Nasoalveolar molding improves appearance of children with bilateral cleft lip-cleft palate

Modified indigenous nasal elevator for cleft lip and palate patient: A novel clinical innovation

Pre-nasoalveolar molding (PNAM) was developed to reduce the severity of the initial cleft alveolar and nasal deformity. The nasoalveolar moulding appliance (NAM) consists of an intraoral moulding plate with nasal stents to mould the alveolar ridge and nasal cartilage concurrently. Use of the NAM technique also reduces surgical columella reconstruction and the resultant scar tissue in bilateral cleft lip and palate. The nasoalveolar moulding technique has been shown to significantly improve the surgical outcome of the primary repair in cleft lip and palate patients compared to other techniques of presurgical orthopaedics. But the adaptability of nasal stent with support from NAM plate is cumbersome for many cleft patients due to its bulkiness, interfere with feeding and difficult for parents to manage at home. The Modified Indigenous Nasal Elevator (MINE) is a novel innovation for nasal correction for cleft lip and palate patients. This innovative design, non-invasive, precision, fewer visits, cost effective and adaptability make it a valuable tool to help surgeons to achieve optimal correction in lip repair surgeries in cleft lip & palate patients. MINE's innovative design allows for customization based on the patient's specific nasal anatomy. This adaptable feature ensures optimal fit and function for each patient, maximizing the surgical outcomes.

Prospective study of nasal growth in bilateral cleft lip and palate patients after naso-alveolar moulding and primary columella lengthening compared to controls at 5, 10 and 20 years

INTRODUCTION

A short columella, wide nostrils and a flat nasal tip are common features in patients with bilateral complete cleft lip and palate (BCLP). The objective of this study was to evaluate nasal morphology during growth in patients treated with naso-alveolar moulding (NAM) and primary surgical columella lengthening (PCL) compared with matched non-cleft individuals.

STUDY DESIGN

Prospective longitudinal case-control study.

PARTICIPANTS AND METHODS

Thirty-four consecutively treated BCLP patients at 5 and 10 years and at the end of growth (19.7 ± 2.0 years) were compared through normalized photogrammetry to a control of 34 age and sex-matched non-cleft individuals. Regression Models for Panel Data assessed how nasal measurements were influenced by surgery, age and gender.

RESULTS

Nasal protrusion was equal to non-cleft controls at all ages. Length of the columella was also comparable to controls at 5 and 10 years, but significantly shorter at the end of growth. Inter-alar and nasal tip width and nasolabial angle were significantly wider than controls at all ages: More than 60% of the patients have asked for correction of the nasal width, but no early surgery for columella lengthening was needed.

CONCLUSIONS

NAM and PCL have provided a nasal projection close to that of non-cleft individuals until adulthood, while length of the columella was physiological at 5 and 10, but shorter than controls at age 20. Width of the nasal tip and width of the alar bases were significantly wider than the controls and eventually required secondary nasal width correction in over two thirds of the sample.

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.

Clinical Outcomes of Bilateral Cleft Lip and Palate Repair with Nasoalveolar Molding and Gingivoperiosteoplasty to Facial Maturity

BACKGROUND

The long-term effects of nasoalveolar molding (NAM) on patients with bilateral cleft lip and palate (BCLP) are unknown. The authors report clinical outcomes of facially mature patients with complete BCLP who underwent NAM and gingivoperiosteoplasty (GPP).

METHODS

A single-institution retrospective study of nonsyndromic patients with complete BCLP who underwent NAM between 1991 and 2000 was performed. All study patients were followed to skeletal maturity, at which time a lateral cephalogram was obtained. The total number of cleft operations and cephalometric measures was compared with a previously published external cohort of patients with complete and incomplete BCLP in which a minority (16.7%) underwent presurgical orthopedics before cleft lip repair without GPP.

RESULTS

Twenty-four patients with BCLP comprised the study cohort. All patients underwent GPP, 13 (54.2%) underwent alveolar bone graft, and nine (37.5%) required speech surgery. The median number of operations per patient was five (interquartile range, two), compared with eight (interquartile range, three) in the external cohort ( P < 0.001). Average age at the time of lateral cephalogram was 18.64 years (1.92). There was no significant difference between our cohort and the external cohort with respect to sella-nasion-point A angle (SNA) [73 degrees (6 degrees) versus 75 degrees (11 degrees); P = 0.186] or sella-nasion-point B angle (SNA) [78 degrees (6 degrees) versus 74 degrees (9 degrees); P = 0.574]. Median ANB (SNA - SNB) was -3 degrees (5 degrees) compared with -1 degree (7 degrees; P = 0.024). Twenty patients (83.3%) underwent orthognathic surgery.

CONCLUSION

Patients with BCLP who underwent NAM and GPP had significantly fewer total cleft operations and mixed midface growth outcomes at facial maturity compared with patients who did not undergo this treatment protocol.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Effect of One-Stage Bilateral Cleft Lip, Nose, and Alveolus Repair Following Nasoalveolar Molding on the Premaxilla Position at Preadolescence: An 8-Year Retrospective Study

BACKGROUND/PURPOSE

This paper describes the changes in maxillary arch morphology in infants with bilateral cleft lip and palate (BCLP) following nasoalveolar molding (NAM) and with follow up to assess the need for secondary alveolar bone grafting (ABG) and premaxillary repositioning surgery at preadolescence.

METHODS/DESCRIPTION

Treatment records of infants with BCLP treated with NAM between 2003 and 2013 were reviewed. Patients with complete BCLP who underwent NAM and had complete sets of maxillary casts at T 0 pre-NAM (mean = 27 days), T 1 post-NAM (mean = 6 months and 5 days), and T 2 before palate surgery (mean = 11 months and 15 days) were included. The sample comprised 23 infants (18 male, 5 female). Casts were digitized and analyzed using three dimensional software. The need for secondary ABG and premaxillary repositioning surgery was assessed at preadolescent follow-up (mean = 8.3 years).

