Nasoalveolar Molding for Unilateral and Bilateral Cleft Lip Repair

Featuring growth of the external nose among patients with congenital cleft anomalies

Cleft lip and palate deformities are usually accompanied by abnormal external nasal morphology which seriously affects facial aesthetics and quality of life. In-depth understanding of the growth pattern of external nasal morphology in patients with cleft lip and palate is essential for deciding the optimal timing of surgical intervention and for furthering improvements in surgical technique. In this review we systematically depict the cross-sectional changes in external nose morphology during growth in the normal population and in patients with clefts, and summarise the iatrogenic impacts on growth of the cleft nose, aiming to provide a reference to further improve the management of the nose in patients with clefts.

The Efficacy of Naso-Alveolar Molding on Premaxilla Pushback and Dentoalveolar Changes in Patients With Bilateral Cleft Lip and Palate

OBJECTIVE

To evaluate the extent of naso-alveolar molding (NAM) in pushing the premaxilla posteriorly in patients with bilateral cleft lip and palate (BCLP).

BACKGROUND

Naso-alveolar molding application in cleft lip and palate cases bridges the cleft gap and increases nasal tip projection. In BCLP, NAM potentially mobilizes the premaxilla posteriorly to allow tension-free primary lip closure. However, some patients with BCLP with NAM history still necessitate osteotomy during labioplasty, questioning the efficacy of NAM for BCLP management.

METHODS

This single-center retrospective study was conducted using medical records of nonsyndromic patients with BCLP. Twenty-six patients with BCLP were enrolled over a 5-year period with a history of NAM application before primary labioplasty. The changes in premaxilla width (P), anterior arch width (A), posterior arch width (R), and anteroposterior projection of the premaxilla (P'-A') were statistically analyzed at 2 time points: (1) at the start of NAM application (T1) and (2) after completion of NAM before surgery (T2).

RESULTS

The average age at NAM initiation was 46.2 ± 40.4 days, and the average duration of NAM usage was 125.14 ± 62.94 days. A and P-A showed significant differences between T1 and T2 (P < 0.0001), whereas the rest did not show significant differences in value following NAM application (P > 0.05). Naso-alveolar molding successfully pushed back the premaxilla portion about 4.68 ± 2.83 mm on average.

CONCLUSION

Naso-alveolar molding can push back the premaxillary protrusion up to 5 mm, which can serve as a cutoff point for the consideration of combined modalities. Prenatal diagnosis, counseling, and cleft education should be the benchmark in cleft centers to improve overall patient outcomes.

Defining biomechanical principles in pre-surgical infant orthopedics in a real cleft finite element model

Presurgical infant orthopedics (PSIO) is the first step in the treatment of cleft lip and palate (CLP) and is designed to approximate the cleft segments as effectively as possible before surgical reconstruction of the lip and palate. The biomechanical efficacy of different PSIO approaches in transferring molding forces to the CLP is unknown. This study aimed to define the biomechanical principles of competing PSIO techniques in a real cleft finite element (FE) model. Active intraoral (Latham), passive alveolar molding (PAM), and extraoral (DynaCleft) molding forces were virtually applied to a real cleft FE model. In the cleft region, PAM (P < 0.001) and Latham (P < 0.05) exerted significantly less stress than DynaCleft. Intraoral molding forces acted primarily at the site of the force initiation without being accompanied by high loads in the midface. PAM showed a tendency toward a better flow behavior of the molding forces than Latham. Extraoral molding transferred high stresses to the cleft, alveolar ridge, and midface. Intraoral passive molding was ultimately characterized by the highest biomechanical efficacy and showed the most favorable load distribution of all of the PSIO approaches considered in this study. Future research is needed to validate the findings against clinical data.

Using an Active Screwed Nasoalveolar Molding Device for Defect Rehabilitation in Patients With Bilateral Cleft Lip and Palate

The present case series aimed to assess non-surgical elongation of the columella and reduction of cleft gaps in patients with bilateral cleft lip and palate using the active nasoalveolar molding (ANAM) device and tissue expansion principles. The study included six complete bilateral cleft patients aged one month: three males and three females. A nasoalveolar molding technique was applied using an active device (ANAM) with a 3D screw, worn by infants for two months. The activation protocol for screw closure is approximately 0.25 mm (quarter turn) on alternating days, resulting in almost 1 mm per week and 4 mm per month and reaching 8 mm after eight weeks. Evaluation involved measuring lip defect sizes and the nostril gap, columellar length and rotation of premaxilla before and two months after the ANAM period before surgical repair. The results show that the anterior rotation of the premaxilla and the lip and nostril gaps were significantly reduced (p < 0.05), with maximum reduction in the anterior rotation of the premaxilla (mean difference ± SD was 4.22 ± 0.4). Simultaneously, the columellar height was significantly increased with a mean difference ± SD of 2.0 ± 0.4 (p < 0.001). The current case series demonstrated that the ANAM device is a safe and effective technique for decreasing the lip and nostril gaps, repositioning the protruded premaxilla, and elevating the depressed columella. No side effects were recorded in current cases.

