Comparison of Early Onset Nasoalveolar Molding With Patients Who Presented for Molding Up to 1 Year of Age

Effectiveness of 2 Lip Taping Techniques in Infants With Bilateral Cleft Lip and Palate: A Randomized Clinical Trial

OBJECTIVES

This trial was designed to test the efficacy of 2 lip taping methods in modifying the maxillary arch dimensions (MADs) of infants with bilateral cleft lip and palate (BCLP) before lip repair surgery.

DESIGN

Parallel-group randomized clinical trial.

SETTING

The trial was conducted at 3 centers in Baghdad city.

PARTICIPANTS

Thirty-six nonsyndromic infants with BCLP.

INTERVENTION

The eligible infants were randomly assigned to either the first experimental group that received a conventional horizontal tape (3 M Steri strip-1/4 inch) or the second experimental group that received a custom-made tape made of Steri strips and orthodontic extra oral elastics. All of the included infants in both groups had rubber base impressions taken for them at the start of treatment (T1) and right before surgical lip repair (T2). A desktop scanner was used to scan each of the generated models, creating digital models that could be used for outcome evaluation.

MAIN OUTCOMES MEASURES

Virtual MAD measurements were performed by a blinded assessor on the generated digital models both before (T1) and after (T2) treatment.

RESULTS

At T2, both groups showed statistically significant changes in all measured MADs, with a mean difference ranging from 1.36 to 2.95 mm for the conventional taping group and from 1.46 to 7.96 mm for the custom-made one. The comparison of the 2 groups revealed both statistically and clinically significant differences with a P value <.05. The custom-made taping demonstrated more constriction in maxillary arch in terms of changes, which could provide easier surgical manipulation for the cleft parts.

CONCLUSION

Lip taping appears to be an efficient technique for modifying the MADs in infants with BCLP.

Nasoalveolar Molding in Lately Presented Moderate to Severe Unilateral Cleft Lip and Palate Infants: Does it Add?

Alignment of the alveolar segments with early nasal cartilage tackling is the foundation upon which excellent surgical results are dependent. The purpose is to evaluate the short-term effect of triple combination of passive alveolar molding with early nasal molding augmented by controlled corrective power of lip tapping in lately presented moderate to severe unilateral complete cleft lip and palate infants. A prospective case series study was conducted in Plastic and Maxillofacial Surgery Department, Ain Shams University in collaboration with Orthodontics Department, from January 2021 till June 2023, 15 infants elder than 2 months till 6 months were enrolled in the study. Eight nasal anthropometric measurements ratios through 2-dimension assessment and 4 maxillary arch measurements ratios through 3-dimension assessment were recorded. Extraoral results revealed clinically and statistically decrease of nasal width, alar base width, alar base height ratios, and columellar angle, while increase of nasal height, nasal dome height, columellar length, and alar projection length ratios. Intraoral results revealed clinically and statistically decrease in cleft width with maintained posterior arch width and intercanine width. In conclusion, this triple combination helped in presurgical lessening the alveolar and nasal deformity of such elder infants in a shorter time in comparison with other conventional methods with lesser number of appointments decreasing burden of care to their families improving their compliance.

Systematic Review and Critical Appraisal of the Evidence Base for Nasoalveolar Molding (NAM)

OBJECTIVE

To critically appraise the body of scientific literature supporting the risks and efficacy of nasoalveolar molding (NAM), specifically in contrast to alternative methods of presurgical infant orthopedics (PSIO) or to treatment without PSIO.

MAIN OUTCOME MEASURES

Five outcome domains were considered: nasolabial aesthetics; dentoalveolar relationship; midfacial growth; cost and burden of care; and number of anesthetic events.

DESIGN

MEDLINE, Embase, and Scopus were queried for articles from the first description of the Grayson-Santiago NAM technique (1993) through December 13, 2021. After the application of inclusionary and exclusionary criteria, selected articles were critically appraised using a systematic framework that included risk of bias assessment using the Cochrane RoB 2.0 and ROBINS-I tools.