RESULTS

Cleft width was reduced on average by 4.73 mm (SD±3.15 mm) and 6.56 mm (SD±4.65) on the right and left sides, respectively. At T 1, 13 (56.52%) patients underwent bilateral gingivoperiosteoplasty (GPP), 8 (34.78%) patients unilateral GPP, and 2 patients (8.7%) did not undergo GPP. 34/46 clefts sites (73.91%) underwent GPP while 12 (26.08%) did not. At preadolescent follow-up of 19 patients, 7 patients (36.84%) did not need ABG on either side, 8 (42.10%) needed ABG on 1 side, and 4 (21.05%) needed ABG on both sides. None of the patients needed premaxillary repositioning surgery.

CONCLUSIONS

Nasoalveolar molding treatment significantly improves the position of the premaxilla before primary repair, and there is a significant reduction in the need for secondary ABG and premaxillary repositioning surgery at preadolescence.

Long-Term Comparison of the Aesthetic Outcomes between Nasoalveolar Molding- and Non-Nasoalveolar Molding-Treated Patients with Unilateral Cleft Lip and Palate

BACKGROUND

The cleft lip-nose deformity in unilateral cleft lip and palate is one of the most challenging problem for surgeons to correct. Although nasoalveolar molding has been shown to be effective in improving presurgical symmetry in patients with complete unilateral cleft lip and palate, there is need for better evidence regarding the long-term nasolabial aesthetics of patients who have received this therapy.

METHODS

Thirty-eight patients treated with nasoalveolar molding and 48 patients not treated with nasoalveolar molding (but otherwise treated similarly) with unilateral cleft lip and palate were studied to assess and compare the nasolabial aesthetics. The objective evaluation of the nasal symmetry was performed on the basal view of two-dimensional photographs and the subjective nasolabial aesthetic evaluation was performed using the Asher-McDade scale.

RESULTS

At 5-year postoperative follow-up, nasoalveolar molding group patients had better mean values on the objective scores; however, these were not statically significant. The nasoalveolar molding group of patients had a statistically significant improvement in the subjective evaluation in comparison to the non-nasoalveolar molding-treated patients. The number of lip revisions was also statistically higher in the non-nasoalveolar molding-treated group of patients.

CONCLUSIONS

In this retrospective, single-center study, the authors found that at 5-year postoperative follow-up, nasoalveolar molding-treated patients had improved nasolabial aesthetics and fewer revision operations. These are, however, preliminary results and the patients will be followed up until the end of growth to assess the longer term effects of nasoalveolar molding on the nasolabial aesthetics in unilateral cleft lip and palate.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

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.

Evolving Trends in Unilateral Cleft Lip Repair Based on Continuous Certification by the American Board of Plastic Surgery

BACKGROUND

The American Board of Plastic Surgery (ABPS) began collecting data from unilateral cleft lip (UCL) corrections in 2011 as a component of the continuous certification process. We evaluated these data to understand practice patterns in UCL repair, in the United States, and whether these practice patterns had changed over the past 9 years.

METHODS

Tracer data for UCL correction were reviewed from its inception in October 2011 through 2016 and compared to UCL cases between 2017 and March 2020. Trends in practice patterns were evaluated against literature reviews meant to coincide with the ABPS continuous certification data.

RESULTS

A total of 520 cases were included from October 2011 to March 2020. Median age of UCL repair was 4 months and 66% of patients were male. Fifty-one percent of cases presented with a complete cleft lip. There was a decrease in postoperative adverse events when data from 2011 to 2016 was compared to 2017 to 2019 (P = 0.020). Revisions were the most common postoperative adverse event (2%). There was a decrease in nasoalveolar molding from 25% to 12% (P < 0.001) and 56% of total cases underwent a concurrent primary cleft rhinoplasty. The rate of gingivoperiosteoplasty at the time of primary cleft lip repair also fell (9% versus 1%; P < 0.001).

CONCLUSIONS

This article reviews tracer data obtained by the ABPS for UCL repair. The American Board of Plastic Surgery tracer data provides a national, cleft lip-specific database with longer follow-up times than other large databases.

The Effectiveness of Preoperative Correction Techniques in Improving Nasal Deformity in Children With Unilateral Complete Cleft Lip and Palate

OBJECTIVE

Unilateral complete cleft lip and palate (UCCLP) is associated with apparent nasal deformities before the cheilorrhaphy. The aim of this study was to determine whether preoperative correction techniques are effective in the treatment of nasal deformities in infant with unilateral UCCLP used by the systematic review and meta-analysis.

METHODS

We searched Medline, Cochrane Library, EMBASE, PubMed, and Chinese BioMedical Literature Database (CBM) until January 31, 2019, to identify studies that compared the effectiveness of preoperative correction techniques in the treatment of nasal deformities in infant with UCCLP. Two authors individually extracted the data and performed the quality assessments. The height of nasal columella, the width of the affected side nasal ala and the inclination of the nasal columella were evaluated.

RESULTS

Seven articles were incorporated into the systematic review, and 5 (274 participants) in the meta-analysis according to the inclusion criteria. The preoperative correction could increase the height of nasal columella in children with UCCLP [SMD: 2.64 mm; 95% confidence intervals (CI); (1.35 mm, 3.94 mm); P < 0.0001]. Moreover, the preoperative correction resulted in reduced width of the affected side nasal ala [SMD: -5.14 mm; 95% CI; (-8.96 mm, -1.31 mm); P = 0.008]; However, the evidence was insufficient to determine a significant effect on the inclination of the nasal columella [SMD: -3.48 degrees; 95% CI; (-7.56 degrees, 0.59 degrees); P = 0.09].

CONCLUSIONS

Preoperative correction for children with UCCLP can increase the height of nasal columella, reduce the width of the affected side nasal ala, improve the nasal symmetry, and reduce nasal deformity, however, no significant effect could be observed for the inclination of the nasal columella.

Three-Dimensional Nasolabial Changes After Nasoalveolar Molding and Primary Lip/Nose Surgery in Infants With Bilateral Cleft Lip and Palate

OBJECTIVE

Utilize 3-dimensional (3D) photography to evaluate the nasolabial changes in infants with bilateral cleft lip and palate (BCLP) who underwent nasoalveolar molding (NAM) and primary reconstructive surgery.