Updates in Cleft Care

Cleft lip and/or palate is a congenital malformation with a wide range of presentations, and its effective treatment necessitates sustained, comprehensive care across an affected child's life. Early diagnosis, ideally through prenatal imaging or immediately postbirth, is paramount. Access to longitudinal care and long-term follow-up with a multidisciplinary approach, led by the recommendations of the American Cleft Palate Association, is the best way to ensure optimal outcomes. Multiple specialties including plastic surgery, otolaryngology, speech therapy, orthodontists, psychologists, and audiologists all may be indicated in the care of the child. Primary repair of the lip, nose, and palate are generally conducted during infancy. Postoperative care demands meticulous oversight to detect potential complications. If necessary, revisional surgeries should be performed before the child begin primary school. As the child matures, secondary procedures like alveolar bone grafting and orthognathic surgery may be requisite. The landscape of cleft care has undergone significant transformation since early surgical correction, with treatment plans now tailored to the specific type and severity of the cleft. The purpose of this text is to outline the current standards of care in children born with cleft lip and/or palate and to highlight ongoing advancements in the field.

The Effects of NAM on the Symmetry of the Face and Maxillary Arch in Babies With Unilateral Cleft

The study aimed to evaluate the effect of nasoalveolar molding (NAM) therapy through reverse engineering, or its absence, to obtain symmetry of the face and maxillary arch. Twenty-six babies with unilateral cleft lip and palate received treatment with NAM, and 12 babies with unilateral cleft lip and palate without presurgical orthopedics (control group). Patients were molded and photographed in 2-stages: the first month of life (T1/pre) and after the use of NAM/before the cheiloplasty (T2/post). In the digital models, the analyses performed were arch perimeter, arch length, and labial frenulum angle. The photographs allowed us to analyze nasal width, mouth width, columella angle, and nostril area. The results demonstrated that there was an increase in arch perimeter and arch length in control and NAM groups in the T2 period in comparison to T1. Labial frenulum angle was reduced in the NAM group compared to the NAM-T1 and control-T2 periods. Treatment with NAM yielded a reduction in nasal width in the period of T2 compared with T1. Columella angle was enhanced after NAM use in T2 and, was different from control group. The nostril area was reduced in the NAM group in T2 compared with control group. Nasoalveolar molding therapy reduced the labial frenulum angle, contributing to a reduction in the extension of the cleft. The NAM protocol improved facial symmetry, mainly through nasal effects, whereas the absence of orthopedic therapy yielded a commitment to the face and maxillary arch symmetry.

The study on the morphological changes of oropharynx in patients with complete unilateral cleft lip and palate after palatopharyngeal closure

Cleft lip and palate can be treated as one of the most common craniofacial congenital malformations in humans. Such disease influences tens of millions of patients all over the world. Cleft lip and palate deformity affects many important physiological functions, including breathing, swallowing, speech, chewing, and aesthetics. This work focuses on investigating the morphology and airway volume of oropharynx patients with unilateral complete cleft lip and palate after palatopharyngeal closure. In addition, this work evaluated the similarities and differences between patients with cleft lip and palate and those without such an issue. The employed data, selected from the Department of Stomatology of Xuzhou First People's Hospital, are based on the conical beam CT images. The study sample was divided into two groups: the selected experimental group, who confronted the cleft lip, cleft palate, and velopharyngeal closure surgery, and the selected control group, who are healthy children at the corresponding age. The parameters, including the airway volume, the airway volume of velopharyngeal and oropharyngeal segments, the minimum cross-sectional area of the pharynx, the horizontal plane airway area of the hard palate and soft one, the horizontal airway area of the hyoid bone, and the vertical distance between the hard palate and soft palate, can be measured by Dolphin. These parameters were analyzed with a statistical approach. The analysis of the above-mentioned parameters reveals that the airway volume, the minimum cross-sectional area of the pharynx, the horizontal cross-sectional area of the hyoid, and the distance between the hard palate and soft palate tip in patients with complete unilateral cleft lip and palate show significant differences between the experimental group and the control group. Meanwhile, other parameters, including the horizontal cross-sectional area of the airway in the horizontal plane of the hard palate and the horizontal plane of the soft palate, did not show noticeable differences in the two groups. The patients, who confronted the unilateral complete cleft lip and palate, can improve with the velopharyngeal closure surgery. Furthermore, the length and vertical distance of the soft palate and the volume of each segment of the airway exhibit differences between the experimental group and the control group.

