, we aimed to examine why auricular cartilage plasticity appeared to diminish with age. Thus, we characterized age-related changes in the biomechanical, biochemical, and morphological properties of auricular cartilage.

METHODS

New Zealand rabbits were used as the experimental animal. We examined immature [postnatal 0 day (P0), 5 days (P5), 15 days (P15)], young [2 months (2M)], and mature [6 months (6M)] rabbits. Rabbits' ears were splinted and folded using adhesive fixation strips. Folding duration ranged from 1 day to 5 days to 10 days. Photographs were taken to calculate the retained fold angle. Cartilage morphology and extracellular matrix (ECM) content were examined histologically (using hematoxylin-eosin, Safranin O, elastic Van Gieson, and Masson's trichrome). Water content, DNA content, and cell density were also analyzed. Biomechanical properties were measured using a Nano indenter.

RESULTS

Immature ears had smaller angles after strip removal, and the angled deformation lasted a longer time. Cartilage matrix compositions, including glycosaminoglycan (GAG), elastin fiber, and collagen, increased over development. The water content, DNA content, and cell density decreased with age. Young's modulus was significantly higher in mature cartilage.

CONCLUSIONS

Here, we successfully established an animal model of ear molding and demonstrated that immature cartilage was associated with better plasticity. We also found that the cartilage's biomechanical property increased with the accumulation of ECM. The biomechanical change could underlie age-related shape plasticity.

LEVEL OF EVIDENCE

NA Laryngoscope, 133:88-94, 2023.

Comparison of conventional impression making and intraoral scanning for the study of unilateral cleft lip and palate

Patients with cleft lip and palate (CLP) encounter various problems, including disorders related to feeding, esthetics, and pronunciation. We compared two impression methods, conventional impression making and intraoral scanning, to study unilateral cleft lip and palate (UCLP). Patients with UCLP (n = 7) were selected, and palatal impressions were taken by two steps: (1) impressions were obtained using an addition silicone rubber impression material, and a plaster model was prepared and (2) optical impressions were obtained using a desktop three-dimensional (3D) scanner and stereolithography (STL). Data were generated by two impression system combinations through STL. The results were analyzed using the Kruskal-Wallis or Mann-Whitney U test. There were no significant differences in the dimensions of the models between both groups. The measured depth of the alveolar cleft defects was deeper in the plaster model group (STL) than in the intraoral scanner group (STL). Digital models may prevent the risk of aspiration and respiratory disorders by using impression materials for preoperative jaw treatment of newborns and infants. We compared the results of both impression methods in the same patient and found that a shift to the 3D printer model is a safe alternative for preoperative jaw correction, as evidenced from the amount of tissue displaced due to the pressure applied during impression taking. In the future, we would like to conduct clinical research with a larger sample size of CLP patients to further corroborate these findings.

The "3D Versascrew": An Innovative Approach for Management of Bilateral Cleft Lip and Palate Case

The purpose behind the innovation of modified nasoalveolar moulding appliance was to achieve simultaneous anteroposterior and transverse correction in bilateral cleft cases with minimal vomeroid bending. This paper presents a 3D Versascrew appliance that has been used for presurgical nasoalveolar moulding in a 15-day-old neonate with bilateral cleft. Treatment was initiated at 30 days and continued for 90 days following which mild expansion of posterior maxilla with establishment of arch continuity and concomitant improvement in nasal morphology was achieved towards the end.

Efficacy of Post-Surgical Nostril Retainer (PSNR) in patients with UCLP Treated with Pre-Surgical NasoAlveolar Molding (NAM) and Primary Cheiloplasty-Rhinoplasty

OBJECTIVE

The aim of this investigation is to determine if the nasal form of patients with unilateral cleft lip and palate (UCLP) treated with pre-surgical nasoalveolar molding (NAM) therapy, primary lip-nose surgery, and post-surgical Nostril Retainer (PSNR) is different from patients treated with pre-surgical NAM and primary lip and nose surgery alone.

DESIGN

A cross-sectional, retrospective review of 50 consecutive non-syndromic patients with UCLP: 24 treated with NAM and primary lip-nose surgery followed by PSNR (Group I) compared to 26 patients treated with NAM and primary lip-nose surgery without PSNR (Group II). Polyvinyl siloxane nasal impressions were performed at the average age of 12 months and 6 days. Bilateral measurements of alar width at maximum convexity, total alar base width, nasal tip projection, columella length, and nostril aperture width and height were recorded. Statistical comparison of cleft versus non-cleft side nasal measurements were performed within Group I and Group II, as well as comparison of the difference between the two groups.

RESULTS

Cleft side nasal dimension was statistically significantly better in Group I than Group II across all measures except nasal projection (P<0.05). Group I showed less difference between the cleft and non-cleft side in all six measurements than Group II (p<0.05).

CONCLUSION

There is a significant difference in the nasal shape of patients who underwent PSNR compared to those that did not. The patients who used PSNR showed better nasal shape at the average age of 12 months than the control group.

The Burden of Care in Nasoalveolar Molding Treatment in Cleft Patients

Objectives  This study, first in Hungary, examined the success of presurgical nasoalveolar molding (NAM) therapy in cleft patients from a caregiver's perspective and revealed factors that can cause inconvenience.

