The role of Nasoalveolar molding: A 3D Prospective analysis

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.

Artificial intelligence-driven automation of nasoalveolar molding device planning: A systematic review

STATEMENT OF PROBLEM

Despite the increasing number of publications on applying artificial intelligence (AI) in the dental field, clarity regarding the performance of different approaches for nasoalveolar molding (NAM) planning and designing is lacking. Additionally, the overall robustness of the evidence in this field remains uncertain.

PURPOSE

The purpose of this systematic review was to evaluate the role of AI in automating the prediction of anatomic landmarks and the design of NAM appliances.

MATERIAL AND METHODS

A comprehensive literature search was conducted in major databases up to April 2024 without language restrictions. Studies applying AI algorithms for NAM landmark detection or appliance design were included. Data on study characteristics, AI methods, outcomes, and limitations were extracted.

RESULTS

Six studies met the eligibility criteria. AI algorithms demonstrated high accuracy in automatically detecting landmarks and designing NAM appliances. Approaches ranged from fully automated to semi-automated workflows. Most studies reported significant time savings compared with manual methods.

CONCLUSIONS

AI applications in NAM demonstrate substantial potential in improving workflow design, as demonstrated by the high accuracy reported in various studies. The incorporation of AI in NAM planning leads to a significant reduction in treatment appointment times when compared with conventional manual methods, thereby potentially decreasing the overall duration of treatment. Nevertheless, additional research is required to foster better collaboration between dental professionals and AI experts, ultimately facilitating more efficient clinical integration.

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.

A multi-centric, single-blinded, randomized, parallel-group study to evaluate the effectiveness of nasoalveolar moulding treatment in non-syndromic patients with complete unilateral cleft lip, alveolus and palate (NAMUC study): a study protocol for a randomized controlled trial

BACKGROUND

Cleft lip and palate (CLP) are among the most common congenital anomaly that affects up to 33,000 newborns in India every year. Nasoalveolar moulding (NAM) is a non-surgical treatment performed between 0 and 6 months of age to reduce the cleft and improve nasal aesthetics prior to lip surgery. The NAM treatment has been a controversial treatment option with 51% of the cleft teams in Europe, 37% of teams in the USA and 25 of cleft teams in India adopting this methodology. This treatment adds to the already existing high burden of care for these patients. Furthermore, the supporting evidence for this technique is limited with no high-quality long-term clinical trials available on the effectiveness of this treatment.

METHOD

The NAMUC study is an investigator-initiated, multi-centre, single-blinded randomized controlled trial with a parallel group design. The study will compare the effectiveness of NAM treatment provided prior to lip surgery against the no-treatment control group in 274 patients with non-syndromic unilateral complete cleft lip and palate. The primary endpoint of the trial is the nasolabial aesthetics measured using the Asher McDade index at 5 years of age. The secondary outcomes include dentofacial development, speech, hearing, cost-effectiveness, quality of life, patient perception, feeding and intangible benefits. Randomization will be carried out via central online system and stratified based on cleft width, birth weight and clinical trial site.

DISCUSSION

We expect the results from this study on the effectiveness of treatment with NAM appliance in the long term along with the cost-effectiveness evaluation can eliminate the dilemma and differences in clinical care across the globe.

TRIAL REGISTRATION

ClinicalTrials.gov CTRI/2022/11/047426 (Clinical Trials Registry India). Registered on 18 November 2022. The first patient was recruited on 11 December 2022. CTR India does not pick up on Google search with just the trial number. The following steps have to be carried out to pick up. How to search: ( https://ctri.nic.in/Clinicaltrials/advsearch.php -use the search boxes by entering the following details: Interventional trial > November 2022 > NAMUC).

Nasolabial morphological changes in patients with unilateral cleft lip and palate using a Korat-modified nasoalveolar moulding appliance with primary correction

OBJECTIVE

The objective of this study is to measure the morphological changes of the nose and lip in patients with unilateral cleft lip and palate before and after cheiloplasty with primary rhinoplasty (primary correction) in conjunction with Korat-NAM usage.

DESIGN

Longitudinal cohort study.

SETTING

Cleft Center Maharat Nakhon Ratchasima Hospital, Nakhon Ratchasima, Thailand.