RESULTS

A total of 88 studies were included. Level-I and -II evidence showed on par or better approximation and alveolar alignment achieved by NAM compared to other PSIO. Level-II and -III evidence showed improved nasolabial aesthetics compared to other PSIOs. Level-II and -III evidence supported no harm to maxillofacial skeletal growth through age 12. Sparse level-III evidence supported a reduced number of labial or nasal revisions following NAM. Level-II and -III evidence showed NAM requiring upfront cost and frequent appointments but reducing caregiver psychosocial burden and reducing long-term costs compared to select alternatives. Many studies carried a high risk of bias.

CONCLUSIONS

Current evidence supports the overall efficacy of NAM regarding short/mid-term outcomes, with a low risk of negative effects on midfacial growth or dental development. The high risk of bias discovered in many papers underscores the need for robust study design in future research.

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.

Presurgical Infant Orthopedic Videos on YouTube™: A Thematic Analysis of Caregiver Narratives

OBJECTIVE

Information regarding how caregivers cope when using presurgical infant orthopedic (PSIO) appliances is sparse. This study aimed to understand caregivers' perspectives and experiences with contemporary PSIO treatment.

DESIGN

PSIO videos shared on the YouTube™ platform were used as the data source. Videos with caregivers were identified (n = 21) and portions with caregiver narratives were transcribed. This was followed by the application of a six-step thematic analysis as conceptualized by Braun and Clarke (2006, 2019).

RESULTS

Two themes were identified from the caregiver narratives in the PSIO videos. The Family Journey theme included reaction to diagnosis, choice of center, burden of care, care commitment, coping, and testimonials. The Information theme included PSIO techniques and PSIO benefits.

CONCLUSION

Multifaceted challenges and coping strategies were described by caregivers during the PSIO phase. Caregivers remained committed to treatment despite the burden of care, were motivated by an understanding of the benefits of PSIO, and customized care based on their individual strengths and needs. Study results can help providers gain an understanding of what caregivers experience outside the clinical environment.

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.

Comparison of post-surgical soft tissue changes between bilateral cleft patients treated with and without a modified nasoalveolar molding appliance: A cohort study

INTRODUCTION

The advantages of nasoalveolar molding (NAM) treatment for cleft lip and palate (CLP) patients have been well documented. A modified design for bilateral CLP was introduced.

AIMS

This paper aimed to: 1- quantify the soft tissue changes after applying modified NAM treatment to these patients; and 2-compare post-surgical changes to a control group where no NAM was used.

MATERIAL AND METHODS

At a tertiary care paediatric hospital, a historical cohort group of complete BCLP patients (n=15) was compared to a prospectively collected group of complete BCLP patients who underwent NAM therapy (n=15). In the NAM group (mean age: 1.1mos±0.2), a new modification of the NAM appliance was implemented. In the control group (mean age: 5mos±0.2), no NAM treatment was adopted prior to lip closure surgery. Soft tissue nasolabial segments were measured on initial (T1), post-NAM (T2) and 3 months post-surgery (T3) photographs; measurements were analysed statistically.

RESULTS

In the NAM group, cleft size was reduced by 68 to 70% in 4-5months and all measurements improved between T1 and T2. Columellar crest inclination decreased by 74%, columellar length increased by 184%, nostril and bialar widths decreased by 36% and 16%, respectively. The lip philtrum was elongated by 49.5%. At T3, all soft tissue variables statistically improved better in NAM versus non-NAM groups.

CONCLUSION

The modified NAM appliance provided improved results of lip approximation and nasal measurements compared to non-NAM treatment.

Protocols in the management of Cleft Lip and Palate: A Systematic Review

AIM

To identify clinical decisions on surgical as well as non-surgical modalities for the treatment of CLP patients based on randomized controlled trials (RCTs).

MATERIALS AND METHODS

PubMed, Ebscohost, and Cochrane Library were searched and 20 articles based on RCTs conducted on cleft patient management were identified.

RESULTS

The topics explored were infant orthopedics, lip and palate repair, alveolar bone grafting, and management of cleft maxillary hypoplasia. Nasoalveolar molding (NAM) was found to have great benefits when carried out within one month of birth. Fisher and Mohler's lip repair technique and use of recombinant human bone morphogenetic protein-2 (rh-BMP2) for alveolar bone grafting showed promising results. rh-BMP2 for alveolar bone grafting appears to be a promising alternative to autografts.