Patients and Methods  A survey-based study was performed using a 32-item questionnaire following NAM therapy. The survey was sent to families whose child underwent NAM therapy from 2010 until 2020 at the 1st Department of Paediatrics, Semmelweis University. The questions focused on four main parts: socioeconomic, origin of the cleft, difficulties of therapy, and self-assessment. Fifty-three families received the questionnaire, 17 of them completed it.

Results  The mean age was 5 ± 3.7 weeks when NAM therapy started. Fifty-eight percent of the patients were male and 42% female. Patients are living more than 60 km from the cleft center (59%). Patients had to make the journey between their residence and the cleft center ∼10 to 15 times. In most cases, NAM therapy was covered by health insurance (83%). The unilateral cleft and lip palate occurred 58%, while the bilateral were 42%. Thirty-five percent of the patients had an allergic reaction against the adhesive, and 35% were affected by wounds on their lips or noses. The way of feeding was variable. Seventeen percent of the parents were able to breastfeed. In all cases, parents were satisfied with the NAM therapy.

Conclusions  The present study highlighted the value of caregivers' role in NAM therapy. The burden of care is acceptable, caregivers have high compliance, and are determined to help the effectiveness of therapy. Limitations of this study include a single-institute data with a small number of cases.

A modified presurgical alveolar molding technique for treatment of cleft in Down syndrome

Craniofacial clefts are extremely rare deformities. Tessier’s classification is a widely accepted system that is based on clinical, radiographical, and surgical observations. The Tessier No. 0 cleft most commonly affects the upper lip, nose, and palate. This case presentation aims to report the outcome of a modified presurgical alveolar molding (PAM) appliance used in the treatment of an infant with Tessier No. 0 cleft as an alternate approach to mold such defects before surgery. The modified PAM appliance consisted of reciprocal parts connected by a helix. The segments were approximated by stripping the appliance at the midline in a V-shaped manner and the force was exerted by the extraoral elastics. The procedure gave results in 8 weeks, which may be regarded as a reasonable duration. The anterior cleft gap, which was 13 mm before the treatment, was reduced to 3 mm after the treatment by using modified PAM appliance. On a 21-month follow-up period, oral reshaping was regarded successful due to stability of the improved oral mold.

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

Objectives

Cleft 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 Methods

Twenty 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.

Results

Groups A and B did not differ significantly in any extraoral or intraoral parameter.

Conclusion

The extraoral NAM technique is as effective as the intraoral NAM technique in achieving significant nasal and alveolar changes in com-plete 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.

Evolving Trends in Unilateral Cleft Lip Repair Based on Continuous Certification by the American Board of Plastic Surgery

BACKGROUND

The American Board of Plastic Surgery (ABPS) began collecting data from unilateral cleft lip (UCL) corrections in 2011 as a component of the continuous certification process. We evaluated these data to understand practice patterns in UCL repair, in the United States, and whether these practice patterns had changed over the past 9 years.

METHODS

Tracer data for UCL correction were reviewed from its inception in October 2011 through 2016 and compared to UCL cases between 2017 and March 2020. Trends in practice patterns were evaluated against literature reviews meant to coincide with the ABPS continuous certification data.

RESULTS

A total of 520 cases were included from October 2011 to March 2020. Median age of UCL repair was 4 months and 66% of patients were male. Fifty-one percent of cases presented with a complete cleft lip. There was a decrease in postoperative adverse events when data from 2011 to 2016 was compared to 2017 to 2019 (P = 0.020). Revisions were the most common postoperative adverse event (2%). There was a decrease in nasoalveolar molding from 25% to 12% (P < 0.001) and 56% of total cases underwent a concurrent primary cleft rhinoplasty. The rate of gingivoperiosteoplasty at the time of primary cleft lip repair also fell (9% versus 1%; P < 0.001).

CONCLUSIONS

This article reviews tracer data obtained by the ABPS for UCL repair. The American Board of Plastic Surgery tracer data provides a national, cleft lip-specific database with longer follow-up times than other large databases.

How to Get Consistently Good Results in Cleft Lip Repair

This article serves as a practical guide for plastic surgeons focusing on repair of primary cleft lip and nasal deformity. We discuss the key anatomic disruption present in cleft lip and nasal deformity and the goals of primary repair. In addition, our preferred surgical technique for unilateral and bilateral cleft lip and nasal deformity is summarized along with technical pearls and pitfalls.

Interdisciplinary Approach for the Treatment of Complex Bilateral Cleft Lip and Palate With Missing Premaxilla

Complex craniofacial deformities such as complete bilateral cleft lip and palate require interdisciplinary approach for proper diagnosis and treatment. A severe skeletal discrepancy caused by bilateral cleft lip and palate and missing premaxilla was successfully managed with orthodontic preparation and distraction osteogenesis. Conventional prosthodontic treatment combined with orthodontic preparation was proven to be a viable option to manage multiple missing teeth in cleft lip and palate.

Three-Dimensional Printing in Cleft Care: A Systematic Review

OBJECTIVE

To determine the current applications of 3-dimensional (3D) printing in the care of patients with cleft lip and palate. We also reviewed 3D printing limitations, financial analysis, and future implications.

DESIGN

Retrospective systematic review.