SUBJECTS

Twenty-six patients with unilateral cleft lip and palate.

INTERVENTIONS

Control group: only active obturator before primary correction. Experimental group: an active obturator and Korat-NAM I before primary correction. A customized endotracheal tube was retained in the nostril for 3 weeks before switching to Korat-NAM II for 1 year.

MAIN OUTCOME MEASURES

Six measurements comprising nostril rim length, nostril height, nostril sill width, columella angle, vertical lip height, and horizontal lip length were measured from the patients' photographs. All measurements, except the columella angle, were reported as the cleft side/non-cleft side value ratio. Measurements were taken at the initial appointment, immediately before, 3 weeks after, and 1 year after primary correction.

RESULTS

Nostril rim length ratio, nostril height ratio, nostril sill width ratio, columella angle on the cleft side, and vertical lip height ratio were improved using Korat-NAM before and 3 weeks after primary correction. Nostril rim length and height ratios were significantly better than the control group.

CONCLUSIONS

Korat-NAM improved nose and lip morphology before primary correction. An overcorrection improved the nose and lip morphology on the cleft side. The nostril rim length and vertical lip height on the cleft side also improved with Korat-NAM II 1 year after primary correction.

3-Dimensional Evaluation of Two PNAM Techniques (Modified Grayson & AlignerNAM) on Facial Soft Tissue Morphology: A Randomised Clinical Trial

OBJECTIVE

Evaluate facial changes after Presurgical Naso-Alveolar Molding (PNAM) in unilateral cleft lip and palate (UCLP) patients treated with Modified Grayson Technique and AlignerNAM (with DynaCleft nasal elevator) using a 3D facial scan.

DESIGN

Randomised clinical trial.

SETTING

Institutional study. Participants: 20 UCLP patients allocated to two groups (10 patients each).

INTERVENTIONS

Group A patients underwent PNAM with Modified Grayson Technique and Group B patients underwent AlignerNAM (with DynaCleft nasal elevator). Their 3D facial scans were obtained by using an iOSbased application (Bellus3D FaceApp) mounted on a novel frame. These .stl files were analysed using 3D software (GOM INSPECT) at three-time intervals; before intervention (T0), after intervention (T1) and one month after lip repair surgery (T2).

MAIN OUTCOME MEASURE(S)

Changes in facial and nasolabial morphology.

RESULTS

Both techniques brought significant improvement in the columellar length, nasal tip projection, columella angle, nasal tip angle and a significant reduction in cleft width. At T1, a statistically significant difference in angular and linear measurements was present in both groups. At T2, no statistically significant difference in linear parameters was observed between the two groups except for the outer lateral height of the non-cleft side, basal lateral height of the non-cleft side, and philtrum width. Similar pattern was observed in angular measurements with no statistically significant difference between the two groups except in nasolabial angle, anterior nasal base triangle III, and anterior nasal root triangle.

CONCLUSIONS

Aligner NAM and Modified Grayson technique are equally effective PNAM methods with similar clinical results in nasolabial morphology after lip repair surgery.

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 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.

Novel Digital Workflow for Nasoalveolar Molding and Postoperative Nasal Stent for Infants With Cleft Lip and Palate

OBJECTIVE

We present a novel digital workflow to provide presurgical infant orthopedic (PSIO) treatment for a patient with a unilateral cleft lip/palate utilizing nasoalveolar molding (NAM) and a custom postsurgical nasal stent.

SETTING

Within the US military healthcare system, the Joint Base San Antonio Craniofacial Anomalies Team utilizes dental scanners, predictive 3D modeling software, and 3D printing technology in a digital workflow for NAM appliance fabrication.

WORKFLOW

Soft tissue facial scanning, peri-oral scanning, and dental putty impressions are used to facilitate fabrication and measure outcomes. Digital modeling software and 3D resin printing are utilized to manufacture the prescribed devices.

MAIN OUTCOME MEASURES AND RESULTS

Extra-oral facial scans and intra-oral impressions are compared between 3 timepoints: pre-treatment, posttreatment with NAM, and postsurgical treatment.

CONCLUSIONS

The ability to share workflows, establish outcome standards, and streamline patient care will continue to advance best practices in digital PSIO.