CONCLUSION

Early commencement of NAM in neonatal life is of great benefit to cleft patients. There is a need for more multicentre collaborations, mainly to identify the ideal surgical technique to reduce the variability in treatment and to ensure that the patient receives appropriate evidence-based treatment.

Mothers' knowledge and experience concerning presurgical orthopedic management for infants with cleft lip and palate

OBJECTIVES:

The present study aimed to assess the level of mothers’ knowledge toward cleft lip and palate and their experience concerning presurgical orthopedic management.

MATERIALS AND METHODS:

This was a cross-sectional study where the mothers were invited to complete a self-administered validated and reliable questionnaire. The questionnaire included questions that aimed to assess mother's knowledge related to the most prevalent aspects of cleft lip and palate anomaly itself and additionally, questions associated with presurgical orthopedic treatment as an adjunct therapy. Descriptive statistics were used to define the characteristics of the study variables. Chi-square test was utilized to assess relationships between categorical variables.

RESULTS:

Totally, 145 mothers completed the survey (response rate was 73%). Forty-six (46%) of the mothers provided an incomplete or improper definition of the anomaly and 35 (24%) claimed that they know the cause of the anomaly. The majority of mothers did not identify family history as a risk factor; consanguinity was identified in 29% (n = 42). Of the total, 58 mothers (40%) agreed that dental management of CLP requires teamwork and the majority (n = 126, 87%) recognized the plastic surgeon as the most important specialist. Mothers aged 20-30 years old (n = 42, 53%), and those who are university graduates (n = 38, 48%), as well as employed mothers (n = 52, 66%) have in general a higher degree of knowledge regarding cleft lip and palate (P < 0.001). More than half of the mothers (n = 70, 57%) reported that presurgical orthopedic treatment was useful and needed for their infants.

CONCLUSIONS:

Most of the mothers reported a high level of knowledge about cleft lip and palate and they experienced the usefulness of the orthopedic appliances for their infants. However, there was uncertainty in some parts such as definition, diagnosis, causes, and risk factors for cleft lip and palate. Therefore, understanding the causes of cleft lip and palate, as well as comprehensive education concerning the essential role of the orthopedic appliances to improve cleft lip and palate are crucial for mothers to improve their infants’ quality of life.

Repair Sequence and Management of the Premaxilla in Patients With Bilateral Cleft Lip and Palate: A Systematic Review of the Literature

BACKGROUND

Bilateral cleft lip and palate (BCLP) remains a difficult surgical problem due to the severely protruding premaxillary segment, with no consensus of optimal treatment sequence in older patients. A systematic review of the literature was performed to assess the current status of BCLP repair based on age.

METHODS

A PRISMA systematic review of the PubMed, Web of Science, and Embase databases was performed using a series of search terms related to BCLP. Studies were categorized based on the age of presentation, repair sequence, and technique.

RESULTS

The database search identified 381 articles. Of these, 72 manuscripts were ultimately included. The lip was repaired first in 1077 patients (86.0%), palate first in 161 patients (12.9%), and simultaneous lip and palate in 14 patients (1.1%). Patients less than 6 months old received lip repair first (n = 959, 98.6%), with complications of unaesthetic appearance (n = 86, 62.3%) and midface retrusion (n = 41, 34.1%) in younger patients and wound dehiscence (n = 8, 40%) in older patients. Primary lip repair was preceded by presurgical orthopedics (n = 760) or lip adhesion (n = 272) to reduce lip tension with nasoalveolar molding (n = 452, 62.9%) or the Latham device (n = 282, 37.1%). In older patients, the palate was repaired first or premaxillary setback (n = 222) was indicated in protruded premaxillae greater than 10 mm, but carried the risk of premaxilla mobility (n = 20, 37.7%) and midface retrusion (n = 10, 18.9%).

CONCLUSION

In younger patients, lip repair is performed first with preoperative orthopedics or lip adhesion. In older patients, the palate is more commonly repaired first compared with the lip; however, there is no difference in complication rate.

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.

