Effective retropulsion and centralization of the severely malpositioned premaxilla in patients with bilateral cleft lip and palate: a novel modified presurgical nasoalveolar molding device with retraction screw

Complications During Grayson Presurgical Nasoalveolar Molding Method in Nonsyndromic Infants With Complete Unilateral Cleft Lip and Palate

INTRODUCTION

Within the treatment protocols of patients with cleft lip and palate, the nasoalveolar molding (NAM) acquire more followers every day.Their benefits have been well documented, but not equally their complications. The purpose of this study was to describe the complications produced during treatment with Grayson presurgical NAM in nonsyndromic infants with complete unilateral cleft lip and palate.

METHODS

Bibliographic review on 8 databases using search algorithms. By applying the exclusion and inclusion criteria, 21 articles were detected, which were analyzed in full text. Complication, cause, and solution data were presented in supplemental tables.

RESULTS

Complications are related to soft tissues, hard tissues, and those derived from care.

SOFT TISSUES

irritation, ulceration, gingival, facial, or nasal bleeding. Candidiasis. An overexpanded nostril creation to improper placement or modifications of the nasal stent at home.The most frequent were lip and cheeks skin irritation by taping, and gingival ulceration due to excessive pressure.

HARD TISSUES

misalignment of alveolar segments and the premature eruption of teeth.

DERIVED FROM CARE

inadequate device retention, adherence problems to treatment, poor/excessive care of the caregiver, intolerance to the device, eating problems, breathing, and socioeconomic issues.

CONCLUSIONS

The main complications occur in soft tissues, related to the retention mechanisms and an inadequate adjustment of the device.The benefits of NAM exceed the complications. It is necessary to know them to avoid any harmful results since they could prolong or stop the treatment, compromising the result. The active collaboration of the family in the insertion and maintenance of the device is crucial for success.

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

OBJECTIVE

This study aimed to observe and analyze the effects of nasoalveolar molding (NAM) on maxillary arch dimensions in patients with bilateral complete cleft lip and palate (BCLP) using 3-dimensional analyses.

DESIGN

Retrospective case series.

MATERIALS AND METHODS

Seventeen infants were treated using modified Khon Kaen University presurgical nasoalveolar molding devices (KKU-NAM). Dental casts were evaluated 3 dimensionally at 3 time points: pretreatment (T1), after using modified KKU-NAM for 2 weeks (T2), and before cheiloplasty (T3). Repeated-measures analysis of variance and Friedman test were used to compare the maxillary arch dimensions between time points.

RESULTS

Both sides of the cleft width, premaxilla deviation, and premaxilla protrusion had significantly reduced with the use of KKU-NAM. Premaxillary rotation had significantly improved, whereas the arch depth did not change significantly. Premaxilla width, posterior arch width, alveolar length, and height had significantly increased. The anterior arch width, intercanine width, and lateral sulcus width showed no significant changes. The intraclass correlation coefficient used to test the measurements indicated substantial reliability.

CONCLUSION

The modified KKU-NAM is an effective device for reducing the severity of bilateral cleft deformities, especially in the premaxilla area.

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.

Surgical Nasoalveolar Molding: A Rational Treatment for Bilateral Cleft Lip Nose and Systematic Review

Background:

The purpose of this study was to evaluate the surgical outcome after using primary surgery to address bilateral cleft lip nose and palate deformities. In addition, the authors performed a systematic review to evaluate the effects of the nasoalveolar molding on non-syndromic bilateral cleft lip and palate.

Methods:

A prospective cohort study on a surgeon’s surgical outcome of 25 consecutively performed primary bilateral cleft lip nasal deformity repairs was conducted and a systematic review of the literature for studies published until December 2019 was done to evaluate the effect of presurgical NAM on nasolabial aesthetics and alveolar gap.

Results:

Since 2014, 25 consecutive patients with complete bilateral cleft have undergone primary anatomical repair of the cleft nasal deformity using primary cheilorhinoplasty. The average columella length was 4.3 ± 1.3 mm. The average ratio of the columella height to nasal height was 0.48 mm 1 year postoperatively and 0.52 mm 5 years postoperatively. Statistically significant differences have been observed between the pre and postoperative alveolar and palatal gaps after using primary cheiloplasty or bilateral lip adhesion. After systematic literature searching, 14 identified studies were qualified for the final analysis, which included 433 patients. The overall study quality according to Oxford CEBM and GRADE scale was low.