Recent Advances in Nasoalveolar Molding Therapy Using 3D Technology

Presurgical Nasoalveolar Molding (NAM) is an adjunctive treatment modality designed to reorient misaligned tissue structures and nasal cartilage in cleft lip and/or palate (CL/P) patients. Recent advances in NAM therapy focus on modifications to the intraoral molding plate or nasal stent intended to improve treatment outcomes, ease of use, compliance, and cost-effectiveness. Notably, 3D technological advancements have been employed to design NAM devices more efficiently and create objective, standardized means of measuring progressive morphological changes during therapy. These advances are designed to incorporate 3D technology in the treatment of cleft lip and/or palate to render it more precise, accurate, and time-efficient.

Short-term surgical outcomes in patients with unilateral complete cleft lip and palate after presurgical nasoalveolar molding therapy: A three-dimensional anthropometric study

OBJECTIVE

This brief research report aimed to evaluate the short-term efficacy of presurgical nasoalveolar molding (PNAM) therapy on the nasolabial morphology three dimensionally in patients with non-syndromic complete unilateral cleft lip and palate (UCLP).

METHODS

Thirty-six patients with non-syndromic complete unilateral complete cleft lip and palate were enrolled retrospectively and categorized into 2 groups: 18 patients who had received PNAM treatment (PNAM group) and 18 age-matched patients who have not receive PNAM treatment (no PNAM group) from 2017 to 2021. The average starting age for PNAM therapy was 18.33 days, and the average PNAM treatment duration was 99.08 days. Twelve nasolabial parameters were measured to compare the postsurgical outcomes of two groups.

RESULTS

In PNAM groups, cleft width, vertical distance between double Crista philtri and columellar deviation were reduced compared to that in no PNAM group. And nostril height was larger than that in no PNAM group. The differences between two groups were statistically significant (p < .05). There were no statistical differences in columellar length, nostril width and bi-alar width between two groups. However, the nostril width on cleft side in PNAM group was decreased by an average of 1.1 mm.

CONCLUSION

Our result indicated that PNAM therapy decreased cleft width and vertical distance between Crista philtri. It also increased nasal symmetry by decreasing columellar deviation, increasing nostril height.

The Effect of Absorbable and Non-Absorbable Sutures on Nasal Width Following Cinch Sutures in Orthognathic Surgery

Background: Non-absorbable materials (nylon) are always used in cinch sutures to maintain nasal width and to improve harmonious facial symmetry in orthognathic surgery. However, a few drawbacks of nylon materials have been clinically reported following orthognathic surgery, such as nasal irritation and exposure of the sutures. An absorbable material (PDS) has been proposed in cinch sutures, not only to avoid the complications of nylon but also to stabilize the nasal width for a long-term follow-up. Methods: Fifty-seven patients with Angle’s malocclusion classification III receiving orthognathic surgery were enrolled in this study. A non-absorbable material (nylon) and an absorbable material (PDS) were utilized for the cinch sutures. Pre-operative (T1) and post-operative six-month (T2) craniofacial 3D images were collected for all patients to measure the alar curvature (Ac) width and the alar base (Al) width. A significance level of p < 0.05 was applied in the statistical analysis. Results: With the approval of IRB, cinch suturing was performed with nylon in 29 patients and with PDS in 28 patients. Pre-operative Ac and Al distances showed no significant difference between these two groups. There were also no significant differences between the suture materials in the peri-operative change in nasal width, including Ac (nylon: 1.999 ± 1.40; PDS: 1.484 ± 0.97; p = 0.112) and Al (nylon: 1.861 ± 1.66; PDS: 1.115 ± 0.92; p = 0.056). Conclusions: For cinch sutures in orthognathic surgery, PDS can maintain the peri-operative nasal width similarly to nylon; additionally, it can be absorbed in a timely manner without the drawbacks of non-absorbable materials.