METHODS

Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines were used by 3 independent reviewers. Articles were identified from Cochrane library, Ovid Medline, and Embase. Search terms included 3D printing, 3 dimensional printing, additive manufacturing, rapid prototyping, cleft lip, and cleft palate. Exclusion criteria included articles not in English, animal studies, reviews without original data, oral presentations, abstracts, opinion pieces, and articles without relevance to 3D printing or cleft lip and palate.

MAIN OUTCOME MEASURES

Primary outcome measure was the purpose of 3D printing in the care of patients with cleft lip and palate. Secondary outcome measures were cost analysis and clinical outcomes.

RESULTS

Eight-four articles were identified, and 39 met inclusion/exclusion criteria. Eleven studies used 3D printing models for nasoalveolar molding. Patient-specific implants were developed via 3D printing in 6 articles. Surgical planning was conducted via 3D printing in 8 studies. Eight articles utilized 3D printing for anatomic models/educational purposes. 3-Dimensional printed models were used for surgical simulation/training in 6 articles. Bioprinting was utilized in 4 studies. Secondary outcome of cost was addressed in 8 articles.

CONCLUSION

3-Dimensional printing for the care of patients with cleft lip and palate has several applications. Potential advantages of utilizing this technology are demonstrated; however, literature is largely descriptive in nature with few clinical outcome measures. Future direction should be aimed at standardized reporting to include clinical outcomes, cost, material, printing method, and results.

Effectiveness of the novel impression tray "cleftray" for infants with cleft lip and palate: a randomized controlled clinical trial

Objectives

Cleft lip and palate (CLP) is one of the most common congenital deformities with worldwide prevalence. It causes a range of issues for infants that mainly involve difficulty in feeding due to abnormal oronasal communication. For this purpose, feeding plates are provided to infants to act as an artificial palate to aid in feeding. The most crucial procedure in fabrication of a feeding plate is creation of the impression using the traditional finger technique or impression trays. This preliminary research aims to compare the effectiveness of novel impression trays with that of the traditional finger technique for recording impressions of infants with CLP.

Materials and Methods

This randomized controlled trial was conducted among 30 infants who were divided into two groups based on the method of obtaining impressions Group I, finger technique; Group II, specialized acrylic tray (cleftray).

Results

Use of cleftray required less impression time, a reduced amount of material, no incidence of cyanosis/choking in infants, and lower anxiety among doctors compared to the traditional method. Additionally, there was no distortion of cleft impressions, recorded maxillary tuberosity, or other fine details. Therefore, the novel impression tray (cleftray) exhibited superior outcomes in all the parameters compared to the finger technique.

Conclusion

Within the limitations of this study, we conclude that impression trays are superior to the traditional finger, spoon, or ice cream stick methods of creating impressions of CLP. However, it is necessary to conduct more clinical trials on a larger population based on other parameters to compare the effectiveness of the two techniques to draw definitive conclusions.

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

OBJECTIVE

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).

DESIGN

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.

RESULTS

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.

CONCLUSIONS

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.

[Pre-surgical orthopedic treatment with Hinostroza nasal retractor modification in complete unilateral palate fissure. Case report]

Complete unilateral palatine fissure affects the region of the middle facial third and individuals born with this condition have altered structures on the side where the malformation developed. The objective of the present case report was to describe a pre-surgical orthopedics alternative in a female infant of 1 month 5 days of age with complete unilateral palatine fissure diagnosed with complete unilateral left palatine fissure. The Hinostroza nasal retractor modification was placed, allowing symmetry to the affected nasal structure with respect to the unaffected side. This procedure provides good results, low cost and easy handling and should be considered as an alternative treatment in neonates born with complete unilateral palatine fissure.

What is the Impact of Prenatal Counseling on Postnatal Cleft Treatment? Multidisciplinary Pathway for Prenatal Orofacial Cleft Care

ABSTRACT

In the pediatric general surgery literature, it has been shown that prenatal diagnosis of a congenital anomaly is an independent predictor of parental psychological distress. Surgical prenatal counseling can decrease parental anxiety by helping families understand the surgical needs and potential outcomes of their infant. In this retrospective analysis (n = 440), the authors sought to present our care pathway for prenatally diagnosed cleft lip and palate (CL/P) and explore the impact of cleft lip and palate-specific prenatal counseling on patient care by comparing the timing of clinical and surgical care between a cohort of patients who received prenatal CL/P consultation and a cohort of patients only seen postnatally. The authors hypothesize that our multidisciplinary prenatal care intervention is associated with earlier postnatal clinic visits and surgical repair. The care of all patients whose mother's presented for prenatal CL/P consultation (prenatal cohort, n = 118) was compared to all new CL/P patients without prenatal consultation at our institution (postnatal cohort, n = 322) from January 2015 through August 2019. 81.4% (n = 96) of the prenatal cohort returned for care postnatally while 2 pregnancies were interrupted, four neonates died, and 15 patients did not return for care. Prenatal consultation was associated with earlier postnatal clinic appointments (P < 0.001) as well as a shorter time to CL repair in patients with CL only (P = 0.002) and CLP (P = 0.047). Our described pre- and postnatal CL/P pathway is a multidisciplinary model associated with high retention rates from the prenatal period through complete surgical repair.

