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

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.

Three-dimensional Changes of Maxillary Alveolar Morphology After Using Modified Nasoalveolar Molding in Patients with Complete Unilateral Cleft lip and Palate

OBJECTIVE

This study aimed to evaluate the three-dimensional changes in maxillary alveolar morphology after using modified NAM in patients with complete unilateral cleft lip and palate.

DESIGN

This is a retrospective study.

SETTING

The study was carried out in the dental hospital, Faculty of Dentistry of Naresuan University, Phitsanulok, which serves as a tertiary care center.

PATIENTS

The population sample consisted of 19 patients with nonsyndromic complete unilateral cleft lip and palate.

INTERVENTION

All patients received the modified NAM treatment based on the treatment protocol of the Naresuan University Cleft and Craniofacial Center, Thailand.

MAIN OUTCOME MEASURE

Dental models obtained at pre-treatment (T0) and post-treatment (T1) were scanned to construct the digital models. The maxillary digital models that showed dimensional changes between T0 and T1 were measured using a computer graphic software.

RESULTS

The modified NAM resulted in a significant decrease in the anterior cleft width, posterior cleft width, and anterior arch width. Conversely, it caused a significant increase in the length of the lesser cleft segment and the greater segment rotation. However, the change in the height of both segments and posterior arch width was not found to be significant.

CONCLUSIONS

The modified NAM was an effective device for reducing the alveolar cleft width while improving the alignment of alveolar cleft segments.

Three-dimensional Analysis of Factors Related to the Effective Alveolar Molding in Presurgical Infant Orthopedics: Findings From a Pilot Study

OBJECTIVE

Presurgical infant orthopedics (PIO) reduces the severity of the original cleft and burden on patients and their parents, provides better esthetics and function, and enables surgeons to achieve better surgical repair. To reduce the alveolar cleft width and to predict treatment difficulty using PIO, various measures were examined in pretreatment cast models.

DESIGN

Retrospective case-control pilot study.

PATIENTS

The patients were 22 infants with non-syndromic unilateral cleft lip and palate (UCLP), and cast models of these infants were used.

METHODS

After PIO using passive plates, infants with UCLP were divided into two groups: contact group (12 cases with close proximity of the greater and lesser segments) and non-contact group (10 cases without proximity of segments). The two groups were compared, and variables related to the proximity between alveolar clefts were examined.

RESULTS

There was no significant difference in age at PIO initiation between the two groups. However, the treatment duration was significantly longer in the non-contact group than in the contact group. Among the 13 variables, the initial lateral deviation of the nasal septum was significantly larger in the contact group than in the non-contact group. A significant positive correlation was observed between the initial lateral deviation of the nasal septum and reduction of the alveolar cleft width by PIO.

CONCLUSION

Initial lateral deviation of the nasal septum is a predictive factor for the proximity between alveolar segments in infants with UCLP at the PIO.

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.

Systematic Review of the Long-Term Effects of Presurgical Orthopedic Devices on Patient Outcomes

Objective:

To perform a systematic review of the literature to identify the long-term effects of presurgical orthopedic (PSO) device use on patient outcomes.

Design:

A comprehensive literature review of Embase and Ovid databases was performed to identify all English-language publications related to unilateral cleft lip and palate, presurgical devices, and patient outcomes. Studies were excluded if they did not report patient outcomes beyond 2 years of age, did not describe the use of a PSO device, were case reports (n < 10), or were purely descriptive studies.

Main Outcome Measures:

Reported patient outcomes following the use of PSO devices.

Results:

Following a review of all articles by 2 independent reviews, 30 articles were selected for inclusion. Overall, there was no reported consensus as to the long-term effects of PSO devices. Furthermore, this study identified that only 10% of published research controlled for confounding factors that could influence the reported results. Confounding factors that were identified included different operating surgeon, different surgical protocols, and different rates of revision surgeries.

Conclusions:

Overall, this systematic review identified 2 important conclusions. Firstly, there is no consensus in the literature about the long-term effects of PSO devices on long-term patient outcomes. Secondly, research in this domain is limited by confounding factors that influence the applicability of the reported results.

The Effect of Immediate Versus Delayed Addition of the Nasal Stent to the Nasoalveolar Molding Plate on Nostrils Shape and Cleft Width in Infants With Unilateral Cleft Lip and Palate

OBJECTIVE

The main aim of this study was to evaluate the effect of immediate versus delayed addition of the nasal stent to the nasoalveolar molding plate on the nose shape and alveolar cleft area in unilateral cleft lip and palate infants.

METHOD

Twenty nonsyndromic newborn infants with unilateral cleft lip and palate were scanned 3 dimensionally using Proface software. In the experimental group, the nasal stent was added on the day the molding plate arrived, and in the control group when the alveolar gap reached 5 mm. Two months after adding nasal stents in each group patients' faces were scanned again and some parameters were measured. In addition, immediately after treatment, 1 month later and at the end of investigation, impressions were taken, and stone casts were scanned by cone-beam computed tomography and the alveolar gap was measured. Fisher exact test, paired t test, and ANOVA were used for data analyses. P < 0.05 was considered as significant.

