Design features and simple methods of incorporating nasal stents in presurgical nasoalveolar molding appliances

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

OBJECTIVE

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

DESIGN

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

RESULTS

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

CONCLUSION

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

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

INTRODUCTION

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

AIMS

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

MATERIAL AND METHODS

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

RESULTS

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

CONCLUSION

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

Aesthetic Assessment of Infants With Different Cleft Types Before, During, and After Orthopedic Treatment

OBJECTIVE

The aim of the present study is to compare the aesthetic assessments of infants with different types of cleft before (T1), during (T2), and after (T3) orthopedic therapy (OT) by orthodontists, dentists, and laypersons.

METHODS

Photographs of 3 patients (incomplete lip [C1], complete unilateral [C2], and complete bilateral cleft [C3]) at T1 (C1, C2, C3 chronologic age: 5, 2, 2 days), T2 (C1, C2, C3 chronologic age: 32, 28, 35 days; using forehead anchoraged nasal stent or conventional nasoalveolar therapy plates), and T3 (C1, C2, C3 chronologic age: 80, 91, 105 days) were collected from the archive. The nasolabial region at stage T3 were masked and also added to the evaluation form (T4). Fifty-one evaluators (17 orthodontists, 17 dentists, and 17 laypersons; mean age = 30.1 ± 3.63) assessed 21 frontal photographs using Asher-McDade et al's 5-point scale.

RESULTS

The scores of the orthodontists for T1 photographs were statistically lower than the dentists and laypersons (P < 0.05). The scores of T3 and T4 were similar in all groups (P > 0.05). The assessment scores progressively decreased from T1 to T3 (P > 0.05). The scores of both treatment methods were similar in the orthodontist group (P > 0.05), whereas the scores were lower for forehead anchored nasal stent in the other groups (P < 0.05).

CONCLUSION

Orthodontists are familiar with cleft patients. Therefore, the aesthetic of infants at any therapy stage with different treatment methods was not categorized as poor. The enhanced scores at post-OT stage and the similar scores of masked and nonmasked post-OT photographs may underline the recognition of the rehabilitation period by not only specialists but also laypersons.

Postoperative alar base symmetry in complete unilateral cleft lip and palate:A prospective study

In the evolution of cleft lip repair, there have been continuous attempts to minimize local trauma and to improve lip and nasal appearances. In order to obtain an aesthetically balanced development of midface, the primary surgical correction of the nasolabial area is of paramount importance. In this study, the importance of a back-cut extending cephalically above the inferior turbinate at the mucocutaneous junction which elevates the nostril floor on the cleft side for the purpose of achieving symmetry of the alar bases are analyzed by pre and postoperative photographic anthropometry. This study comprised of fifty cases of the unilateral complete cleft lip. At the time of surgery, the patient age ranged from 3-9 months. The surgeries, performed by a single surgeon, employed the standard Millard technique, incorporating Mohler modifications of lip repair. Anthropometric analysis revealed that the preoperative mean difference between the normal side and the cleft side was 0.2056 with a standard deviation of 0.133. In the postoperative analysis, the mean difference was reduced to 0.0174 with a standard deviation of 0.141. The paired t-test showed that the p-value is <0.001, indicating high statistical significance. To conclude, in complete unilateral cleft lip and palate, the geometrically placed nasal back-cut incision has a definite role in the correction of the alar base symmetry during primary surgery.

Effective retropulsion and centralization of the severely malpositioned premaxilla in patients with bilateral cleft lip and palate: a novel modified presurgical nasoalveolar molding device with retraction screw

PURPOSE

A novel, modified presurgical nasoalveolar molding (MPNAM) device with retraction screw was designed and used in patients with bilateral complete cleft lip and palate (BCCLP) to rapidly retract and centralize the protuberant and malpositioned premaxilla and correct the nasolabial and palatal deformities. The orthopedic effects and possible complications were evaluated.

PATIENTS AND METHODS

Nine patients with BCCLP who met the inclusion criteria were selected. After the maxillary model was obtained, the new MPNAM device with retraction screw was designed and worn until cheilorrhaphy. Changes in local deformities and complications were observed continuously, and the orthopedic effect was evaluated.

RESULTS

All patients quickly adapted to the MPNAM appliance, and the treatment was finished after 5-8 return visits. The columella was significantly prolonged, the nasal tip was elevated, and the collapsed nasal dome was obviously improved. Simultaneously, the premaxilla was rapidly retracted and rotated, and gradually centralized; the clefts were gradually reduced and closed, and a nearly normal dental arch was formed. Although there were some complications, the orthopedic treatment was continued until cheiloplasty.

CONCLUSIONS

The MPNAM device with retraction screw can simultaneously correct nasolabial and palatal deformities and also rapidly retract and centralize the premaxilla.