DESIGN

This is a retrospective serial longitudinal study of consecutively enrolled infants from September 2012 to July 2016 with BCLP who underwent NAM before primary lip and nose reconstructive surgery. It included infants who had digital 3dMD stereophotogrammetry records at initial presentation (T1), completion of NAM (T2), and 3 weeks following primary repair (T3). Twelve infants fulfilled the inclusion criteria. 3dMD Vultus software was used to orient images and plot 16 nasolabial points with x, y, z coordinates to obtain the linear and angular measurements. Nasal form changes were measured and analyzed between T1 (0.5 months old), T2 (5 months old), and T3 (6 months old). Intraclass correlation coefficient was performed for intrarater reliability. Averaged data from the 3D images was statistically analyzed from T1 to T2 and T2 to T3 with Wilcoxon tests. Unaffected infant norms from the Farkas publication were used as a control sample.

RESULTS

After NAM therapy, statistically significant changes in the position of subnasale and labius superius improved nasolabial symmetry. Both retruded after NAM were displaced downward after NAM and surgical correction with respect to soft tissue nasion. The nasal tip's projection was maintained with NAM and surgical correction. The columella lengthened from 1.4 to 4.71 mm following NAM.

CONCLUSIONS

There was a significant improvement in the nasolabial anatomy after NAM, and this was further enhanced after primary reconstructive surgery.

The Nasoalveolar Molding Cleft Protocol: Long-Term Treatment Outcomes from Birth to Facial Maturity

BACKGROUND

The authors present outcomes analysis of the nasoalveolar molding treatment protocol in patients with a cleft followed from birth to facial maturity.

METHODS

A single-institution retrospective review was conducted of cleft patients who underwent nasoalveolar molding between 1990 and 2000. Collected data included surgical and orthodontic outcomes and incidence of gingivoperiosteoplasty, alveolar bone grafting, surgery for velopharyngeal insufficiency, palatal fistula repair, orthognathic surgery, nose and/or lip revision, and facial growth.

RESULTS

One hundred seven patients met inclusion criteria (69 with unilateral and 38 with bilateral cleft lip and palate). Eighty-five percent (91 of 107) underwent gingivoperiosteoplasty (unilateral: 78 percent, 54 of 69; bilateral: 97 percent, 37 of 38). Of those patients, 57 percent (52 of 91) did not require alveolar bone grafting (unilateral: 59 percent, 32 of 54; bilateral: 54 percent, 20 of 37). Twelve percent (13 of 107) of all study patients underwent revision surgery to the lip and/or nose before facial maturity (unilateral: 9 percent, six of 69; bilateral: 18 percent, seven of 38). Nineteen percent (20 of 107) did not require a revision surgery, alveolar bone grafting, or orthognathic surgery (unilateral: 20 percent, 14 of 69; bilateral: 16 percent, six of 38). Cephalometric analysis was performed on all patients with unilateral cleft lip and palate. No significant statistical difference was found in maxillary position or facial proportion. Average age at last follow-up was 20 years (range, 15 years 4 months to 26 years 10 months).

CONCLUSIONS

Nasoalveolar molding demonstrates a low rate of soft-tissue revision and alveolar bone grafting, and a low number of total operations per patient from birth to facial maturity. Facial growth analysis at facial maturity in patients who underwent gingivoperiosteoplasty and nasoalveolar molding suggests that this proposal may not hinder midface growth.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

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.

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.

Comparative Photographic, Retrospective Analysis of Nonsyndromic Cleft Noses Treated with or without NAM

Supplemental Digital Content is available in the text.

Background:

Long-term results and efficacy of nasoalveolar molding (NAM) on the perinasal region are reported controversially in the literature. With this study, we demonstrate our experiences, contribute to the ongoing discussion, and describe our decision-making when NAM is indicated or not.

Methods:

Conventional pre- and postinterventional photographs of patients with nonsyndromic unilateral and bilateral cleft lip and palate (UCLP and BCLP) were analyzed. The 2 independent raters were blinded to therapy (NAM versus non-NAM), and 7 parameters were measured. Intraclass correlation coefficient for intra- and interrater reliability was calculated. The Mann–Whitney U test was performed to compare therapy- and appearance-matched pairs. Finally, 30 specialists in cranio-maxillofacial surgery performed a subjective, blinded rating of matched NAM and non-NAM cases.

Results:

Thirty-six patients, 16 UCLP and 20 BCLP, were enrolled. The intraclass correlation coefficients for intra- and interrater reliability were excellent for all measurements, except for nasal sill (0.77 intrarater and 0.80 interrater). Height-to-width ratio (P = 0.012) was significantly different in the comparison of non-NAM and NAM-treated severe cases with UCLP. Thirty blinded raters evaluated NAM-treated cases with severe UCLP better than matched non-NAM cases. Non-NAM-treated cases with moderate UCLP and BCLP were rated better than matched NAM cases.

Conclusions:

Children with severe UCLP may benefit from NAM therapy in the sense of better symmetry and a more homogenous appearance. Patients with moderate UCLP and BCLP did not benefit, and the risk of the burden of care increased.

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.

The Effects of Nasoalveolar Molding on Nasal Proportions at the Time of Nasal Maturity

BACKGROUND

The aim of this study is to assess the effect of nasoalveolar molding (NAM) versus no-NAM on nasal morphology in patients with unilateral cleft lip and palate (UCLP) at the time of nasal maturity.

METHODS

A retrospective, single-institution review was conducted on all non-syndromic patients with UCLP. Inclusion criteria included age 14 years or above, unilateral cleft repair at the time of infancy, and adequate photography taken at nasal maturity and prior to rhinoplasty. Exclusion criteria included age less than 14 years, syndromic diagnosis, and rhinoplasty prior to nasal maturity. Ten parameters were measured twice from standardized clinical photographs using the Dolphin Imaging Software for establishment of intrarater reliability. Subjective analysis was achieved through completion of the Asher McDade grading scale by 3 expert cleft practitioners.

RESULTS

Nostril height, columellar angle, alar cant, vertical alar height, alar height angle, nasofacial angle, and nasolabial angle were found to be significantly less severe in patients who had undergone NAM in conjunction with surgical repair when compared with those who had undergone surgical repair alone. Asher McDade grading revealed significant improvement in nasal form, nasal symmetry/deviation, nasal profile, vermillion border, and overall score in patients who underwent NAM compared to no-NAM.

CONCLUSION

The use of presurgical NAM during infancy can improve nasal symmetry and nasal proportions at the time of nasal maturity.