Effect of Cleft Width on the Outcome of Presurgical Nasoalveolar Molding in Patients With Unilateral Cleft Lip and Palate

ABSTRACT

The purpose of this study was to investigate the short-term effects of presurgical nasoalveolar molding (PNAM) according to cleft width (CW) in patients with unilateral cleft lip and palate (UCLP). In this retrospective study, 32 newborns with nonsyndromic UCLP treated with PNAM were allocated to 2 groups based on CW (group A, CW ≤5 mm; and group B, CW >5 mm). The following measurements were carried out using standardized photographs taken before and after PNAM therapy (before primary lip surgery): nostril axis inclination of healthy (NAI-NC) and cleft sides (NAI-C), columellar angle (CA), nasal base inclination (NBI), nasal floor width ratio (NFWR), alar base height ratio (ABHR), and columellar length ratio. Before PNAM therapy, there were significant differences between the 2 groups with respect to NAI-C, NBI, NFWR, and ABHR, indicating greater deformation of the nose in group B. After PNAM therapy, CA, NAI-C, NAI-NC, NFWR, and columellar length ratio were significantly improved in both the groups, whereas NBI and ABHR significantly worsened in group B. The improvement in CA, NAI-C, and NFWR was significantly greater in group B. Although a larger CW had some negative effects on the outcome of PNAM, it was found to be advantageous for nasal symmetry, if initiated as early as possible. Nevertheless, it is important to consider those aspects of the nasolabial area that are involved in the perception of symmetry when evaluating the effect of CW on PNAM outcomes in UCLP.

NAM-help or burden? Intercultural evaluation of parental stress caused by nasoalveolar molding: a retrospective multi-center study

Objectives

Nasoalveolar molding (NAM) was developed to facilitate easier treatment and better outcomes for cleft lip and palate (CLP) patients. The aim of this study was to investigate the parental burden and possible intercultural differences of this treatment modality, which is often argued to burden parents to an extraordinary amount.

Materials and methods

Standardized questionnaires (available in English, Mandarin, and German) with 15 non-specific and 14 NAM-specific items to be retrospectively answered by Likert scales by parents of unilateral CLP patients with completed NAM treatment.

Results

The parents of 117 patients from two treatment centers in Taiwan and Germany were included. A very high level of overall satisfaction was found in both countries with significant intercultural differences in prenatal parent information, feeding problems, dealing with 3rd party’s perception, and experienced personal effort.

Conclusion

NAM is an effective treatment tool for children’s CLP deformities and their caregivers in overcoming the feeling of helplessness. Intercultural differences may be due to infrastructural reasons, cultural attitudes and habits, or different public medical education.

Clinical relevance

In addition to facilitating easier surgical treatment, NAM can be seen as a powerful coping strategy for parents dealing with a CLP deformity of their child and does not seem to burden them extraordinarily.

Evaluation of the Clinical Effectiveness of Nasoalveolar Molding (NAM) Using Grayson Method Versus Computer-Aided Design NAM (CAD/NAM) in Infants With Bilateral Cleft Lip and Palate: A Randomized Clinical Trial

OBJECTIVE

The aim is to compare between the clinical effectiveness of nasoalveolar molding (NAM) versus the computer-aided design NAM (CAD/NAM) in patients with bilateral clefts.

DESIGN

The trial is a randomized comparative trial with 1:1 allocation ratio.

PARTICIPANTS

Thirty infants with bilateral complete cleft lip and palate were recruited.

INTERVENTIONS

Patients were randomized between NAM and CAD/NAM groups. The treatment steps described by Grayson were followed for the NAM group. In the CAD/NAM group, digitized maxillary models were made to create series of modified virtual models which were used to fabricate the molding plates using 3-dimensional printing technology. The nasal stents were then added to the plates following Grayson method. The study lasted for 4 months.

MAIN OUTCOMES

The primary outcome was to evaluate the changes in the intersegment cleft gap. Secondary outcomes included the analysis of the maxillary arch in transverse, anteroposterior, and vertical dimensions as well as the premaxillary deviation and rotation. Chair side time was assessed for both methods.

RESULTS

Both modalities decreased the intersegment cleft gap. The CAD/NAM plates caused more reduction in the total arch length by 1.99 mm (-3.79 to 0.19, P = .03) as compared to the NAM treatment. No differences were found between groups in the transverse and vertical maxillary arch changes.

CONCLUSIONS

Both interventions were effective in narrowing the cleft gap. Similar maxillary changes were found in both groups. The CAD/NAM modality required less chair side time compared to the NAM treatment.