Unilateral cleft lip: principles and practice of surgical management

Management of cleft lip and palate requires a unique understanding of the various dimensions of care to optimize outcomes of surgery. The breadth of treatment spans multiple disciplines and the length of treatment spans infancy to adulthood. Although the focus of reconstruction is on form and function, changes occur with growth and development. This review focuses on the surgical management of the primary cleft lip and nasal deformity. In addition to surgical treatment, the anatomy, clinical spectrum, preoperative care, and postoperative care are discussed. Principles of surgery are emphasized and controversies are highlighted.

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

PATIENT

A 2-day-old female infant with complete unilateral cleft lip, alveolus, and palate (left side) was presented to the Department of Prosthodontics, Government Dental College and Hospital, Nagpur for evaluation and treatment with presurgical nasoalveolar molding (PNAM) prior to surgical intervention.

DISCUSSION

The alignment of the alveolar segments creates the foundation upon which excellent results of primary lip and nasal surgery are dependent in the repair of the cleft lip, alveolus, and palate patient. Presurgical infant orthopedics has been employed since the 1950s as an adjunctive neonatal therapy for the correction of cleft lip and palate. One of the problems that the traditional approach failed to address was the deformity of the nasal cartilages and the deficiency of columella tissue in infants with unilateral and bilateral cleft lip and palate. The purpose of this article is to illustrate the step-by-step fabrication process of the PNAM prosthesis used to direct growth of the alveolar segments, lips, and nose in the presurgical treatment of cleft lip and palate.

CONCLUSION

As a result, the primary surgical repair of the lip and nose heals under minimal tension, thereby reducing scar formation and improving the esthetic result. Frequent surgical intervention to achieve the desired esthetic results can be avoided by PNAM.

Nerve glue for upper extremity reconstruction

Nerve glue is an attractive alternative to sutures to improve the results of nerve repair. Improved axon alignment, reduced scar and inflammation, greater and faster reinnervation, and better functional results have been reported with the use of nerve glue. The different types of nerve glue and the evidence to support or oppose their use are reviewed. Although the ideal nerve glue has yet to be developed, fibrin sealants can be used as nerve glue in select clinical situations. Technology to allow suture-free nerve repair is one development that can potentially improve functional nerve recovery and the outcomes of upper extremity reconstruction.

Nasoalveolar molding with active columellar lengthening in severe bilateral cleft lip/palate: a clinical report

Severe bilateral cleft-lip/palate patients are difficult to manage even if nasoalveolar molding therapy is advocated before surgical repair. A 5-day-old male infant with bilateral cleft-lip-palate was managed with the nasoalveolar molding technique. Periodic adjustments of the appliance were continued every week to mold the nasoalveolar complex into the desired shape for the 5 months of infancy. The cleft width of 12 mm on the right and 14 mm on the left side was completely reduced, and the absent columella was lengthened to 6 mm with the active molding appliance. The horizontal bar of the nasal stent of the appliance was modified by adding an additional 1 mm layer of resilient liner on the tissue surface to achieve rapid columellar lengthening. In severe bilateral cleft-lip/palate cases, simple modifications in the appliance can achieve rapid results.

Comparative study of nasoalveolar molding methods: nasal elevator plus DynaCleft® versus NAM-Grayson in patients with complete unilateral cleft lip and palate

Objective : To compare nasoalveolar molding (NAM) effect employing a nasal elevator plus DynaCleft® and NAM-Grayson system in patients with complete unilateral cleft lip and palate. Method : Prospective study in two groups. Group A included 20 consecutive patients treated with DynaCleft® and a nasal elevator before lip surgery. Group B included 20 patients treated with NAM-Grayson system. Maxillary casts and standard view photographs were done before and after treatment. Columella deviation angle, soft tissue distance of the cleft, intercommisural distance, and nostril height and width were traced and measured on the printed photos; a ratio was obtained and compared before and after treatment. Cleft width, anterior width, and anteroposterior distances were measured on the maxillary cast. Results : Group A began treatment at an average age of 14.3 days and group B at an average age of 16.9 days; no complications were observed. For group A, the initial average alveolar cleft within the cast was 10.7 mm, and after treatment it was 6.6 mm. For group B, pretreatment width was 11.2 mm, and after treatment it was 5.9 mm. No differences were found on the anterior and posterior width, and A-P distance of both groups. The initial mean columellar angle in group A was 38.1°, and after treatment it was 61.5°; for group B the initial mean columellar angle was 33.6°, and after treatment it was 59.5°. Results of Mann-Whitney U and Student's t tests showed no differences (P > .05). Width and height dimensions of the nostril showed minor differences. Conclusions : Both methods significantly reduced the cleft width and improved the nasal asymmetry. Our findings show that both methods produced similar results.