Sociodemographic Predictors of Treatment Success and Difficulty in Nasoalveolar Molding

OBJECTIVE

To assess social and demographic influences on caregiver success and difficulty with nasoalveolar molding (NAM).

DESIGN

Retrospective review identified patients who began NAM between April 22, 2013, and April 18, 2017, at the New York University Langone Medical Center. Records were reviewed, and the following sociodemographic data retrieved: parental marital status, parental ages, number of siblings, distance traveled to clinic, insurance coverage, concurrent medical conditions, and need for an interpreter.

PATIENTS

Patients were included if complete charting was available; 106 patients met the inclusion criteria; 79 patients with unilateral and 27 with bilateral clefts.

OUTCOME MEASURES

Chart entries indicating incorrect appliance usage, emergency visits, phone calls, and noncompliance were recorded. Alveolar cleft gap closure was measured on pre- and posttreatment models in unilateral cases. Multiple regression analyses were performed to assess the influence of social variables on these outcomes.

RESULTS

Alveolar cleft gap closure was 7.2 ± 3.0 mm, or 78.5% ± 19.1%. Cleft closure increased with paternal age by 0.33 mm (P = .007) or 2.0% (P = .017) per year, decreased with maternal age by 0.29 mm (P = .041) per year, and increased in married and partnered parents by 39% (P = .018). Incorrect appliance usage averaged 0.62 fewer instances for married and partnered parents (P = .018) and 0.43 fewer for those with private insurance (P = .019).

CONCLUSIONS

Alveolar cleft gap closure was more successful for older fathers, younger mothers, and married couples. Married couples were also less likely to experience treatment difficulties such as incorrect appliance usage or inadequate duration of wear, as were those with private insurance coverage.

A Longitudinal Study of The Nasal Symmetry in Unilateral Cleft Lip And Palate Patients Treated With Nasoalveolar Molding

Background  Nasoalveolar molding (NAM) has been extensively used as a presurgical technique in the treatment of unilateral cleft lip and palate (UCLP) over the last two decades. It has proven to be a useful tool to reduce the cleft size, improve nasal symmetry, and increase the columellar length. The long-term stability of these findings has not been conclusively proven.

Methods  In this longitudinal study, the nasal symmetry of 24 NAM treated UCLP patients was evaluated to assess the 5-year stability of NAM. The basal photographs were shot postcheiloplasty (T1), at 1-year follow-up (T2), at 3-year follow-up (T3), and 5-year follow-up (T4) appointments.

Results  In this study, we found that NAM was a useful adjuvant in achieving nasal symmetry in patients with UCLP in the immediate postoperative period. However, as the patients aged, there was a gradual loss of mean nasal height (by 22.83%) and columella length (by 24.89%), a mean gain in nasal width (by 40.25%) and alar base width (by 40.69%), and an increase in the columella deviation (by 3.46%) from the T1 to the T4 follow-up.

Conclusion  Although there is no conclusive evidence, the loss of symmetry may be due to the unequal growth on the cleft and noncleft sides. These patients will be followed-up till end of growth for a definite conclusion on the long-term effect of NAM.

An Intraoperative Rescue Procedure for the Protruding Premaxilla in the Repair of Complete Bilateral Cleft Lip: Rapid Premaxillary Molding

BACKGROUND

Primary reconstruction of complete bilateral cleft lip and palate (BCLP) with protruding premaxilla in one-stage surgery is challenging because of the tension on muscle repair. Such patients are also common in the developing countries. For this condition, we have applied intraoperative "rapid premaxillary molding (RPM)" technique and obtained satisfactory results.

METHODS

We reviewed the data of patients with complete BCLP with protruding premaxilla applying intraoperative RPM including both our institution and cleft missions to developing countries in the past 20 years. Selection criteria were patients receiving either no or insufficient preoperative molding presenting with significant protruding premaxilla, had consecutive follow-ups after surgery. To perform this technique, the surgeon holds the patient's face with both hands and compresses the protruding premaxilla with both thumbs. An intermittent but stable backward pressure is applied to the premaxilla until the segment is gradually flexible. Repeated compression is performed prior to tying the muscle sutures, at which time the premaxilla is retro-positioned and aligned with the lateral maxillary segments. Pre- and postoperative data were evaluated.

RESULTS

We have treated a total of 60 patients with complete BCLP with protruding premaxilla applying intraoperative RPM. All patients tolerated the operations and there were no major intra- and postoperative complications including lip dehiscence and vomer fracture. All of them had satisfactory results such as adequate muscle repair and symmetry of the lip and nostrils.

CONCLUSION

The RPM is a reliable and valuable intraoperative adjunct procedure for patients with complete BCLP presenting the protrusive premaxilla.

Sociodemographic Factors That Influence the Choice to Pursue Nasoalveolar Molding: One Pediatric Hospital's Experience

OBJECTIVE

To identify demographic factors that influence choosing nasoalveolar molding (NAM) in the treatment of cleft lip with or without cleft palate (CL±P), and NAM treatment compliance.

DESIGN

This work is a retrospective cohort study.

SETTING

Tertiary pediatric hospital.

PATIENTS, PARTICIPANTS

One hundred forty-nine patients with a diagnosis of unilateral complete CL±P receiving treatment when NAM was offered (January 1, 2008-July 26, 2016).

MAIN OUTCOME MEASURE(S)

Demographic variables collected included race, ethnicity, ZIP code, number of caregivers, caregiver employment status, and health insurance status. Medical variables collected included diagnosis, treatment pursued, compliance with NAM, completion of NAM, and the treating cleft surgeon and orthodontist. Data were analyzed via Fisher exact tests, χ² tests, and multivariate logistic regression to identify factors that influence the decision to pursue NAM and treatment compliance.

RESULTS

Univariate analyses identified the following significant factors predicting the pursuit of NAM: race and insurance type (both P < .001), surgeon (P = .005), income level (P = .009), comorbidities (P = .015), and syndromic diagnosis (P = .033). Driving distance trended toward significance (P = .078). Multivariate regression analyses indicated that Asian race (P = .047), insurance type (P = .046), driving distance (P = .019), and surgeon (P = .017) were significant predictors of pursuit of NAM.

CONCLUSIONS

There are disparities in patient choice of NAM at our center for children with complete cleft lip. African American patient families were less likely to pursue this intervention. A stronger understanding of the barriers that lower income and minority patients face is needed in order to better characterize disparities in cleft care.