The Rule of 10s for Cleft Repair: A Historical Review of the Literature

BACKGROUND

Cleft lip is a ubiquitous maxillofacial birth defect encountered globally. Repair of this anomaly has been well established in the literature. Historically, studies have recommended initiating surgical repair by the "Rule of 10s." This states that a baby should be at least 10 weeks of age or older, achieve a weight of 10 pounds, have a hemoglobin exceeding 10 g/dL, and have a white blood cell count <10,000/mm3 before undergoing surgery. However, with advances in both pediatric anesthesia and surgical technique, the concept of prioritizing earlier surgery requires a closer examination of this widespread concept.

OBJECTIVE

The aim of this study was to assess the validity of the Rule of 10s for cleft lip repair and to determine whether plastic surgeons should continue to follow this as a strict rule or employ it as a guideline.

METHODS

A literature search was conducted by G.S., and reviewed by J.L. and M.K. All studies that addressed the "Rule of 10s" for cleft lip patients were considered. Articles were chosen from a comprehensive set of databases, including EMBASE, MEDLINE, and Cochrane Central Register of Controlled Trials databases in March 2022. A literature search was conducted using the following keywords: rule of 10s, Millard criteria, cleft lip/palate, cleft lip/palate repair, and cleft lip/palate complications. Reference lists of selected studies were reviewed for other appropriate publications. Meta-analyses, prospective, randomized clinical trials, retrospective reviews, letters, and literature reviews were included. Single case reports, non-English publications, animal studies, and comments were excluded.

RESULTS

Among the studies included in this review, the authors found that the Rule of 10s has undergone a limited evaluation within the context of today's advances in surgical technique and anesthesia. The current articles generally conclude surgeons may proceed with earlier cleft repair on otherwise healthy infants who do not meet all criteria of the Rule of 10s.

CONCLUSIONS

When taking into consideration the current advances in surgical technique and diminished risks of anesthesia, the Rule of 10s should be applied only as a guideline instead of a rule in plastic surgery. Surgeons should address each patient individually and adhere more rigidly to the Rule of 10s when the infant does not have characteristics warranting expedited repair.

The Evolution of Unilateral Cleft Lip Repair

ABSTRACT

The understanding of cleft lip etiology and approaches for surgical repair have evolved over time, allowing for improved ability to restore form and function. The variability of cleft lip presentations has necessitated a nuanced surgical approach with multidisciplinary cleft care. The earliest documentation of unilateral cleft lip repair predates the 19th century, with crude outcomes observed before the advent of curved incisions and advancement flaps. In the 20th century, straight line, quadrilateral flap, and triangular flap repairs were introduced to mitigate post-repair surgical scarring, increase lip length, and restore the symmetry of the Cupid's bow. Towards the latter part of the century, the development of rotation-advancement principles allowed for improved functional and aesthetic outcomes. Future technical improvements will continue to address the goals of lip and nasal symmetry, muscular continuity, precise scar concealment, and improved patient satisfaction in an increasing range of cleft phenotypes and during subsequent years of growth.

[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.

Does Infant Orthopedics and Neonate Lip Surgery Influence the Occlusal Relationship in Patients With Unilateral Cleft Lip and Palate (UCLP)?

OBJECTIVE

To compare occlusal relationship in patients undergoing neonate versus conventional lip surgery (LS) with and without infant orthopedics (IO) by assessment of dental arch relationship in individuals with complete unilateral cleft lip and palate.

MATERIAL AND METHODS

Three groups treated by different protocols; Group I: neonate LS (1-15 days) + IO and palatoplasty (13-31 months); Group II: LS (3-12 months) + IO and palatoplasty (15-35 months); and Group III: LS (3-6 months) without IO and palatoplasty (12-18 months). The 112 intraoral photographs of individuals of all groups, obtained between 6 and 12 years of age, were assessed by the occlusal index for intraoral photograph rating. The groups were compared by the χ² test. The correlation between surgical timing and the scores was tested by the Spearman test (P < .05).

RESULTS

Group I presented the highest percentage of score 5, group II exhibited highest percentage of score 1, and group III presented the lowest percentage of score 5 according to the χ² test (P = .029). The Spearman correlation test revealed statistically significant difference between timing of LS and the occlusal index. The earlier the surgical timing, the higher the occlusal index (P = .019).

CONCLUSIONS

Infant orthopedics has demonstrated the possibility of postponing primary plastic surgeries. Patients submitted to late lip and palate repair had the best prognosis, while patients undergoing lip repair from 1 to 15 days of life, even operating the palate later, had the worst prognosis. Neonate LS negatively influenced the occlusal relationships.