Automated Measurement of Intracranial Volume Using Three-Dimensional Photography

BACKGROUND

Current methods to analyze three-dimensional photography do not quantify intracranial volume, an important metric of development. This study presents the first noninvasive, radiation-free, accurate, and reproducible method to quantify intracranial volume from three-dimensional photography.

METHODS

In this retrospective study, cranial bones and head skin were automatically segmented from computed tomographic images of 575 subjects without cranial abnormality (average age, 5 ± 5 years; range, 0 to 16 years). The intracranial volume and the head volume were measured at the cranial vault region, and their relation was modeled by polynomial regression, also accounting for age and sex. Then, the regression model was used to estimate the intracranial volume of 30 independent pediatric patients from their head volume measured using three-dimensional photography. Evaluation was performed by comparing the estimated intracranial volume with the true intracranial volume of these patients computed from paired computed tomographic images; two growth models were used to compensate for the time gap between computed tomographic and three-dimensional photography.

RESULTS

The regression model estimated the intracranial volume of the normative population from the head volume calculated from computed tomographic images with an average error of 3.81 ± 3.15 percent (p = 0.93) and a correlation (R) of 0.96. The authors obtained an average error of 4.07 ± 3.01 percent (p = 0.57) in estimating the intracranial volume of the patients from three-dimensional photography using the regression model.

CONCLUSION

Three-dimensional photography with image analysis provides measurement of intracranial volume with clinically acceptable accuracy, thus offering a noninvasive, precise, and reproducible method to evaluate normal and abnormal brain development in young children.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Diagnostic, V.

Comparative Study of Presurgical Infant Orthopedics by Modified Grayson Method and Dynacleft With Nasal Elevators in Patients With Unilateral Cleft Lip and Palate-A Clinical Prospective Study

OBJECTIVE

To compare the effects of presurgical infant orthopedics using 2 different methods, that is, the Dynacleft with Nasal elevator system versus the modified Grayson's technique in patients with complete unilateral cleft lip and palate.

DESIGN

Prospective comparative cohort study.

MATERIALS AND METHODS

Twenty-eight patients were divided into 2 groups, that is, Group A consisting of 14 patients who underwent correction with DynaCleft with Nasal elevator system and Group B consisting of 14 patients undergoing correction using the modified Grayson technique. Maxillary cast measurements were taken at 2-time intervals (pre- and posttreatment) to assess various parameters using a laser scanning machine (C500 Solutionix) and 3D software (GOM Inspect). Similarly, standardized anterior-posterior and worm's-eye view photographs using a custom box were taken and imported to Adobe Photoshop CS6 for measurements. Paired t test and independent t test were used to compare intra- and intergroup changes, respectively.

RESULTS

The analysis of cast (primary outcome) and photographic (secondary outcome) measurements showed improved nasal asymmetry and alveolar correction in both groups which showed no significant intergroup difference when assessed using the independent t test (P > .05). Group A showed higher chances (42.8%) of causing a T-shaped defect (due to excessive mesial-inward rotation of the minor segment) when compared to the Group B possibly due to a more controlled molding vector (P < .05).

CONCLUSION

Both methods proved effective in improving the nasal asymmetry, reducing the alveolar cleft gap, and approximating the lips together; but care must be taken when applying the alveolar molding vector in the Dynacleft system.

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.

A Surgical and Educational Video of the Inferior Turbinate Mucosal Flap for the Nasal Floor and Intraoral Reconstruction in Unilateral Complete Cleft Lip Repair

Since the original description of Millard rotation advancement principle for cleft lip repair, many important contributions have subsequently been described by other surgeons worldwide. However, the reconstruction of the nasal floor and intraoral lining has received less attention over time. This article demonstrates a modified unilateral complete cleft lip repair using the rotation advancement principle plus multipurpose inferior turbinate mucosal flap. The accompanying videos display the 10 key steps for rationale, design, and proper execution of the inferior turbinate mucosal flap for the nasal floor and intraoral reconstruction.

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.