The Effect of Immediate Versus Delayed Addition of the Nasal Stent to the Nasoalveolar Molding Plate on Nostrils Shape and Cleft Width in Infants With Unilateral Cleft Lip and Palate

OBJECTIVE

The main aim of this study was to evaluate the effect of immediate versus delayed addition of the nasal stent to the nasoalveolar molding plate on the nose shape and alveolar cleft area in unilateral cleft lip and palate infants.

METHOD

Twenty nonsyndromic newborn infants with unilateral cleft lip and palate were scanned 3 dimensionally using Proface software. In the experimental group, the nasal stent was added on the day the molding plate arrived, and in the control group when the alveolar gap reached 5 mm. Two months after adding nasal stents in each group patients' faces were scanned again and some parameters were measured. In addition, immediately after treatment, 1 month later and at the end of investigation, impressions were taken, and stone casts were scanned by cone-beam computed tomography and the alveolar gap was measured. Fisher exact test, paired t test, and ANOVA were used for data analyses. P < 0.05 was considered as significant.

RESULTS

In this study, changes in the parameters showed significant differences between the case and controls for the columellar angle, nostril width on the cleft side, nostril height on the cleft side, soft tissue cleft width, and nasal surface area. However, the nostril's width and height in the noncleft side, intercommissural distance, nasal surface area on the noncleft side, nostril area between the cleft and noncleft side after treatment, and the alveolar gap did not show significant differences between the groups (P > 0.05).

CONCLUSION

Early use of nasal stents showed more desirable results in decreasing the width of the nostrils and increasing its height and correcting the angle of the columella without any adverse effects on the nostrils after treatment.

Secondary Care of Cleft Lip and Palate: Analysis of Dentofacial Orthopedic and Orthognathic Treatments

INTRODUCTION

Orthodontic and orthognathic management of cleft lip and/or palate (CLP) is a highly controversial subject. We present herein a retrospective study of 214 secondary cases followed over 22 years in order to assess the factors of successful management.

MATERIAL AND METHODS

The study focuses on the results of gingivoperiosteoplasty, and occlusal stability. Nine subgroups were identified, taking into account the age of the patients, the history of surgery on the alveolar region, and the presence or absence of skeletal discrepancy.

RESULTS

Results clearly demonstrate a higher rate of poor outcomes and failures in the multioperated population. The success rate of the graft is 80.82% in the multioperated population versus 100% non-multioperated population. Periodontitis problem or orthodontic difficulties affect 19.17% of the patient in the multioperated groups versus 12% in the other groups. Relapse, particularly the transversal dimension, is also found mostly in the multi-operated population: 17.8% versus 6% in the non-multioperated population.

DISCUSSION

Several factors are involved in the success of orthodontics, dentofacial orthopedics, and orthognathic surgery of CLP patients. Our study shows that previous surgeries, especially when they are multiple with repeated failures, jeopardize the chances of success of secondary treatments. This is explained by the secondary fibrosis of the tissues around the cleft. Finally, major palatal surgeries performed early, have adverse effects on maxillary growth. Many other factors play an important role in the stability of the success that are linked with orofacial functions. These data must be taken into account in the treatment of CLP patients.

A Three-Dimensional Study of the Nasolabial Soft Tissue Symmetry in Children With Unilateral Complete Cleft Lip and Palate Using Traditional and Split-Type Nasoalveolar Molding

BACKGROUND

Presurgical nasoalveolar molding (NAM) is the most common preoperative treatment for cleft lip and palate. However, NAM may have some limitations such as requiring high technical sensitivity and frequent visits. To simplify the device, some scholars have changed the traditional NAM into a split-NAM consisting of a alveolar molding plate and a nasal hook. This study compared the shaping effect of split NAM and traditional NAM on nasolabial soft tissue using three-dimensional (3D) measurement.

METHODS

A total of 39 patients with unilateral cleft lip and palate (UCLP) were enrolled and divided into 2 groups. 13 patients were treated with split-NAM while the other 26 patients were treated with traditional NAM. 3D images of all patients' craniofacial soft tissue before and after NAM treatment were recorded and measured by three-dimensional software. Statistical analysis of measurements in both groups was performed using SPSS software.

RESULTS

After treatment, nasal soft tissue symmetry in the split-NAM group was better improved than that in the NAM group in vertical and anterior-posterior direction, but was worse improved in transverse direction. There was no significant difference in labial soft tissue symmetry between two groups.

CONCLUSIONS

The split NAM can better elevate the alar and nostrils of the cleft side, and have a better forward effect on alar outer edge, nasal base, and nostrils. However, the traditional NAM can better reduce the width of nasal base.

The Effects of Nasoalveolar Molding on Nasal Proportions at the Time of Nasal Maturity

BACKGROUND

The aim of this study is to assess the effect of nasoalveolar molding (NAM) versus no-NAM on nasal morphology in patients with unilateral cleft lip and palate (UCLP) at the time of nasal maturity.

METHODS

A retrospective, single-institution review was conducted on all non-syndromic patients with UCLP. Inclusion criteria included age 14 years or above, unilateral cleft repair at the time of infancy, and adequate photography taken at nasal maturity and prior to rhinoplasty. Exclusion criteria included age less than 14 years, syndromic diagnosis, and rhinoplasty prior to nasal maturity. Ten parameters were measured twice from standardized clinical photographs using the Dolphin Imaging Software for establishment of intrarater reliability. Subjective analysis was achieved through completion of the Asher McDade grading scale by 3 expert cleft practitioners.

