Systematic Review and Critical Appraisal of the Evidence Base for Nasoalveolar Molding (NAM)

Evaluating quality of life changes in patients with cleft lip or palate: a mixed method pre- and postsurgical analysis in Karachi

BACKGROUND

Cleft lip and/or palate (CLP) is the most common orofacial congenital disability, presenting significant medical, psychological, and social challenges. In Pakistan, the incidence of CLP is high, estimated at one in 523 live births, but accurate data are lacking due to the absence of a birth registry. Early diagnosis and intervention are crucial for improving outcomes. This study evaluated the impact of CLP on patients' quality of life in Karachi, comparing pre- and post-surgical phases.

METHODS

A sequential exploratory quantitative-qualitative mixed-methods study was conducted at two tertiary care hospitals in Karachi. In the quantitative phase, 280 patients with CLP, either awaiting or post-surgery, completed the Oral Health Impact Profile (OHIP-14) questionnaire to assess oral health-related quality of life (OHRQoL). Based on questionnaire responses, 30 participants were purposively selected for in-depth, semi-structured interviews exploring their experiences. Quantitative data were analyzed using SPSS version 25; qualitative data were analyzed thematically.

RESULTS

Quantitative findings revealed significant gender disparities in cleft types and correction status; females had a higher prevalence of unilateral cleft lip, while males had more cleft palate cases. Dental and oral health issues significantly affected daily activities, with higher impacts in cleft palate patients. OHRQoL varied by gender, cleft type, and correction status, with those post-surgery reporting poorer OHRQoL. Qualitative analysis identified six themes: Diagnosis and Early Treatment, Challenges and Impact, Postsurgical Experiences, Support Systems, Healthcare Experiences, and Future Perspectives. Inconsistencies in psychological support, accessibility and financial burdens were presented as significant issues. Sentiment analysis highlighted varied emotions, from despair to hope and gratitude.

CONCLUSIONS

CLP significantly affects patients' quality of life in Karachi across multiple dimensions. Early diagnosis and surgical intervention are essential but often hindered by financial and accessibility issues. Psychological effects, including low self-esteem and social isolation, highlight the need for integrated mental health support. Family and community support are critical for patient resilience. A comprehensive approach addressing medical, psychological, social, and systemic factors is necessary to improve outcomes for individuals with CLP.

The Impact of Presurgical Nasoalveolar Molding on Midface Growth in Unilateral Cleft Lip and Palate: A Systematic Review and Meta-Analysis

OBJECTIVE

Nasoalveolar molding (NAM) can optimize aesthetic outcomes in patients with cleft lip and palate (CLP), particularly in those with wider clefts. However, its impact on long-term postoperative sequelae such as midface hypoplasia (MFH) remains unclear. This study analyzed cephalometric data to evaluate NAM's effect on MFH in patients with complete unilateral CLP (UCLP).

DESIGN

Systematic Review and Meta Analysis.

PATIENTS

Included studies reported cephalometrics of patients ≥ 7 years old with repaired UCLP who underwent presurgical NAM versus no-NAM (control). Studies of bilateral cases or unoperated clefts were excluded.

MAIN OUTCOME MEASURES

Main outcomes were cephalometric angles (sella-nasion-A point (SNA), sella-nasion-B point (SNB), and A point-nasion-B point (ANB)) of patients treated with NAM vs. no-NAM.

RESULTS

Of 2063 articles, three met inclusion criteria. Cephalometrics were reported for 171 patients (89 NAM, 82 no-NAM) at an average age of 8.5 ± 0.9 years. On pooled analysis, compared to the no-NAM cohort, the NAM cohort had insignificantly smaller SNA (78.8°±1.5° vs. 76.7°±1.5°, p = 0.169), SNB (75.5°±1.0° vs. 75.5°±1.0°, p = 0.954), and ANB (3.6°±1.4° vs. 1.23°±1.2°, p = 0.089) angles. Upon meta-analysis, compared to the no-NAM cohort, the NAM cohort had significantly smaller SNA (Mean Difference (MD) -1.96 [-3.31 to -0.61], p = 0.005) and ANB angles (MD -2.22 [-3.20 to -1.24], p < 0.001).

CONCLUSION

This meta-analysis revealed that patients with UCLP who underwent presurgical NAM had significantly smaller SNA and ANB angles, possibly indicating worse MFH. Before choosing NAM, clinicians should consider CLP severity, potential sagittal growth restrictions, and feasibility, particularly in low-resource settings.