NAM Therapy-Evidence-Based Results

Many orthodontists working on patients with cleft lip and palate (CLP) have shown great enthusiasm for presurgical infant orthopedics (PSIO) to improve surgical outcomes with minimal intervention. Even though every clinician aims to use the best treatment modality for their patients, PSIO effects can be confounded by surgical type and timing of the primary repair, as is discussed in many studies. In such cases, one should be cautious when evaluating the particular outcomes for patients with CLP since it is difficult to differentiate the sole effect of an individual surgical or orthodontic intervention. As with any treatment methodology, nasoalveolar molding (NAM) has both benefits and limitations. Commonly cited concerns with NAM, and PSIO in general, include increased cost, increased burden of care, and a negative impact on maxillary growth. However, NAM cannot be deemed as having apparent long-term negative or positive effects on skeletal or soft tissue facial growth, based on previous studies. A review of the literature suggests that NAM does not alter skeletal facial growth when compared with the samples that did not receive PSIO. Nevertheless, the published studies on NAM show evidence of benefits to the patient, caregivers, the surgeon, and society. These benefits include documented reduction in severity of the cleft deformity prior to surgery and as a consequence improved surgical outcomes, reduced burden of care on the care givers, reduction in the need for revision surgery, and consequent reduced overall cost of care to the patient and society.

Facilitating CAD/CAM nasoalveolar molding therapy with a novel click-in system for nasal stents ensuring a quick and user-friendly chairside nasal stent exchange

Nasoalveolar molding (NAM) aims to improve nasal symmetry with a nasal stent in cleft lip and palate (CLP) patients. When plates have to be exchanged because of dentoalveolar growth or cleft reduction, the nasal stent has to be mounted onto a new plate. This procedure elongates visiting hours for patients and parents or requires second treatment sessions. This study introduces a quick-lock additive manufacturing solution for chairside nasal stent exchange called RapidNAM. A novel taping retention pin has been designed that enables nasal stent insertion. Patients with unilateral CLP were included in this study. Plaster models were digitalized and measured by two independent observers. Two methods of CAD/CAM-molding therapies were compared: (i) conventional adhesion of a nasal stent (CAD/CAM NAM); (ii) quick-lock system in which the nasal stent was transferred to another plate (RapidNAM). CAD/CAM NAM and its refinement RapidNAM significantly increased the cleft-side nasal height and tilted the nose towards symmetry. The quick-lock system minimizes wire adaptations, since the pre-existing stent can be reused. The new nasal stent development seems a feasible solution to minimize visiting hours but with clinically satisfactory results. This new nasal stent system combines traditional elements of NAM with CAD/CAM-technology.

A semi-automated virtual workflow solution for the design and production of intraoral molding plates using additive manufacturing: the first clinical results of a pilot-study

Computer-aided design and computer-aided manufacturing (CAD/CAM) technology has been implemented in the treatment of cleft lip and palates (CLP) by several research groups. This pilot study presents a technique that combines intraoral molding with a semi-automated plate generation and 3D-printing. The clinical results of two intraoral molding approaches are compared. This is the first clinical investigation of semi-automated intraoral molding. Our study included newborns with unilateral CLP. Plaster models were digitalized and measured by two independent observers. Two methods of CAD/CAM-assisted intraoral molding were compared: (i) stepwise manual design of molding plates (conventional CAD/CAM-intraoral molding) and (ii) a semi-automated approach with an automated detection of alveolar ridges (called RapidNAM) assisted by a graphical user interface (GUI). Both approaches significantly narrowed the clefts and resulted in a harmonic alveolar crest alignment. The GUI was easy to use and generated intraoral molding devices within minutes. The presented design solution is an efficient technical refinement with good clinical results. The semi-automated plate generation with a feasible GUI is fast but allows individual adaptations. This promising technique might facilitate and foster the more widespread use of CAD/CAM-technology in intraoral molding therapy.

The possibilities of a portable low-budget three-dimensional stereophotogrammetry system in neonates: a prospective growth analysis and analysis of accuracy

Background

With the technical development, portable three-dimensional (3D) photogrammetry systems are becoming more en vogue because of cost-effectiveness and comparable accuracy to common stationary 3D systems. The purpose of the study was to evaluate the feasibility and accuracy of a low-budget portable system for 3D image acquisition with special regard to the gracile nasal region in neonates. Furthermore, the study aimed to establish a 3D data set of the first 180 days post partum.

