Simplifying cleft surgery by presurgical nasoalveolar molding (PNAM) for infant born with unilateral cleft lip, alveolus, and palate: a clinical report

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.

Presurgical Nasoalveolar Molding and Columella Lengthening for Early Unilateral Cleft Lip and Palate Rehabilitation: A Comprehensive Clinical Case Report

Aim and background

In presurgical infant orthopedics, nasoalveolar molding (NAM) therapy has gained more popularity worldwide in treating patients with cleft lip and palate because of its soft tissue nasal corrections in addition to the alignment and close approximation of the cleft alveolar segments, which gives better postsurgical stability and esthetics with minimal tissue tension and scar formation to the patients.The clinical case report aims to show the better post-NAM results, which had helped to gain better postsurgical results in terms of stability and aesthetics in hard and soft tissues.

Case description

This clinical report presents the case of a 9-day-old female patient reported in the Department of Orthodontics and Dentofacial Orthopedics at Sharad Pawar Dental College and Hospital with nonsyndromic complete left-sided unilateral cleft lip and palate with a defect size of 13 mm, which was treated with a presurgical nasoalveolar molding (PNAM) appliance. NAM therapy takes advantage of circulating maternal estrogen, bringing pliability to the cartilage cells for presurgical cartilage molding. This has resulted in the closure of the alveolar defect from 13 mm to <2 mm in the present case, with nasal symmetry restoration due to nasal stent within 12 weeks of active treatment; hence, the postsurgical esthetics are maintained.

Conclusion

NAM therapy remained beneficial and had significant aesthetic results in reducing the cleft defect size. Because of this, it gained a big surgical advantage in reducing tissue tension, primary stability, and scar formation.

Clinical significance

By reducing the cleft defect size of the dysplastic maxillae, which brings the lip segments and alveolar segments closer to each other, it thus reduces the defect size for primary lip and palate repair. This serves as the biggest advantage for maxillofacial and plastic surgeons to maintain the posttreatment results with redefined aesthetics and symmetry.

How to cite this article

Taori KP, Niranjane P, Kamble R. Presurgical Nasoalveolar Molding and Columella Lengthening for Early Unilateral Cleft Lip and Palate Rehabilitation: A Comprehensive Clinical Case Report. Int J Clin Pediatr Dent 2024;17(8):955-961.

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.

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.

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.

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.

Use of Nasal Conformer After Birth Effectively Improves Nostril Symmetry in Patients With Unilateral Incomplete Cleft Lip

PURPOSE

To investigate the clinical effects of preoperative nasoalveolar molding (NAM) and nasal conformer use in patients with unilateral incomplete cleft lip on the basis of their medical records and images.

PATIENTS AND METHODS

Data and images of 16 patients born with unilateral incomplete cleft lip who were hospitalized between January 2015 and August 2017 were retrieved from the medical records. The primary outcome was the extent of improvement in columella height (CH) before cheiloplasty. Other outcome measurements included the CH, nostril width, and nostril height, which were measured by ImageJ image processing software (version 1.4; National Institutes of Health, Bethesda, MD) and presented as ratios. Mann-Whitney U tests were used to compare the non-normally distributed data.

RESULTS

Patients in the NAM group and those in the nasal conformer group showed significantly improved (P < .05) preoperative cleft-side CH-to-normal-side CH ratios compared with the corresponding ratios at birth. There was no significant difference in terms of the extent of improvement in CH between the groups.

CONCLUSIONS

Preoperative use of nasal conformers in patients with unilateral incomplete cleft lip not only corrects the deformed nasal cartilage but also increases the CH and improves the overall preoperative nasal symmetry. In addition, compared with NAM, this method costs less, is more straightforward, and requires fewer outpatient clinic visits.

Effects of pre-surgical nasoalveolar moulding on maxillary arch and nasal form in unilateral cleft lip and palate before lip surgery

OBJECTIVES

To investigate the effects of pre-surgical nasoalveolar moulding (PNAM) on the maxillary arch and nasal form in patients with unilateral cleft lip and palate (UCLP).

SETTING AND SAMPLE POPULATION

This is a retrospective case series study. The subjects were infants with complete UCLP who were treated with PNAM (n = 18) at Kagoshima University Medical and Dental Hospital (Japan) between 2006 and 2013.

MATERIAL AND METHODS

Maxillary dental casts and facial photographs were taken at the time of the first visit and immediately prior to lip surgery to evaluate the maxillary arch and nasal form changes. The dental casts were scanned with a laser scanner, and changes in the 3-Dimensional coordinates of anatomical landmarks and alveolar cleft width were analysed. Moreover, we investigated the correlation between the changes in the maxillary alveolar arch and nasal form.

RESULTS

Regarding the maxillary alveolar arch form, the anterior points of the major segment had moved significantly to the cleft side just prior to the time of lip repair, and the alveolar cleft width was significantly decreased. For nasal form, the inclination and displacement of the columella were significantly improved. The improvement of columella inclination was moderately correlated with the posterior movement of the anterior points of the major segment.

CONCLUSIONS

These findings indicate that PNAM for infants with UCLP enhanced symmetry in the maxillary alveolar arch and nasolabial form. In addition, the posterior movement of the anterior points of the maxillary alveolar arch was correlated with the improvement of columella deformation.

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.

Comparison of Oxygen Saturation During Impression Taking Before and After Presurgical Orthopedic Therapy in Babies With Cleft Lip and Palate

AIM

The objective of this study was to (1) evaluate the oxygen saturation (SpO₂) levels during intraoral and extraoral impression taking and (2) compare the SpO₂ levels during impression taking before and after presurgical orthopedic therapy (POT) of infants with cleft lip and palate (CLP).

PATIENTS AND METHODS

In our study, 31 babies with CLP before (mean age 7.6 ± 3.2 days) and after (mean age 108.3 ± 24.2 days) POT were monitored, and SpO₂ levels were measured under operating conditions before any intervention (T1), after oxygenation (T2), during taking intraoral (T3), and extraoral (T4) impressions with oxygen support and immediately before the discharge from the operating room (T5).

RESULTS

In both groups, statistically significant differences in SpO₂ measurements at T1, T2, T3, T4, and T5 stages were found (P < .01). For the pre-POT measurements, increases in SpO₂ levels from T1 to T2 and T4 to T5 (P < .05) and decreases from T2 to T3 and T3 to T4 (P < .01) were noted. Similarly, SpO₂ levels decreased significantly from the intraoral (T3) to extraoral (T4) post-POT impression periods (P < .01). Comparisons of pre- and post-POT measurements revealed that the SpO₂ level of each time period was higher at the post-POT impression taking except for stages T2 and T5 (P < .01).

CONCLUSION

The SpO₂ values were low at the onset of POT in infants with CLP before any intervention. Oxygen saturation levels may decrease particularly during extraoral impression taking in infants with CLP despite the supplemental oxygen. SpO₂ measurements were higher during post-POT intraoral and extraoral impression taking when compared with pre-POT measurements.