Effects of Nasoalveolar Molding Therapy on Alveolar and Palatal Cleft Deformities in Unilateral and Bilateral Cleft Lip and Palate

OBJECTIVE

The purpose of this study was to evaluate and compare the efficacy of nasoalveolar molding (NAM) therapy in the improvement of alveolar and palatal cleft deformity on unilateral (UCLP) versus bilateral (BCLP) cleft lip and palate.

MATERIALS AND METHODS

A total of 19 UCLP (14 boys and 5 girls) and 8 BCLP (7 boys and 1 girl) infants completed NAM therapy were included in this study. Standardized parameters of cleft width of alveol and palate were measured on photocopies taken from the pre- and post-treatment plaster casts. To assess the intragroup differences, paired-samples test in UCLP and Wilcoxon test in BCLP groups were used. Mann-Whitney U test was used to evaluate the differences between the groups.

RESULTS

Significant decreases in alveolar and palatal cleft gaps were achieved in an average period of 3.3 ± 1.9 and 3.7 ± 1.6 months in UCLP and BCLP patients, respectively. The alveolar cleft decreased 7.85 ± 4.59 mm in UCLP and 4.25 ± 3.13 and 3.81 ± 3.50 mm in right and left alveolar cleft sides in BCLP, respectively. The palatal clefts were decreased 4.63 ± 2.44 mm in medial and 3.72 ± 2.62 mm in posterior parts in UCLP. The decrements in BCLP were 3.00 ± 2.75 mm in medial and 2.88 ± 2.75 mm in posterior palatal cleft distances. No significant differences were determined in the amount of alveolar or palatal cleft closure between UCLP and BCLP groups. The only decrease in arch width was 1.39 mm in medial part of palate in UCLP.

CONCLUSION

The NAM device provides significant decreases in both alveolar and palatal cleft deformities in UCLP and BCLP infants, as compared with their birth status.

Nasoalveolar Molding Therapy for the Treatment of Unilateral Cleft Lip and Palate Improves Nasal Symmetry and Maxillary Alveolar Dimensions

OBJECTIVE

The aim of this study is to assess the esthetic and morphologic outcomes before surgery using nasoalveolar molding (NAM) therapy in children with unilateral cleft lip and palate.

DESIGN

A prospective analysis was performed.

SETTING

The study was carried out in the Congenital Malformations Craniofacial and Cleft Lip and Palate Unit, Hospital Virgen de las Nieves, Andalusian Health Service, Granada (Spain).

PATIENTS

Twenty consecutively enrolled infants ranging in age from 7 to 30 days with nonsyndromic unilateral cleft lip and palate treated from 2008 to 2012.

INTERVENTIONS

All patients were treated with NAM appliances to align the alveolar segments and reduce severity of the nasal deformity.

MAIN OUTCOME MEASURE

The extraoral nasal measurements were performed on casts and nasal photographs. The measurements consisted of bialar width (BAW), columellar deviation (CD), cleft nostril height (CNH), cleft nostril width (CNW), non-CNH, non-CNW, and the deviation of the columella to the horizontal line represented by bilateral pupil line (BIA). The authors have made the measurements following Barilla method. Also 2 intraoral measurements were taken.

RESULTS

Following NAM the extraoral records showed a statistically significant decrease in CD (P < 0.0001), CNW (P < 0.0001), and BAW (P < 0.001). Furthermore, statistically significant increases in CNH (P < 0.05) and BIA (P < 0.0001) were observed.Following Barilla measurements, the authors have found a high percentage of symmetry in all the nasal measurements after the NAM therapy.Intraoral results showed a statistically significant decrease in the gap between the greater and lesser alveolar segments and a statistically significant increase in maxillary arch width.

CONCLUSIONS

Nasoalveolar molding improves nasal symmetry and achieves an improvement of all maxillary alveolar dimensions, increasing alveolar rim width, reducing the size of alveolar cleft gap, and improving shape of the maxillary dental arch. As a consequence of reducing the alveolar and nasal deformities before surgery, it is expected that the primary repair will be easier for the surgeon and more successful.