Methods

Thirty-three healthy, full-term newborn were enrolled and 3D photographs were prospectively taken monthly with a portable low-budget 3D stereophotogrammetry system (FUEL3D® SCANIFY®) for six months. In the third month, age-matched and corresponding 3D models were acquired by taking an impression of the perinasal area. The resulting plaster models were scanned (3Shape D700, 3Shape® A/S, Denmark). Three examiners analyzed independently 21 defined landmarks of the generated Standard Tessellation Language files with regard to accuracy by using 3dMDvultus™ software. A semi-automatic 3D best-fit analysis of 3D photo and plaster models were performed by using Geomagic® and the Root Mean Squared (RMS) errors were calculated.

Results

Statistically significant changes of midfacial distances and angles with a focus on nasal growth during the first 180 days postpartum could be specified in absolute and relative dimensions. Best-fit analysis in the third month revealed a RMS error of 0.72 ± 0.22 mm with a mean standard deviation of 0.71 ± 0.21 mm.

Conclusions

The analyzed portable 3D stereophotogrammetry system is a feasible methodology with good accuracy, even in newborn. A description of the growth as well as the establishment of a 3D data set was performed. Its implementation for basic documentation for example in cleft patients is possible and might reduce the need for impressions and facilitate the communications with parents and the interdisciplinary team.

Quantifying Soft Tissue Changes in Cleft Lip and Palate Using Nonionizing Three-Dimensional Imaging: A Systematic Review

PURPOSE

The use of nonionizing 3-dimensional (3D) imaging in cleft lip and palate (CLP) research is well-established; however, general guidelines concerning the assessment of these images are lacking. The aim of the present study was to review the methods for quantification of soft tissue changes on 3D surface images acquired before and after an orthopedic or surgical intervention in CLP patients.

MATERIALS AND METHODS

A systematic literature search was performed using the databases MEDLINE (through PubMed), CENTRAL, Web of Science, and EMBASE. The literature search and eligibility assessment were performed by 2 independent reviewers in a nonblinded standardized manner. Only longitudinal studies reporting the assessment of pre- and postoperative 3D surface images and at least 10 CLP patients were considered eligible.

RESULTS

Fifteen unique studies (reported from 1996 to 2017) were identified after an eligibility assessment. The assessment of the 3D images was performed with landmark-dependent analyses, mostly supported by superimposition of the pre- and postoperative images. A wide spectrum of superimposition techniques has been reported. The reliability of these assessment methods was often not reported or was insufficiently reported.

CONCLUSIONS

Soft tissue changes subsequent to a surgical or an orthopedic intervention can be quantified on 3D surface images using assessment methods that are primarily based on landmark identification, whether or not followed by superimposition. Operator bias is inherently enclosed in landmark-dependent analyses. The reliability of these methods has been insufficiently reported.

Evaluation of a portable low-budget three-dimensional stereophotogrammetry system for nasal analysis

BACKGROUND

Three-dimensional (3D) photogrammetry has reached high standards and accuracy but is mainly conducted with stationary and expensive systems. The purpose of this study was to evaluate the accuracy of a low-budget portable system with special regard to the gracile and challenging nasal region.

MATERIAL AND METHODS

3D models of the perinasal area were acquired by impression-taking and the scanning of the generated plaster models (3Shape D500) or with a portable low-budget 3D stereophotogrammetry (FUEL3D^® SCANIFY^®) system. Four examiners analysed defined landmarks of the generated Standard Tessellation Language files with regard to accuracy and interobserver reliability by using 3dMDvultus™ software. A semi-automatic 3D best-fit analysis of both models was performed by using Geomagic^® and the Root Mean Squared (RMS) errors were calculated.

RESULTS

41 volunteers were included, with 22 perinasal and perioral landmarks, 15 3D distances and eight 3D angles being analysed per data set. In a point-based analysis the mean spreads were partially smaller in the plaster model scans. Most measurements showed very high (>0.8) to excellent (>0.9) intraclass correlation coefficients, the lowest being found for columella length (0.686) and left nostril width (0.636). Overall, the mean RMS error between the superimposed surfaces was 0.89 ± 0.22 mm in the best-fit analysis.

CONCLUSIONS

The corresponding software program was operator-friendly. The findings indicate that the analysed, affordable and portable system is a feasible solution for 3D image acquisition with comparable accuracy reported in the literature. Further studies will analyse the feasibility in neonates.