Nasoalveolar Molding for Unilateral and Bilateral Cleft Lip Repair

Nasoalveolar molding (NAM) is a powerful tool in the treatment of patients with unilateral or bilateral cleft lip and palate. The primary goal of NAM is to improve alignment of critical anatomic elements before surgical repair of the unilateral or bilateral cleft lip. Modifications of the position of the alveolar segments and their associated lip elements, the lower lateral cartilages, and the columella achieved with NAM are helpful for creating a suitable platform for tension-free lip repair.

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.

Evaluation of a Digital Protocol for Pre-Surgical Orthopedic Treatment of Cleft Lip and Palate in Newborn Patients: A Pilot Study

The aim of this study was to evaluate the accuracy, invasiveness and impact on clinical results of a digital oral impression protocol in the pre-surgical orthopedic treatment (PSOT) of newborn cleft lip and palate (CLP) patients undergoing primary alveolar surgical repair. Six patients were divided, according to impression technique used, into a digital (intraoral scanner (IOS)) and a non-digital (tray and putty (T&P)) group. Parents considered IOS impressions to be less invasive, compared to T&P impressions. The clinician that took all the impressions considered the IOS to be less stressful compared to the T&P method. In two T&P patients, the impression was repeated because some important anatomical details were missing, in one case due to patient regurgitation during the first attempt. No impression was repeated, and any adverse event was reported in the IOS group. There were no significant differences between these two protocols in pre-surgical alveolar gap reduction and surgical challenge. The study results indicate that this digital protocol can accelerate the production process of the passive molding plate with an instantaneous transmission of the digital impression to the dental lab, maintaining the same accuracy level and clinical outcomes of classical techniques and reducing the invasiveness of impression taking, avoiding any risk of impression material ingestion or inhalation.

Preschool Age Anthropometric Evaluation of the Nose After Bilateral Complete Cleft Lip Repair

OBJECTIVE

To evaluate the aesthetic outcomes of surgery in preschool-aged bilateral complete cleft lip patients by comparing their nasal aesthetic parameters with those of normal children.

SETTING AND SAMPLE POPULATION

Twenty-six 4 to 6-year-old (preschool age) patients with bilateral complete cleft lip who underwent primary cheiloplasty and a control group of 30 children in Northeast Thailand of the same age were enrolled.

MATERIALS AND METHODS

Nasal aesthetic parameters were analyzed in terms of 3 ratios and 1 angle using three-dimensional photographs. The data from bilateral cleft lip patients were compared with those from a control group.

RESULTS

The nasal parameters of patients in the cleft group were the same as those in the control group in terms of nasal tip height (NTH), columella height (CH), and dome height (DH) (P values were 0.361, 0.494, and 0.086), but nasal width (NW) was greater in the cleft group (P < 0.001). The nasal aesthetic parameters differed significantly between the 2 groups in terms of CLA (P < 0.001) and ratio of NTH and NW (P < 0.001), but not in terms of the CH:NW (P = 0.190) and DH:CH ratios (P = 0.147).

CONCLUSION

This treatment protocol for bilateral cleft lip was able to achieve most of the aesthetic goals in terms of NTH, CH, DH, ratio of CH to NW, and ratio of DH to CH. However, more surgical correction of NW and CLAs may be needed.

Dynamic Nasolabial Growth After Primary Surgery for Patients With Bilateral Cleft Lip: A Five-Year Follow-Up Study

PURPOSE

Bilateral complete cleft lip (BCCL) causes severe tissue deficit and usually requires multiple revisions after primary repair. In the present study, we aimed to illustrate the nasolabial changes after primary BCCL correction.

PATIENTS AND METHODS

The present retrospective cohort study compared patients who had undergone BCCL and palate (BCCLP) and cleft palate only (CPO). All included patients had undergone surgery at the same treatment center (West China Hospital of Stomatology) from 2007 to 2012. The patients returned for follow-up surgery at 6 months and 5 years after their primary repair surgery. We retrieved the facial plaster casts of the enrolled patients and recorded the key nasolabial measurements. The outcome variables included the prolabial length (PL), peak distance, nasal width, and columellar length (CL). The data were analyzed using a general linear model for repeated measures, and the linear association was tested using SPSS. The level of testing efficiency (P value) was set at .05.

RESULTS

A total of 160 patients, 80 who had undergone BCCLP and 80 CPO controls, were included. All nasolabial measurements in the BCCLP group had increased during the 5-year follow-up period. The PL of the BCCLP group had increased more quickly than the PL of the CPO group (P = .000 < .05), but the CL had increased nearly as much (P = .270).

CONCLUSIONS

For the primary correction of bilateral cleft lip nose deformity, dissection and repositioning of the cleft lip and nose did not significantly inhibit the growth of the nasolabial region in the first 5 years after surgery. Nose deformities should not remain uncorrected after primary surgical repair. In contrast, cleft surgeons should focus on the finer adjustment of columella with less doubt regarding adverse effects.

Long-Term Nasal Growth after Primary Rhinoplasty for Bilateral Cleft Lip Nose Deformity: A Three-Dimensional Photogrammetric Study with Comparative Analysis

Nasal deformity is associated with congenital cleft lip and palate. Primary rhinoplasty for reconstruction of the nasal deformity at the time of bilateral cleft lip repair is a controversial issue in cleft care due to traditional teaching concerning the potential impairment of nasal growth. This study assessed long-term nasal growth in patients with bilateral cleft lip and palate who underwent primary rhinoplasty by a single surgeon between 1995 and 2002 and reached skeletal maturity (n = 39; mean: 19 ± 2 years). Normal age-, gender-, and ethnicity-matched subjects (n = 52) were enrolled for comparative analyses. Three-dimensional nasal photogrammetric measurements (10 linear, 4 angular, 6 proportional, 1 surface area, and 1 volume parameter) were collected from patients with bilateral cleft lip and palate and normal subjects. Patients who underwent rhinoplasty presented with significantly (all p < 0.05) smaller nasal tip projection and nasal tip angles, but greater values for nasal dorsum length, nasal protrusion, alar width, columellar height, dome height, columellar angle, labiocolumellar angle, nasal tip height ratio, nasal index, alar width/intercanthal distance ratio, and alar width/mouth width ratio compared to normal subjects. There were no differences (all p > 0.05) in nasal height, tip/midline deviation, nasal dorsum angle, dome-to-columella ratio, columella height/alar width ratio, area surface, and volume parameters between the two groups. This study shows that primary rhinoplasty performed in patients with bilateral cleft lip and palate during infancy does not result in deficiency of the nasal dimensions relative to controls.