Conclusions:

The results of this study suggest that the proposed primary cheilorhinoplasty is a good alternative to improve nose appearance and alveolar gap in patients with primary bilateral cleft lip nose and palate deformity. Based on the available scientific evidence, definitive conclusions about the effectiveness of presurgical Naso Alveolar Molding on nasolabial aesthetics cannot be drawn. Quality of the included articles were too low to make a conclusion.

Three-dimensional development of the palate in bilateral orofacial cleft newborns 1 year after early neonatal cheiloplasty: Classic and geometric morphometric evaluation

OBJECTIVES

The aim of this study was to assess palatal growth in newborns with complete bilateral cleft lip and palate (cBCLP) and bilateral cleft lip and palate with tissue bridges (BCLP + B) 1 year after early neonatal cheiloplasty (ENC).

MATERIAL AND METHODS

The methodology was based on classic and morphometric analysis of dental models of newborns with cBCLP or BCLP + B. These analyses included metric analysis, coherent point drift-dense correspondence analysis, superprojection methods, and multivariate statistics. Dental casts were observed in two age categories, which were compared with each other. The first cast was obtained from each patient before ENC (T0, 5 ± 5 days) and the second one prior to palatoplasty (T1, 12 ± 6 months).

RESULTS

Fifty-two dental models obtained from 26 newborns with cBCLP and BCLP + B were evaluated. The results showed that over the 12-month period, alveolar clefts were narrowed in both cleft types due to anterior growth combined with the formative effect of suturing. This was confirmed by decreases in the dimensions of the right (T0 9.93 ± 2.80 mm, T1 6.64 ± 2.43 mm; p ≤ 0.003) and left (T0 10.71 ± 4.13 mm, T1 6.69 ± 4.29 mm; p ≤ 0.003) alveolar clefts in cBCLP patients. Similar reductions in alveolar cleft widths occurred on the left side (T0 11.69 ± 4.75 mm, T1 4.34 ± 2.97 mm; p ≤ 0.001) of BCLP + B patients, while on the right side, which was connected by a combined tissue bridge, there was non-significant narrowing of the alveolar cleft (T0 1.61 ± 1.34 mm, T1 1.04 ± 0.70 mm; p = 0.120). The ENC did not restrict posterior palatal growth, meaning that intertuberosity width was extended in cBCLP (T0 32.80 ± 3.15 mm, T1 35.86 ± 2.80 mm; p ≤ 0.001) and in BCLP + B neonates (T0 34.01 ± 2.15 mm, T1 36.21 ± 2.14 mm; p ≤ 0.004). Width and length measurements in the observed groups showed growth tendencies equivalent to those in noncleft or LOP patients. Palatal variability was greater in neonatal cBCLP, but was reduced during the monitored period, approximating that for BCLP + B. Regions with the most notable palatal growth were located primarily at the premaxilla and at the anterior and partially posterior ends of the maxillary segments.

CONCLUSION

Early neonatal cheiloplasty had no negative effect on palatal growth in any direction. There was no reduction in the length or width of the palate during the first year of life, nor was there narrowing of the dentoalveolar arch. The formative effect of the operated lip on the anterior part of the palate was confirmed. This, in combination with the favorable growth, lead to closure of the alveolar cleft.

Management of the protuberant premaxilla: where does it fit in?

PURPOSE OF REVIEW

To discuss multidisciplinary treatment options for the protuberant premaxilla associated with bilateral cleft lip and palate. Lessons have been learned throughout the years regarding the effect of growth restriction after early and aggressive therapy. Multiple surgical and orthodontic interventions are discussed. Recent literature will be highlighted and discussed.

RECENT FINDINGS

A paucity of long-term studies was noted. Recent literature revealed numerous studies introducing innovative presurgical orthopedic devices as less expensive and easier to use alternatives to nasoalveolar molding. Multiple approaches to premaxillary setback were presented, offering multiple approaches to improve success rates and minimize burden to the patient. Novel orthodontic and advanced microvascular procedures were discussed as additional tools for treatment of the malpositioned premaxilla once skeletal maturity is reached.