RESULTS

Nostril height, columellar angle, alar cant, vertical alar height, alar height angle, nasofacial angle, and nasolabial angle were found to be significantly less severe in patients who had undergone NAM in conjunction with surgical repair when compared with those who had undergone surgical repair alone. Asher McDade grading revealed significant improvement in nasal form, nasal symmetry/deviation, nasal profile, vermillion border, and overall score in patients who underwent NAM compared to no-NAM.

CONCLUSION

The use of presurgical NAM during infancy can improve nasal symmetry and nasal proportions at the time of nasal maturity.

A novel method for fabricating nasoalveolar molding appliances for infants with cleft lip and palate using 3-dimensional workflow and clear aligners

INTRODUCTION

Nasoalveolar molding (NAM) was introduced over 20 years ago as adjunctive therapy for the correction of cleft lip and palate. In the current study, we propose a new approach using a digital workflow and 3-dimensional printing to fabricate clear aligner NAM devices.

METHODS

A polyvinyl siloxane (PVS) impression of an infant with a unilateral complete cleft lip and palate (UCLP) is acquired and poured, and the stone model is scanned with an intraoral scanner. The stereolithography file is digitized, and the alveolar segments are digitally segmented and moved to the desired final position. The total distance moved is divided into a sequence of 1-1.5 mm increments, creating a series of digital models. The models are 3-dimensionally printed along with button templates to allow free form positioning of the button on each model. A Vacuform machine (Taglus, Mumbai, India) was used to fabricate a 0.040-in aligner for each stage.

RESULTS

We present 1 case that was treated successfully with this approach. Appointments for the NAM adjustments were primarily to monitor progress and counseling with less time spent adjusting the appliance. The appointment length was reduced by over 30 minutes. Benefits of the aligner are improved fit, more precise increments of activation, reduced chairside time, and potentially minimized number of visits.

CONCLUSIONS

NAM custom aligners may provide similar benefits to the traditional approach while reducing the burden of care by reducing the number of visits and appointment duration. Further studies with a sample and longitudinal observations are needed to investigate the benefits of the proposed digital approach.

An Intraoperative Rescue Procedure for the Protruding Premaxilla in the Repair of Complete Bilateral Cleft Lip: Rapid Premaxillary Molding

BACKGROUND

Primary reconstruction of complete bilateral cleft lip and palate (BCLP) with protruding premaxilla in one-stage surgery is challenging because of the tension on muscle repair. Such patients are also common in the developing countries. For this condition, we have applied intraoperative "rapid premaxillary molding (RPM)" technique and obtained satisfactory results.

METHODS

We reviewed the data of patients with complete BCLP with protruding premaxilla applying intraoperative RPM including both our institution and cleft missions to developing countries in the past 20 years. Selection criteria were patients receiving either no or insufficient preoperative molding presenting with significant protruding premaxilla, had consecutive follow-ups after surgery. To perform this technique, the surgeon holds the patient's face with both hands and compresses the protruding premaxilla with both thumbs. An intermittent but stable backward pressure is applied to the premaxilla until the segment is gradually flexible. Repeated compression is performed prior to tying the muscle sutures, at which time the premaxilla is retro-positioned and aligned with the lateral maxillary segments. Pre- and postoperative data were evaluated.

RESULTS

We have treated a total of 60 patients with complete BCLP with protruding premaxilla applying intraoperative RPM. All patients tolerated the operations and there were no major intra- and postoperative complications including lip dehiscence and vomer fracture. All of them had satisfactory results such as adequate muscle repair and symmetry of the lip and nostrils.

CONCLUSION

The RPM is a reliable and valuable intraoperative adjunct procedure for patients with complete BCLP presenting the protrusive premaxilla.

Sociodemographic Factors That Influence the Choice to Pursue Nasoalveolar Molding: One Pediatric Hospital's Experience

OBJECTIVE

To identify demographic factors that influence choosing nasoalveolar molding (NAM) in the treatment of cleft lip with or without cleft palate (CL±P), and NAM treatment compliance.

DESIGN

This work is a retrospective cohort study.

SETTING

Tertiary pediatric hospital.

PATIENTS, PARTICIPANTS

One hundred forty-nine patients with a diagnosis of unilateral complete CL±P receiving treatment when NAM was offered (January 1, 2008-July 26, 2016).

MAIN OUTCOME MEASURE(S)

Demographic variables collected included race, ethnicity, ZIP code, number of caregivers, caregiver employment status, and health insurance status. Medical variables collected included diagnosis, treatment pursued, compliance with NAM, completion of NAM, and the treating cleft surgeon and orthodontist. Data were analyzed via Fisher exact tests, χ² tests, and multivariate logistic regression to identify factors that influence the decision to pursue NAM and treatment compliance.

RESULTS

Univariate analyses identified the following significant factors predicting the pursuit of NAM: race and insurance type (both P < .001), surgeon (P = .005), income level (P = .009), comorbidities (P = .015), and syndromic diagnosis (P = .033). Driving distance trended toward significance (P = .078). Multivariate regression analyses indicated that Asian race (P = .047), insurance type (P = .046), driving distance (P = .019), and surgeon (P = .017) were significant predictors of pursuit of NAM.