The role of Nasoalveolar molding: A 3D Prospective analysis

Nasoalveolar molding (NAM) is commonly employed to reduce the alveolar segments into proper alignment and to improve nasal symmetry in patients with cleft lip and palate. This study examines the periodical progression of NAM treatment over time. 20 patients with complete unilateral cleft lip and palate were prospectively recruited. A 2 stage NAM treatment protocol was applied. Stage 1 involved adjustment of the alveolar segments (mean age 15.6 days), while Stage 2 added nasal stents and started average 43 days after stage 1. 3D images (n = 241) were obtained prior to NAM initiation and weekly until the end of treatment. The cleft lip area, bilateral nostril areas, and the nostril height and width were measured. Treatment was assessed in the Cleft (C) side and the Non-cleft (N). There was significant difference in the C/N ratio of the nostril area, width, and height at pre-treatment (0.9 ± 0.3, 4.1 ± 1.1, and 0.5 ± 0.2), at the end of stage 1 (1.1 ± 0.3, 2.2 ± 0.6, and 0.8 ± 0.2), and at the end of stage 2 treatment (1.8 ± 0.3, 1.8 ± 0.4, and 1.2 ± 0.1); p < 0.05. Comparative 3D analysis with dense sampling offers a precise methodology for showing effects of NAM treatment. The morphological changes achieved with NAM therapy occur in early treatment phase.

Correlation between Nasoalveolar Molding and Surgical, Aesthetic, Functional and Socioeconomic Outcomes Following Primary Repair Surgery: a Systematic Review

OBJECTIVES

The authors performed a systematic review to evaluate the potential beneficial effects of the nasoalveolar molding appliance on nonsyndromic unilateral clefts of the lip and/or palate prior to primary lip repair.

MATERIAL AND METHODS

A literature search was performed using three electronic databases (PubMed, Embase, Web of Science) and three journals ("Cleft Palate-Craniofacial Journal", "Plastic and Reconstructive Surgery Journal" and "American Journal of Orthodontics and Dentofacial Orthopaedic") from January 1980 to April 2017. Data extraction was performed with tables treating different subjects: surgical, aesthetical, functional, socio-economical effects of nasoalveolar molding (NAM) appliances and the evolution of NAM appliances, especially three-dimensional technology.

RESULTS

Of the 145 articles retrieved in the literature surveys, 28 were qualified for the final analysis and 20 studies were excluded because of their small sample size (less than 10 patients) and/or too long follow-up (exceeded 18 months). Four randomized controlled trials were available. Although literature allowed discussing the short-term benefits of NAM appliance and the three-dimensional technology, scientific evidence is lacking.

CONCLUSIONS

Based on the results, nasoalveolar molding appliances have positive surgical, aesthetical, functional and socio-economical effects on unilateral clefts of the lip and/or palate treatment before the primary repair surgeries. Three-dimensional technology results in a more efficient and predictable nasoalveolar molding appliance treatment. However, nasoalveolar molding appliance effect in a short term remains unclear with the available literature. Further studies that integrate three-dimensional technology in a large scale are still needed.

Long-term effect of presurgical nasoalveolar molding on growth of maxillary arch in unilateral cleft lip and palate: randomized controlled trial

The objective of this study was to investigate the long-term effect of presurgical nasoalveolar molding (PNAM) on growth of the maxillary arch through early childhood until 6 years of age in complete unilateral cleft lip and palate (UCLP) patients presenting for PNAM at different ages. Complete UCLP patients who were treated at our centre were divided into two groups. The study group underwent PNAM and was further subdivided into three subgroups (PNAM initiated within 1 month, between 1 and 6 months, and between 6 and 12 months of age in subgroup I, II, and III, respectively). The control group did not undergo PNAM and was further subdivided into three subgroups. Patients were evaluated at T1 (first visit), T2 (before cheiloplasty), and T3 (at 6 years). Between T1and T2, the intersegment distance (ISD) reduced significantly in the study group but increased in the control group, whereas the intercanine width (ICW) in both the study and control groups did not show significant change. Between T2 and T3, ISD and ICW were reduced significantly in the control group due to arch collapse, whereas in the study group, ISD reduced slightly with ICW remaining almost similar to noncleft norms. We conclude that reduced ISD following PNAM improves arch symmetry and stability, and thus may prevent arch collapse in the long term.