Treatment outcomes of digital nasoalveolar moulding in infants with cleft lip and palate: A systematic review with meta-analysis

The aim of this systematic review was to compare the treatment outcomes of digital nasoalveolar moulding (dNAM) technique with conventional nasoalveolar moulding (cNAM) or non-presurgical intervention protocol in infants with unilateral (UCLP) or bilateral (BCLP) cleft lip and palate. A bibliometric search by MEDLINE (via Ovid), Embase, Cochrane Library, grey literature and manual method was conducted without language restriction until November 2023. Literature screening and data extraction were undertaken in Covidence. The risk of bias was evaluated using the Newcastle-Ottawa Scale and RoB-2. Pooled effect sizes were determined through random-effects statistical model using R-Software, and the certainty of evidence was assessed using the GRADE approach. Among 775 retrieved articles, nine studies were included for qualitative synthesis (6-UCLP, 3-BCLP), with only three eligible UCLP studies for meta-analysis. In the UCLP group, very low certainty of evidence indicated no difference in alveolar cleft width (SMD, 0.13 mm; 95% CI, -0.31 to 0.57; I2, 0%), soft tissue (lip) cleft gap, nasal width, nasal height, and columellar deviation angle changes between dNAM and cNAM. In the BCLP group, qualitative synthesis suggested similar changes in alveolar, lip, and nasal dimensions with dNAM and cNAM. In both cleft groups (UCLP, BCLP), reduced alveolar cleft width was observed in the dNAM group compared to the non-presurgical intervention protocol, along with fewer clinical visits and reduced chairside time for dNAM compared to cNAM. It can be concluded that the treatment outcomes with dNAM were comparable to cNAM in reducing malformation severity and were advantageous in terms of chairside time and clinical visit frequency. However, the overall quality of evidence is very low and standardization is needed for the virtual workflow regarding the alveolar movements and growth factor algorithms. Registration: PROSPERO-database (CRD42020186452).

The nasoalveolar molding technique versus DynaCleft nasal elevator application in infants with unilateral cleft lip and palate

BACKGROUND

The introduction of presurgical nasoalveolar molding represented a significant departure from traditional molding methods. Developed by Grayson and colleagues in 1993, this technique combines an intraoral molding device with a nasal molding stent. This study aimed to compare the Grayson nasoalveolar molding appliance versus DynaCleft appliance as two methods of presurgical nasoalveolar molding.

METHODS

A single-blinded, randomized, parallel-arm clinical trial was conducted. Sixteen infants with complete unilateral cleft lip and palate were enrolled and divided into two groups of eight. Group 1 was treated with a modified Grayson nasoalveolar molding appliance that included a nasal stent, while group 2 was treated with DynaCleft elastic adhesive tape and an external nasal elevator. Standardized digital photographs of each infant were taken at baseline and post-treatment using a professional camera. Nine extraoral anthropometric measurements were obtained from each image using image measurement software.

RESULTS

The modified Grayson nasoalveolar appliance demonstrated a more significant improvement compared to DynaCleft in terms of alar length projection (on both sides), columella angle, and nasal tip projection. Symmetry ratios also showed enhancement, with significant improvements observed in nasal width, nasal basal width, and alar length projection (p< 0.05).

CONCLUSION

Both the modified Grayson nasoalveolar appliance and DynaCleft appear to be effective presurgical infant orthopedics treatment options, demonstrating improvements in nasolabial aesthetics. The modified Grayson appliance, equipped with a nasal stent, improved nasal symmetry more effectively than DynaCleft, resulting in a straighter columella and a more medially positioned nasal tip.

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

OBJECTIVE

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

DESIGN

Randomised clinical trial.

SETTING

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

INTERVENTIONS

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

MAIN OUTCOME MEASURE(S)

Changes in facial and nasolabial morphology.

RESULTS

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

CONCLUSIONS

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

Advances in Cleft Lip and Palate Surgery

Cleft lip with or without cleft palate is one of the most common congenital malformations, with an average prevalence of 1 in 1000 live births. Cleft lip and/or palate is incredibly phenotypically diverse, with constant advancements and refinements in how we care for patients. This article presents an in-depth review of the latest advances and current evidence in cleft lip and palate surgery. This includes presurgical infant orthopedics, perioperative practice patterns including use of enhanced recovery after surgery (ERAS) protocols, patient-reported outcome measures, and the latest adjuncts in cheiloplasty and palatoplasty.