CONCLUSIONS

There are disparities in patient choice of NAM at our center for children with complete cleft lip. African American patient families were less likely to pursue this intervention. A stronger understanding of the barriers that lower income and minority patients face is needed in order to better characterize disparities in cleft care.

The First-Year Follow-Up of a Cleft Lip and Palate Patient Treated With Nasoalveolar Molding (NAM)

The objectives of pre-surgical orthopedics are to allow surgical repair with minimal tension of the involved tissues and less restriction to the craniofacial growth. The aim of this study was to evaluate the benefits of nasoalveolar model (NAM) as a pre-operative therapy in a patient with bilateral cleft lip and palate followed by labioplasty and palatoplasty. A 15-day-old patient underwent orthopedic treatment with NAM. After pre-operative treatment, retraction of the pre-maxilla was observed with reduction of the fissure. Due to the successful effects of NAM treatment the patient had a one-step surgery for lip correction. Six months later, due to lip pressure the fissure was further decreased. After six months, the patient underwent palatoplasty. Both surgeries contributed to the remaining closure of the fissure, which were reduced by half compared to the end of pre-operative treatment. The uses of NAM as a pre-operative treatment approached the alveolar segments, centralized the pre-maxilla, decreased the cleft palate resulting in a marked improvement of the arch and provide superior surgical results. In addition, it allows the primary repair of the patient's lip with asymmetric bilateral fissure in only one-step surgery; in consequence, it will reduce treatment morbidity and decrease cost of treatment.

What Is the Burden of Care of Nasoalveolar Molding?

OBJECTIVE

This systematic review aims to evaluate nasoalveolar molding (NAM) in the context of burden of care defined as physical, psychosocial, or financial burden on caregivers.

SEARCH METHODS

Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, 5 databases were searched from inception through December 24, 2019, for keywords and subject headings pertaining to cleft lip and/or palate and NAM.

ELIGIBILITY CRITERIA

Clinical studies on NAM with reference to physical (access to care, number of visits, distance traveled), psychosocial (caregiver perceptions, family interactions, breast milk feeding), and financial (direct and indirect costs) burden were included.

DATA COLLECTION AND ANALYSIS

Study selection was performed by 2 independent reviewers.

RESULTS

The search identified 1107 articles and 114 articles remained for qualitative synthesis. Burden of care domains were discussed but not measured in 43% of articles and only 25% assessed burden of care through a primary outcome. Of these, 20 articles reported on physical, 8 articles on psychosocial, and 12 articles on financial burden. Quality of evidence is limited by study design and risk of bias.

CONCLUSION

Nasoalveolar molding has been indiscriminately associated with burden of care in the literature. Although NAM may not be the ideal treatment option for all patients and families, the physical considerations are limited when accounting for the observed psychosocial advantages. Financial burden appears to be offset, but further research is required. Teams should directly assess the impact of this early intervention on the well-being of caregivers and advance strategies that improve access to care.

Nasoalveolar Molding for Unilateral and Bilateral Cleft Lip Repair

Nasoalveolar molding (NAM) is a powerful tool in the treatment of patients with unilateral or bilateral cleft lip and palate. The primary goal of NAM is to improve alignment of critical anatomic elements before surgical repair of the unilateral or bilateral cleft lip. Modifications of the position of the alveolar segments and their associated lip elements, the lower lateral cartilages, and the columella achieved with NAM are helpful for creating a suitable platform for tension-free lip repair.

Assessment of Treatment Outcome of Presurgical Nasoalveolar Molding in Patients With Cleft Lip and Palate and Its Postsurgical Stability

OBJECTIVE

To analyze the effects of presurgical nasoalveolar molding (PNAM) in newborns with cleft lip and palate and evaluate its postsurgical stability at 1-year follow-up using a nasal stent.

DESIGN

Prospective clinical trial.

SETTING

Department of Orthodontics, Maulana Azad Institute of Dental Sciences, Delhi.

PATIENTS

Patients with cleft lip and palate of 0 to 6 months. Sample size 25 recruited, 16 satisfactorily completed the procedure.

INTERVENTIONS

Presurgical nasoalveolar molding done as indicated in all the patients. Postsurgical external nasal stents were given for 1 year to maintain the nasal correction.

MAIN OUTCOME MEASURES

Changes in cleft defect and maxillary arch were recorded pre- and post-PNAM. Changes in nasal morphological parameters assessed pre- and post-PNAM and 1 year after surgical repair following the use of nasal stent.

RESULTS

There was a significant reduction in cleft defect assessed both intraorally ( 4.16 mm) and extra orally ( 4.42 mm) at the end of PNAM therapy (average treatment time 4 months). The nasal morphology improved with an increase in columella height (1.5 mm) and reduction in columella width. Bialar width reduced (2.90 mm) with an increase in nostril height ( 2.10 mm). Better symmetry was achieved in all cases as the nostril height and width difference changed significantly pre- and post-nasoalveolar molding. The percentage increase in columella height was greater for infants less than 6 weeks.