Clinical Outcomes Utilizing a "Modified Latham" Appliance for Presurgical Infant Orthopedics in Patients With Unilateral Complete Cleft Lip and Palate

Presurgical infant orthopedic manipulation is utilized prior to cleft lip/nasal repair to facilitate a gingivoperiosteoplasty (GPP) and primary nasolabial repairs. The Latham dentomaxillary advancement appliance uses a screw that must be tightened daily to approximate the cleft segments in unilateral complete clefts. Our cleft center has been utilizing a "modified Latham" appliance since 1987, including an orthodontic elastic power chain to close the gap in a shorter amount of time. We performed a retrospective chart review of all patients undergoing treatment at Johns Hopkins All Children's Hospital (JHACH) with a unilateral complete cleft lip and palate between 1987 and 2017. Patients were identified by the International Classification of Diseases, Ninth Revision code (749.21). The majority of the patients represent the experience of the senior authors (E.R. and R.F.). Two hundred and eighty-one patients with unilateral complete cleft lip/palate were identified. Seventy-five patients were treated with a "modified Latham" appliance prior to their lip repair. The "modified Latham" appliance remained in place on average 20.6 days (range: 4-82), and average hospital stay after placement was 1.18 days. Nearly 96% of patients underwent a successful GPP at the time of nasolabial repair. Modification of the Latham appliance by utilizing an elastic power chain and eliminating the screw allows rapid closure of the alveolar cleft with limited need for adjustments and outpatient visits. Direct approximation of the palatal segments allows successful completion of a GPP in 95.9% of patients with limited dissection.

Cleft Lip and Palate

Orofacial clefts are common congenital malformations with genetic and environmental risk factors. In the perinatal period, feeding and nutrition can be a challenge and the need for specialized feeders is common. Lip taping and nasoalveolar molding are early interventions that can be used to preoperatively modify cleft defects to enhance surgical outcomes. Multiple techniques are available for repair of orofacial clefts and choice of technique depends on cleft extent and surgeon preference. After definitive repair, children remain at increased risk for middle ear disease, velopharyngeal dysfunction, and malocclusion and require ongoing follow-up with a multidisciplinary team.

A Comparative Cephalometric Study of Nasoalveolar Molding- and Non-Nasoalveolar Molding-Treated Bilateral Cleft Patients at Early Mixed Dentition Period

OBJECTIVE

To evaluate and compare early maxillary growth in 2 groups of patients with repaired bilateral cleft lip and palate (BCLP) who had and had not received nasoalveolar molding (NAM) therapy in infancy.

HYPOTHESIS

Nasoalveolar molding does not have any effect on maxillomandibular growth at the early mixed dentition period.

DESIGN

Retrospective study.

PATIENTS

The study group consisted of forty-two 7-year-old patients with BCLP-20 in the NAM group and 22 in the no-NAM group. The control group consisted of nineteen 7-year-old noncleft, normal patients.

INTERVENTIONS

Nasoalveolar molding was carried out prior to surgeries in those children who were brought in within 8 weeks of birth. Children brought in later were treated without a presurgical intervention. All patients were treated with a single-stage modified Millard cheiloplasty without gingivoperiosteoplasty. Palatoplasty was done by single-stage Bardach palatoplasty with muscle repositioning.

MEAN OUTCOME MEASURES

Hard tissue and dental cephalometric values measured on lateral cephalograms, recorded at 7 years of age.

RESULTS

A comparison of the mean sagittal values showed a statistically significant maxillomandibular retrusion and incisor retroclination of both BCLP groups in comparison to the control group. None of the cephalometric parameters varied statistically between NAM and no-NAM groups. The maxillomandibular relation, lower face height ratio, mandibular plane, and mandibular axis angles did not show statistically significant difference between all 3 groups.

CONCLUSIONS

On the basis of this study, NAM does not have any effect on maxillomandibular growth at the early mixed dentition period.

A Personal Approach to Bilateral Cleft Lip Repair

Dr Michael B. Lewis has been using his personal approach to bilateral cleft lip (BCL) repair for 30 years to achieve a loose, pouting upper lip, a 90-degree columellar-labial angle, and a projecting nasal tip. This article describes technique and results.

The Effects of Presurgical Nasoalveolar Molding on the Midface Symmetry of Children with Unilateral Cleft Lip and Palate: A Long-term Follow-up Study

Background:

Midface symmetry is an important indicator of success of complete unilateral cleft lip and palate (CUCLP) treatment. There is little literature on the long-term effects of presurgical nasoalveolar molding (PNAM) on midface symmetry in children treated for CUCLP. This study aimed to compare children with CUCLP who underwent PNAM before surgical interventions, children who did not receive PNAM, and age- and sex-matched controls in terms of midface symmetry.

Methods:

We evaluated 39 frontal facial photographs of 13 patients with CUCLP who underwent PNAM as part of the treatment (group 1: PNAM), 13 patient with CUCLP who did not undergo PNAM (group 2: no nasoalveolar molding), and 13 age- and sex-matched controls. The children were evaluated in their fifth year of life. Three midline and 3 bilateral orthopometric midface landmarks were programmed using a custom software (OnyxCeph3, Image Instruments GmbH, Germany), and corresponding linear measurements from the midline were obtained and compared between the groups using 1-way analysis of variance and Scheffe’s post hoc test.

Results:

Significant differences were observed between the control and CUCLP groups for the measurements of the proanasale, subnasale, and zygion. However, there were no significant differences between the PNAM and no nasoalveolar molding groups for the 6 midface landmarks.

Conclusions:

PNAM does not seem to significantly impact the long-term midface symmetry in children with CUCLP.