RESULTS

In this study, changes in the parameters showed significant differences between the case and controls for the columellar angle, nostril width on the cleft side, nostril height on the cleft side, soft tissue cleft width, and nasal surface area. However, the nostril's width and height in the noncleft side, intercommissural distance, nasal surface area on the noncleft side, nostril area between the cleft and noncleft side after treatment, and the alveolar gap did not show significant differences between the groups (P > 0.05).

CONCLUSION

Early use of nasal stents showed more desirable results in decreasing the width of the nostrils and increasing its height and correcting the angle of the columella without any adverse effects on the nostrils after treatment.

Comparison of Anatomical Features of Alveolar Cleft in Unilateral Cleft Lip and Palate Patients of Different Ages

OBJECTIVES

This study aimed to compare the anatomical features of alveolar cleft in patients with complete unilateral cleft lip and palate (UCLP) of different ages.

METHODS

Sixty UCLP patients were divided into 3 groups as follows: group 1 (7-12 years old), group 2 (13-18 years old) and group 3 (more than 18 years old). The radiographic images were analyzed based on cone beam computed tomography (CBCT) images.

RESULTS

The mean age in 3 groups was 10.45 ± 1.15, 15.05 ± 1.90, and 22.55 ± 3.00 years (P < 0.0001). The lip-palatal width in Group 2 and 3 was 15.14 ± 3.67 mm and 15.50 ± 3.92 mm, which was significantly larger than 12.97 ± 1.82 mm in Group 1 (P = 0.037). The volume of alveolar defect was 1.09 ± 0.23 cm, 1.28 ± 0.38 cm and 1.40 ± 0.58 cm in 3 groups, and the difference between any 2 of them was significant (P = 0.0004). The prevalence of ipsilateral but contralateral maxillary sinusitis was significant among 3 groups (P = 0.0015) while the other nasal deformities including nasal septum deviation and inferior turbinate hypertrophy was not found significant.

CONCLUSIONS

Alveolar cleft volume increased with age, which is properly due to enlarged width of lip-palatal defect. The significant higher frequencies of ipsilateral maxillary sinusitis in patients under 18 could increase the risk of bone infection.

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 First-Year Follow-Up of a Cleft Lip and Palate Patient Treated With Nasoalveolar Molding (NAM)

The objectives of pre-surgical orthopedics are to allow surgical repair with minimal tension of the involved tissues and less restriction to the craniofacial growth. The aim of this study was to evaluate the benefits of nasoalveolar model (NAM) as a pre-operative therapy in a patient with bilateral cleft lip and palate followed by labioplasty and palatoplasty. A 15-day-old patient underwent orthopedic treatment with NAM. After pre-operative treatment, retraction of the pre-maxilla was observed with reduction of the fissure. Due to the successful effects of NAM treatment the patient had a one-step surgery for lip correction. Six months later, due to lip pressure the fissure was further decreased. After six months, the patient underwent palatoplasty. Both surgeries contributed to the remaining closure of the fissure, which were reduced by half compared to the end of pre-operative treatment. The uses of NAM as a pre-operative treatment approached the alveolar segments, centralized the pre-maxilla, decreased the cleft palate resulting in a marked improvement of the arch and provide superior surgical results. In addition, it allows the primary repair of the patient's lip with asymmetric bilateral fissure in only one-step surgery; in consequence, it will reduce treatment morbidity and decrease cost of treatment.

Three-dimensional evaluation of the effect of nasoalveolar molding on the volume of the alveolar gap in unilateral clefts

Over the last few decades it has been shown that nasoalveolar molding (NAM) has had an effect on the correction of nasal cartilage deformities and the alveolar process. This three-dimensional (3D) analysis evaluated the effects of NAM on the alveolar cleft region in patients with unilateral cleft lip and palate. Alveolar gap volumes were measured in a retrospective review of 40 dental casts of 20 patients with unilateral clef lip and palate before and after treatment. Ten patients who began undergoing NAM immediately after birth were included in this study. An additional 10 patients with unilateral clefts but without NAM were included as a control group. All of the casts (pretreatment and post-treatment) were 3D scanned, and the cleft volumes and anterior gap widths underwent computer-aided evaluations. NAM resulted in a significant reduction (p < 0.05) in alveolar gap volume and anterior cleft width from birth until lip closure time, while half of the control group showed slight increases in cleft volume. Based on these results, NAM is an effective and helpful treatment that can be used to significantly reduce alveolar gap volume and anterior cleft width in patients with unilateral clefts. Harmonization of the dental arch and a reduction in the alveolar cleft region are desirable treatment goals.