CONCLUSIONS

Presurgical nasoalveolar molding considerably reduces the cleft gap and improves arch form making surgical union easier along with improved nasal morphology which can be maintained at 1-year postsurgery by use of a postsurgical external nasal stent.

Presurgical nasoalveolar molding with 3D printing for a patient with unilateral cleft lip, alveolus, and palate

An 8-day-old male infant with unilateral cleft lip, alveolus, and palate had a wide alveolar defect, soft tissue deformity, and a markedly sunken nasal wing at the cleft side. The patient was treated with a series of 3D-printed molding plates and synchronously with a nasal hook. The cleft edges moved closer by 9 mm at the alveolar ridge and the nasal wing was lifted considerably. Split-type 3D printing of presurgical nasoalveolar molding helped to reduce the cleft gap, improve the arch form, approximate lip segments, and distinctly improve the morphology of the nose by correcting the flattened nasal wings.

Management of the Cleft Nasal Tip: An Overview of Classic Techniques and Strategies

The challenges of cleft reconstruction have been present for centuries. However, understanding of the cleft nasal tip and the evolution of techniques decidedly began in the 20th century and refinement continues into the present day. Although a multitude of technical descriptions and case series have been published, a compendium of seminal techniques, which have shaped modern thought, has not been compiled in the literature. In this review, we discuss the anatomical disturbances in the cleft nasal tip anomaly, the timing and strategy of tip correction, and the major classic techniques for management of the cleft nasal tip. In addition, we have categorized the classic techniques into concepts that they embody.

Two Methods of Cleft Palate Repair in Patients With Complete Unilateral Cleft Lip and Palate

OBJECTIVE

The objective of this study was to compare the surgical outcome between 2 patient groups with complete unilateral cleft lip and palate who underwent different types of palatoplasty.

METHODS

This is a cohort study between 2 groups of patients with complete unilateral cleft lip and palate who were operated using different surgical techniques from 2008 to 2011. About 28 patients were operated using a primary lip nose repair with vomer flap for hard palate single-layer closure and delayed soft palate repair (modified Oslo protocol) and 32 patients were operated using our protocol in Lima. Data collection was accomplished by evaluation of symptomatic oronasal fistulas, presence of velopharyngeal insufficiency and evaluation of dental arch relationships (scored using the 5-year-olds' index).

RESULTS

Our comparative study observed statistically significant differences between the 2 groups regarding the presence of oronasal fistulas and velopharyngeal insufficiency in favor of our palatoplasty technique. A statistically significant difference was not found in functional vestibular oronasal fistula development between the studied techniques for unilateral cleft palate repair. This comparative study did not observe significant differences in dental arch relationships between the studied techniques.

CONCLUSION

In this study, better surgical outcome than modified Oslo protocol regarding oronasal fistulas and velopharyngeal insufficiency on patients with complete unilateral cleft lip and palate was observed. The results arising from this study do not provide evidence that one technique is enough to obtain better functional closure of the alveolar cleft and dental arch relationship at 5 years.

Early Weight Gain in Infants With Cleft Lip and Palate Treated With and Without Nasoalveolar Molding: A Retrospective Study

OBJECTIVE

To assess weight gain of infants with cleft lip and/or palate (CL ± P) treated with nasoalveolar molding (NAM).

DESIGN

Retrospective, case-control chart review.

SETTING

Doernbecher Children's Hospital, Oregon Health & Science University, Portland, Oregon.

PATIENTS, PARTICIPANTS

Infants with nonsyndromic CL ± P and noncleft controls.

INTERVENTIONS

Prior to primary lip surgery, NAM was either included (+NAM) or not included (-NAM) in the cleft treatment protocol.

MAIN OUTCOME MEASURE(S)

Weight gain and percentage weight gain relative to initial weight were compared among +NAM, -NAM, and control groups from birth to 7 months and from birth to 36 months.

RESULTS

Comparing +NAM and -NAM groups, no significant difference in weight or percentage weight gain was found in either time window. Compared to controls, from birth to 7 months, both CL ± P groups weighed less (P < .001), while percentage weight gain was greater for the +NAM (P < .001) and did not differ for -NAM. From birth to 36 months relative to controls, weight for +NAM showed no significant difference and -NAM weighed less (P < .01), while percentage weight gain was greater for both CL ± P groups (P < .001).

CONCLUSIONS

Comparisons of CL ± P infants treated with and without NAM showed that with the NAM appliance, despite its added complexity, there was no adverse impact on weight gain. Comparisons to noncleft, control infants suggests that NAM treatment may have a beneficial impact on weight gain.

Assessing Burden of Care in the Patient With Cleft Lip and Palate: Factors Influencing Completion and Noncompletion of Nasoalveolar Molding

OBJECTIVE

Evaluate the factors that influence caregiver-reported completion of nasoalveolar molding (NAM) therapy for patients with cleft lip and palate.

DESIGN

An IRB-approved 30-question survey.

SETTING

Outpatient clinic for patients with cleft lip.

PATIENTS

Patients with unilateral or bilateral cleft lip treated with NAM therapy.

INTERVENTIONS

Survey of previous experiences.

MAIN OUTCOME MEASURE(S)

Rate of noncompletion for patients initiating NAM therapy and identifiable causes.