SUMMARY

Multidisciplinary team management of the protuberant premaxilla and bilateral cleft lip and palate is becoming increasingly embraced worldwide. Numerous surgical procedures and orthodontic treatments are required to optimally reposition the premaxilla; however, these interventions can inhibit growth, resulting in maxillary retrusion. Long-term follow-up studies are needed to determine what protocol is best. Studies should also include ways to overcome barriers to treatment success, such as late intervention, resource disparity, and limited access to care.

Modifications in Presurgical Nasoalveolar Molding Treatment of Bilateral Cleft Lip and Palate Patients With Severely Malpositioned Premaxillae

OBJECTIVE

The aim of this study was to evaluate a modified presurgical nasoalveolar molding (PNAM) treatment for patients with bilateral cleft lip and palate (BCLP) with severely malpositioned premaxillae.

SETTING

This study was conducted at the Faculty of Dentistry, Department of Orthodontics, Ege University, Bornova, Izmir, Turkey.

METHOD

Retention arms were manufactured using a mold that we developed, and prefabricated retraction apparatuses were applied to the plaster model obtained from the patient. During the acrylic curing process, the flanges of the appliances were elongated into the sulcus without including the premaxilla. The premaxilla was aligned with the midline with an elastic band system, and the lip hanger was constructed with 0.023-in stainless steel wire. Elastic bands were stretched between the retraction apparatuses and the lip hanger based on the desired force. Nasal stents were added to the retention arms when the cleft width was reduced to less than 6 mm.

CONCLUSION

The modified PNAM treatment enabled faster derotation of the premaxilla and earlier initiation of retraction. The prefabricated retraction apparatus and retention arm provided efficient PNAM for patients with BCLP.

[Application of team approach and key techniques of cleft lip and palate]

The development of an expert consensus based on specific domestic situations will provide practical guidance to the efforts aiming at improving cleft care in China. The team approach of twenty-one cleft centers were pooled together, covering pre-surgical orthopedics, primary surgical repair, orthodontic treatment, alveolar bone graft, secondary deformity correction, palatal fistulae repair, the diagnosis and treatment of velopharyngeal incompetence, speech therapy, otitis media management, and skeletal deformity correction. Agreement was achieved among the authors concerning the application of critical surgical and non-surgical techniques. The ambition of this consensus is to introduce more clinicians to the revolution of sequential treatment of clefts, and form the basis for a more comprehensive cleft care manual in the future.

Changes in nose symmetry in unilateral cleft lip and palate treated by differing pre-surgical assistance: An objective assessment of primary repair

BACKGROUND

Residual deformity of the nose, not lip, continues to be the greater challenge in UCCLP rehabilitation. Platform distortions often re-emerge following primary reconstruction revealing the stereotypical cleft-nose. Nasal alveolar molding reduces nose asymmetry. However, this study applies directional mechanics to the underlying platform distortions and soft tissue nose, introducing a novel device addressing the distorted septo-premaxillary junction.

METHODS

Retrospective assessment of 47 UCCLP patients by 2-dimensional photographic analysis with 24 subjects treated by dento-maxillary advancement (DMA) and nasal septum button-head pin (NSBP), 17 having nasal molding (NM), compared to 23 subjects without nose treatment, 16 with DMA and 7 with passive plates. Measurements were assessed by t tests, ≤ 05 confidence.

RESULTS

Frontal view: nose-treatment sample achieved ideal ala-bases vertical symmetry (p = 0.00065 & 0.00073); significantly improved ala-rims "slump" angle (p = 0.0071). Both samples had nose positioning within the facial frame like non-cleft population. Sub-nasal view: significant differences were for columella angle (p = 0.0015), nares "offset" (p = 0.002), and columella symmetry (p = 0.022) with nose-treatment achieving near ideal columella symmetry score (0.92) vs. (0.81).

CONCLUSIONS

NM and the novel NSBP procedures integrated with the platform correction effect of the DMA successfully treated at three distorted anatomic-levels native to UCCLP to improve nasal aesthetics.