Comparison of Efficacy Outcomes of Lidocaine Spray, Topical Lidocaine Injection, and Lidocaine General Anesthesia in Nasal Bone Fractures Surgeries: A Randomized, Controlled Trial

Background

Lidocaine is widely used as a general and local anesthetic in minor or major surgeries. The objective of the study was to compare postoperative pain relief and adverse events using different forms of lidocaine administration in patients following closed nasal bone reduction surgery.

Material/Methods

A total of 381 patients with a solitary nasal fracture that could be managed with closed reduction were included in this study and divided into 3 groups of 127 patients in each group. Patients had received 1% lidocaine HCl with epinephrine (LL group), inserted a mesh impregnated with lidocaine spray (TL group), or 1 mg/kg/h lidocaine infusion (GL group) before surgeries. Patients also received morphine when the pain was not controlled. The postoperative pain was assessed at 6 hours and 48 hours after surgery. Postoperative vomiting and nausea were evaluated. Repeated ANOVA/Tukey-Kramer multiple comparisons test was performed at 95% confidence level.

Results

At 6 hours after surgery, patients in the general lidocaine (GL) group reported decreased postoperative pain compared with those in the topical lidocaine (TL) group (P<0.001, q=6.633) and LL group (P<0.001, q=8.056). The morphine consumption within 48 hours was least in GL group than TL group (P<0.001, q=172.9) and LL group (P<0.001, q=226.42). Lidocaine infusion caused nausea (P<0.001, q=6.742) and vomiting (P<0.001, q=4.306).

Conclusions

Topical lidocaine anesthesia had the same postoperative pain relief and the least adverse events as local and general lidocaine anesthesia.

Three-Dimensional Soft Tissue Nasal Changes After Nasoalveolar Molding and Primary Cheilorhinoplasty in Infants With Unilateral Cleft Lip and Palate

OBJECTIVE

To quantify 3-dimensional (3D) nasal changes in infants with unilateral cleft lip with or without cleft palate (UCL±P) treated by nasoalveolar molding (NAM) and cheilorhinoplasty and compare to noncleft controls.

DESIGN

Retrospective case series of infants treated with NAM and primary cheilorhinoplasty between September, 2012 and July, 2016. Infants were included if they had digital stereophotogrammetric records at initial presentation (T1), completion of NAM (T2), and following primary cheilorhinoplasty (T3). Images were oriented in 3dMD Vultus software, and 16 nasolabial points identified.

PATIENTS

Twenty consecutively treated infants with UCL±P.

INTERVENTIONS

Nasoalveolar molding and primary cheilorhinoplasty.

MAIN OUTCOME MEASURES

Anthropometric measures of nasal symmetry and morphology were compared in the treatment group between time points using paired Student t tests. Postsurgical nasal morphology was compared to noncleft controls.

RESULTS

Nasal tip protrusion increased, and at T3 was 2.64 mm greater than noncleft controls. Nasal base width decreased on the cleft side by 4.01 mm after NAM and by 6.73 mm after cheilorhinoplasty. Columellar length of the noncleft to cleft side decreased from 2:1 to 1:1 following NAM. Significant improvements in subnasale, columella, and nasal tip deviations from midsagittal plane were observed. Treatment improved symmetry of the alar morphology angle and the nasal base-columella angle between cleft and noncleft sides.

CONCLUSIONS

Three-dimensional analysis of UCL±P patients demonstrated significant improvements in nasal projection, columella length, nasal symmetry, and nasal width. Compared to noncleft controls, nasal form was generally corrected, with overcorrection of nasal tip projection, columella angle, and outer nasal widths.

Comparative Analysis of Three-Dimensional Nasal Shape of Casts from Patients With Unilateral Cleft Lip and Palate Treated at Two Institutions Following Rotation Advancement Only (Iowa) or Nasoalveolar Molding and Rotation Advancement in Conjunction With Primary Rhinoplasty (New York)

OBJECTIVES

To compare 3-dimensional nasal symmetry in patients with UCLP who had either rotation advancement alone or nasoalveolar molding (NAM) followed by rotation advancement in conjunction with primary nasal repair.

DESIGN

Pilot retrospective cohort study.

MATERIALS AND METHODS

Nasal casts of 23 patients with UCLP from 2 institutions were analyzed; 12 in the rotation advancement only group (Iowa) and 11 in the NAM, rotation advancement with primary nasal repair group (New York). Casts from patients aged 6 to 18 years were scanned using the 3Shape scanner and 3-dimensional analysis of nasal symmetry performed using 3dMD Vultus software, Version 2507, 3dMD, Atlanta, GA. Cleft and noncleft side columellar height, nasal dome height, alar base width, and nasal projection were linearly measured. Inter- and intragroup analyses were performed using t tests and paired t tests as appropriate.

RESULTS

A statistically significant difference in mean-scaled 3-dimensional asymmetry index was found between groups with group 1 having a larger measure of asymmetry (4.69 cm³) than group 2 (2.56 cm³; P = .02). Intergroup analysis performed on the most sensitive linear measure, alar base width, revealed significantly less asymmetry on average in group 2 than in group 1 ( P = .013).

CONCLUSION

This study suggests the NAM followed by rotation advancement in conjunction with primary nasal repair approach may result in less nasal asymmetry compared to rotation advancement alone.

Factors Associated With Adherence to Nasoalveolar Molding (NAM) by Caregivers of Infants Born With Cleft Lip and Palate

OBJECTIVE

Identify factors associated with adherence to nasoalveolar molding (NAM) therapy.

DESIGN

Retrospective case-control study.

SETTING

Tertiary referral center.

PATIENTS, PARTICIPANTS

Infants with cleft lip, with or without cleft palate, referred for NAM. One hundred thirty-five patients met criteria.

MAIN OUTCOME MEASURE(S)

Adherence to NAM therapy, defined as continuous use of the appliance and attendance of NAM adjustment visits.

RESULTS

Female sex (OR = 2.85, 95% CI 1.21-6.74), bilateral cleft (OR = 2.88, 95% CI 1.29-6.46), and travel distance (OR = 1.01, 95% CI 1.00-1.01) were independent predictors of nonadherence. Bilateral clefts (OR = 8.35, 95% CI 2.72-25.64) and public-payer insurance (OR = 3.67, 95% CI 1.13-11.91) for male patients were significantly associated with nonadherence, in our sex-stratified multivariate model. The majority of the families (58%) had public health insurance. Males comprised 77.0% of the cohort.