RESULTS

Of 94 patients who underwent NAM, 13 (13.8%) failed to complete NAM therapy. Reasons for incomplete treatment included: obstructive sleep apnea, device intolerance, tape issues, and lack of support. Patients who did not complete NAM therapy were less likely to have primary caregivers >30-year old (P = .045) and more likely to be the first child for the family (P = .021) and have a bilateral cleft (P = .03). Caregivers of NAM patients were less satisfied with the outcome (P < .001) when they did not complete therapy.

CONCLUSION

This study shows that a high number of parents fail to complete this therapy for many reasons, personal and medical. More data are needed to elucidate true prevalence of NAM noncompletion and to establish evidence-based guidelines to reduce barriers to care for completing NAM treatment.

One-Stage versus Two-Stage Repair of Asymmetric Bilateral Cleft Lip: A 20-Year Retrospective Study of Clinical Outcome

BACKGROUND

Both one- and two-stage approaches have been widely used for patients with asymmetric bilateral cleft lip. There are insufficient long-term outcome data for comparison of these two methods. The purpose of this retrospective study was to compare the clinical outcome over the past 20 years.

METHODS

The senior author's (L.J.L.) database was searched for patients with asymmetric bilateral cleft lip from 1995 to 2015. Qualified patients were divided into two groups: one-stage and two-stage. The postoperative photographs of patients were evaluated subjectively by surgical professionals and laypersons. Ratios of the nasolabial region were calculated for objective analysis. Finally, the revision procedures in the nasolabial area were reviewed. Statistical analyses were performed.

RESULTS

A total of 95 consecutive patients were qualified for evaluation. Average follow-up was 13.1 years. A two-stage method was used in 35 percent of the patients, and a one-stage approach was used in 65 percent. All underwent primary nasal reconstruction. Among the satisfaction rating scores, the one-stage repair was rated significantly higher than two-stage reconstruction (p = 0.0001). Long-term outcomes of the two-stage patients and the unrepaired mini-microform deformities were unsatisfactory according to both professional and nonprofessional evaluators. The revision rate was higher in patients with a greater-side complete cleft lip and palate as compared with those without palatal involvement.

CONCLUSIONS

The results suggested that one-stage repair provided better results with regard to achieving a more symmetric and smooth lip and nose after primary reconstruction. The revision rate was slightly higher in the two-stage patient group.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Three-Dimensional Soft Tissue Nasal Changes After Nasoalveolar Molding and Primary Cheilorhinoplasty in Infants With Unilateral Cleft Lip and Palate

OBJECTIVE

To quantify 3-dimensional (3D) nasal changes in infants with unilateral cleft lip with or without cleft palate (UCL±P) treated by nasoalveolar molding (NAM) and cheilorhinoplasty and compare to noncleft controls.

DESIGN

Retrospective case series of infants treated with NAM and primary cheilorhinoplasty between September, 2012 and July, 2016. Infants were included if they had digital stereophotogrammetric records at initial presentation (T1), completion of NAM (T2), and following primary cheilorhinoplasty (T3). Images were oriented in 3dMD Vultus software, and 16 nasolabial points identified.

PATIENTS

Twenty consecutively treated infants with UCL±P.

INTERVENTIONS

Nasoalveolar molding and primary cheilorhinoplasty.

MAIN OUTCOME MEASURES

Anthropometric measures of nasal symmetry and morphology were compared in the treatment group between time points using paired Student t tests. Postsurgical nasal morphology was compared to noncleft controls.

RESULTS

Nasal tip protrusion increased, and at T3 was 2.64 mm greater than noncleft controls. Nasal base width decreased on the cleft side by 4.01 mm after NAM and by 6.73 mm after cheilorhinoplasty. Columellar length of the noncleft to cleft side decreased from 2:1 to 1:1 following NAM. Significant improvements in subnasale, columella, and nasal tip deviations from midsagittal plane were observed. Treatment improved symmetry of the alar morphology angle and the nasal base-columella angle between cleft and noncleft sides.

CONCLUSIONS

Three-dimensional analysis of UCL±P patients demonstrated significant improvements in nasal projection, columella length, nasal symmetry, and nasal width. Compared to noncleft controls, nasal form was generally corrected, with overcorrection of nasal tip projection, columella angle, and outer nasal widths.

The Effect of Nasoalveolar Molding on Nasal Airway Anatomy: A 9-Year Follow-up of Patients With Unilateral Cleft Lip and Palate

OBJECTIVE

To determine the effects of nasoalveolar molding (NAM) on nasal airway architecture.

DESIGN

Retrospective case-control study of patients with unilateral cleft lip treated with NAM vs without NAM.

SETTING

Tertiary referral center specializing in cleft and craniofacial care. Patients, Participants, and Interventions: Thirty-six patients with complete unilateral cleft lip and alveolus: 19 with NAM therapy and 17 without NAM therapy.

MAIN OUTCOME MEASURES

Cone beam computed tomography (CBCT) scans were compared in multiple coronal sections and were evaluated for linear and angular septal deviation, inferior turbinate hypertrophy, and linear and 2-dimensional airway area.

RESULTS

There were no significant differences in linear or angular septal deviation, inferior turbinate area, linear stenosis, or airway area between NAM- and non-NAM-treated patients.

CONCLUSIONS

NAM effectively molds the external nasal cartilage and structures but may have limited effects on internal nasal structures.