Presurgical nasoalveolar molding (PNAM) for a unilateral cleft lip and palate: a clinical report

Cleft lip and palate deformity is a congenital defect of the middle third of the face. Incidence varies from 1:500 to 1:2500 live births. Etiology depends upon hereditary and environmental factors. Restoration of these defects is important not only for functional and esthetic reasons, but also because there may be a positive psychological impact for the patient and parents. The goal of primary closure of the lip for unilateral cleft lip is to ensure a normal and symmetrical lip and nose. Presurgical infant orthopedics has been employed since the 1950s as an adjunctive neonatal therapy for the correction of cleft lip and palate. Presurgical nasoalveolar molding (PNAM) represents a paradigm shift from the traditional methods of presurgical infant orthopedics. PNAM consists of active molding of the alveolar segments as well as the surrounding soft tissues. This clinical report describes a new approach of PNAM therapy for an infant with complete unilateral cleft lip and palate showing significant reduction in cleft defect size and improved contour and topography of deformed surrounding soft tissues.

Nasoalveolar molding and long-term postsurgical esthetics for unilateral cleft lip/palate: 5-year follow-up

The nasoalveolar molding (NAM) technique has been shown to significantly improve the surgical outcome of the primary repair in cleft lip and palate patients. A 6-day-old female infant was managed with the presurgical NAM technique. Periodic adjustments of the appliance were continued every week to mold the nasoalveolar complex into the desired shape for the next 5 months. The 13 mm of alveolar cleft width was reduced to 1.5 mm. The depressed nostril on the cleft side was molded into the normal anatomy. The nose and upper lip were surgically repaired at the age of 5 months. The second stage surgery of palatal closure was performed at the age of 18 months. The patient was followed up regularly at 6-month intervals for the next 5 years.

Presurgical presentation of columellar features, nostril anatomy, and alveolar alignment in bilateral cleft lip and palate after infant orthopedics with and without nasoalveolar molding

OBJECTIVES

(1) To evaluate quantitative differences in presurgical presentations of alveolar alignment and nostril anatomy of infants with BCLP treated with nasoalveolar molding (NAM) from those treated with maxillary infant orthopedics only (IO) and (2) to detect interrelationships between presurgical nasoalveolar anatomy, age at lip surgery, age of commencing, and durations of alveolar and nasal molding.

METHODS

A retrospective analysis was conducted on nasal-alveolar measurements and presurgical treatment records of infants with BCLP who received lip repair by a single surgeon in a tertiary-care, referral teaching hospital consecutively from 2000 to 2009 after undergoing NAM (n  =  29; 51 nostrils) or IO (n  =  17; 32 nostrils). Paired t tests analyzed nostril and alveolar symmetry in each group. Intergroup comparisons were made by linear mixed-model regression analyses. Pearson's correlation tests were conducted to detect significant interrelationships within groups.

RESULTS

Significant between-group differences were noted in alveolar irregularity (NAM: 3.58 ± 1.02 mm; IO: 7.31 ± 1.28 mm; p < .01), columellar length (NAM: 2.88 ± 0.27 mm; IO: 1.48 ± 0.34 mm; p < .001), columellar width (NAM: 6.10 ± 0.21 mm; IO: 6.88 ± 0.26 mm; p < .01), columellar length/width ratio (NAM: 0.48 ± 0.05; IO: 0.20 ± 0.07; p < .05), and columellar angle (NAM: 0.98 ± 1.1°; IO: 3.69 ± 1.37°; p < .05). Differences in age of commencing presurgical orthopedics, lip surgery, and treatment durations were not significant. Better-aligned alveolar segments in the NAM group did not statistically correlate with nostril dimensions. Alveolar irregularity and nostril height in the IO group strongly correlated.

CONCLUSIONS

Infants who received NAM had longer columellae and better-aligned alveolar segments than those who received only IO. Other nostril dimensions were not significantly different.

Rhinoplasty for cleft and hemangioma-related nasal deformities

PURPOSE OF REVIEW

To provide a concise review of recent articles on rhinoplasty approaches for cleft nasal deformity and nasal hemangiomas published in 2008-2010.

RECENT FINDINGS

Cleft nasal deformity rhinoplasty approaches have undergone further refinements as well as new development in techniques and surgical principles to minimize recurrent cleft nasal deformities. There is a paucity of studies addressing cleft septal deformity although there appears to be a greater emphasis on functional outcome in cleft rhinoplasty. Complications from primary cleft rhinoplasty and presurgical nasoalveolar molding were also reported. Similarly, nasal hemangioma rhinoplasty approaches have undergone further modifications with open rhinoplasty and subunit approaches gaining wider acceptance.

SUMMARY

There are several new studies that compare different rhinoplasty techniques to determine which approaches offer superior surgical outcomes; however, there needs to be a greater acceptance of objective measurements when assessing surgical results to identify a uniform surgical protocol and technique for both cleft rhinoplasty and nasal hemangiomas.