CONCLUSIONS

NAM treatment adherence is impaired by bilateral clefts, female sex, increased travel distance, and public insurance. Further studies are warranted to investigate how these factors affect adherence, and to develop interventions to improve adherence in families at risk due to economic or psychosocial barriers.

Initial experiences with NAM-assisted primary repair of the BCLP deformity

BACKGROUND

Primary surgical repair of the bilateral cleft lip and palate (BCLP) deformity is challenging. Infant Orthopedic (IO) procedures are often used to assist surgical reconstruction of normal anatomy. Nasoalveolar molding (NAM) is a presurgical infant orthopedic procedure that attempts to reduce the cleft nasal deformity, in addition to the lip and alveolus, leading to an esthetic primary surgical repair.

OBJECTIVE

NAM provides the surgical team with a better foundation for an easier and more esthetic single stage repair at the level of nose in addition to the lip and alveolus.

METHOD

Infant nasal cartilages are amenable to correction with NAM in the first few weeks of infancy when they retain their plasticity. NAM-assisted surgical repair of a complete BCLP infant is discussed. Postoperatively nasal stents were used to retain results and minimize relapse.

RESULTS

NAM helped correct premaxillary deviation and protrusion, reduce alveolar cleft width and improve the nasal morphology prior to surgery in the BCLP infant.

CONCLUSIONS

NAM helped reduce the severity of the cleft deformity in the BCLP infant and facilitated an easier and esthetic single stage primary surgical repair.

Effect of Preoperative Nasal Retainer on Nasal Growth in Patients with Bilateral Incomplete Cleft Lip: A 3-Year Follow-Up Study

Background

The purpose of this study was to evaluate changes in nasal growth after the implementation of a preoperative nasal retainer in patients with bilateral incomplete cleft lip.

Methods

Twenty-six infants with bilateral incomplete cleft lip and cleft palate were included in the study. A preoperative nasal retainer was applied in 5 patients from the time of birth to 2.6–3.5 months before primary cheiloplasty. Twenty-one patients who were treated without a preoperative nasal retainer were placed in the control group. Standard frontal, basal, and lateral view photographs were taken 3 weeks before cheiloplasty, immediately after cheiloplasty, and at the 1- and 3-year postoperative follow-up visits. The columella and nasal growth ratio and nasolabial angle were indirectly measured using photographic anthropometry.

Results

The ratio of columella length to nasal tip protrusion significantly increased after the implementation of a preoperative nasal retainer compared to the control group for up to 3 years postoperatively (P<0.01 for all time points). The ratios of nasal width to facial width, nasal width to intercanthal distance, columellar width to nasal width, and the nasolabial angle, for the two groups were not significantly different at any time point.

Conclusions

Implementation of a preoperative nasal retainer provided significant advantages for achieving columellar elongation for up to 3 years postoperatively. It is a simple, reasonable option for correcting nostril shape, preventing deformities, and guiding development of facial structures.

Early Cleft Lip Repair Revisited: A Safe and Effective Approach Utilizing a Multidisciplinary Protocol

Background:

The optimal timing for cleft lip repair has yet to be established. Advances in neonatal anesthesia, along with a growing body of literature, suggesting benefits of earlier cleft lip and nasal repair, have set the stage for a reexamination of current practices.

Methods:

In this prospective study, cleft lip and nasal repair occurred on average at 34.8 days (13–69 days). Nasal correction was achieved primarily through molding the nasal cartilage without the placement of nasal sutures at the time of repair. A standardized anesthetic protocol aimed at limiting neurotoxicity was utilized in all cases. Anesthetic and postoperative complications were assessed. A 3-dimensional nasal analysis compared pre- and postoperative nasal symmetry for unilateral clefts. Surveys assessed familial response to repair.

Results:

Thirty-two patients were included (27 unilateral and 5 bilateral clefts). In this study, the overall complication rate was 3.1%. Anthropometric measurements taken from 3-dimensional-image models showed statistically significant improvement in ratios of nostril height (preoperative mean, 0.59; postoperative mean, 0.80), nasal base width (preoperative mean, 1.96; postoperative mean, 1.12), columella length (preoperative mean, 0.62; postoperative mean, 0.89; and columella angle (preoperative mean, 30.73; postoperative mean, 9.1). Survey data indicated that families uniformly preferred earlier repair.

Conclusions:

We present evidence that early cleft lip and nasal repair can be performed safely and is effective at improving nasal symmetry without the placement of any nasal sutures. Utilization of this protocol has the potential to be a paradigm shift in the treatment of cleft lip and nasal deformity.

Surgeon's and Caregivers' Appraisals of Primary Cleft Lip Treatment with and without Nasoalveolar Molding: A Prospective Multicenter Pilot Study

BACKGROUND

Despite the increasing use of nasoalveolar molding in early cleft treatment, questions remain about its effectiveness. This study examines clinician and caregiver appraisals of primary cleft lip and nasal reconstruction with and without nasoalveolar molding in a nonrandomized, prospective, multicenter study.

METHODS

Participants were 110 infants with cleft lip/palate (62 treated with and 48 treated without nasoalveolar molding) and their caregivers seeking treatment at one of six high-volume cleft centers. Using the Extent of Difference Scale, standard photographs for a randomized subset of 54 infants were rated before treatment and after surgery by an expert clinician blinded to treatment group. Standard blocked and cropped photographs included frontal, basal, left, and right views of the infants. Using the same scale, caregivers rated their infants' lip, nose, and facial appearance compared with the general population of infants without clefts before treatment and after surgery. Multilevel modeling was used to model change in ratings of infants' appearance before treatment and after surgery.

RESULTS

The expert clinician ratings indicated that nasoalveolar molding-treated infants had more severe clefts before treatment, yet both groups were rated equally after surgery. Nasoalveolar molding caregivers reported better postsurgery outcomes compared with no-nasoalveolar molding caregivers (p < 0.05), particularly in relation to the appearance of the nose.

CONCLUSIONS

Despite having a more severe cleft before treatment, infants who underwent nasoalveolar molding were found by clinician ratings to have results comparable to those who underwent lip repair alone. Infants who underwent nasoalveolar molding were perceived by caregivers to have better treatment outcomes than those who underwent lip repair without nasoalveolar molding.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, II.