A modified muscle-activated maxillary orthopedic appliance for presurgical nasoalveolar molding in infants with unilateral cleft lip and palate

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

OBJECTIVE

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

DESIGN

Prospective comparative cohort study.

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

A New Approach to Presurgical Nasoalveolar Molding in Patients With Unilateral Cleft Lip and Palate and Severe Cleft Width

The aim of this study was to describe a new approach to the presurgical orthopedic treatment of unilateral cleft lip and palate patients with severe cleft width. Modified nostril retainers manufactured from soft acrylic were used for the nasal molding. This technique enables the separation of the nasal molding without having to reduce the cleft width to 5 mm. Nasal molding with the modified nostril retainer resulted in the patient and the physician experiencing a more comfortable treatment period.

Orthopaedic traction with passive nasoalveolar moulding in a bilateral cleft lip and palate patient - Rediscovering the old

Introduction

A 22-day-old male infant presented with complete bilateral cleft lip and palate with prominent premaxillary segment, wide alar base, flat alar domes and no columellar tissue, thus leading to a severe facial deformity. A presurgical nasoalveolar moulding (PNAM) procedure was planned to facilitate an optimal surgical approximation of the cleft and surrounding tissues.

Methods

PNAM was performed on the basis of the hypothesis that ‘The palatal shelves continue to grow unabated if adequate relief is provided by wax mock up while preparing the feeding plate’. An intraoral device, which consisted of an acrylic feeding plate, was constructed after adequate wax mock up in the cleft area for passive moulding, along with extraoral traction force through active lip taping. A nasal stent was subsequently attached to lift the nasal domes and lengthen the columella. The changes thus achieved with PNAM were assessed using innovative photographic and model analyses.

Results

On completion of PNAM, the qualitative photographic changes showed significant premaxillary setback, columellar lengthening and fullness of alar domes. The quantitative model analysis revealed reduction in the anteroposterior cleft gap by 5 mm and 5.5 mm on right and left sides, respectively. Transverse distance between the two palatal segments reduced by 3.5 mm, 8 mm and 8.5 mm in anterior, middle and posterior regions, respectively.

Conclusion

Orthodontic intervention performed for 11 weeks by PNAM helped to retract the premaxilla, reduce the cleft gap, improve the arch form, approximate lip segments and distinctly lengthen the columella. Hence, it improved the morphology of the nose by correcting the flattened nasal wings. This aided the surgeon to achieve an optimal surgical repair.

Primary Repair of Cleft Lip and Nose in the Neonatal Period

Facial cleft malformations belong to the most common problems of the congenital facial anomalies. At the Clinic of Plastic, Aestetic and Reconstructive Surgery at the Faculty Hospital in Banská Bystrica we have been performing primary cleft lip repairs during the first week of life of a newborn since 1995. During this life period the fetal healing still persists. Modern anesthetic techniques have considerably reduced respiratory complications after the lip closure. The adequate postoperative sedation together with monitoring of the pacient remarkably reduces the occurrence of wound dehiscence. The advantages of the neonatal cleft lip repair are the scarless healing, no negative effect on the growth of the middle thirt of the face, as well as the pschychosocial effect on the family and the fact that the ortodontic aparat has not been needed.

Presurgical Preparation of Infants With Unilateral Cleft Lip and Palate: The SAC-PP-MR Innovative Technique

In this article, we demonstrate an effective, cheap, and fast way to shape the nasal alar cartilage in patients with unilateral cleft lip and palate. This technique straightens the vomer and brings the philtrum, columella, premaxilla, and the maxillary frenum to the midsagittal plane, while the alveolar ridges are shaped and positioned. This reduces the lip and palatal cleft to zero even in a 4-week period.

Modifications in Presurgical Nasoalveolar Molding Treatment of Bilateral Cleft Lip and Palate Patients With Severely Malpositioned Premaxillae

OBJECTIVE

The aim of this study was to evaluate a modified presurgical nasoalveolar molding (PNAM) treatment for patients with bilateral cleft lip and palate (BCLP) with severely malpositioned premaxillae.

SETTING

This study was conducted at the Faculty of Dentistry, Department of Orthodontics, Ege University, Bornova, Izmir, Turkey.

METHOD

Retention arms were manufactured using a mold that we developed, and prefabricated retraction apparatuses were applied to the plaster model obtained from the patient. During the acrylic curing process, the flanges of the appliances were elongated into the sulcus without including the premaxilla. The premaxilla was aligned with the midline with an elastic band system, and the lip hanger was constructed with 0.023-in stainless steel wire. Elastic bands were stretched between the retraction apparatuses and the lip hanger based on the desired force. Nasal stents were added to the retention arms when the cleft width was reduced to less than 6 mm.

CONCLUSION

The modified PNAM treatment enabled faster derotation of the premaxilla and earlier initiation of retraction. The prefabricated retraction apparatus and retention arm provided efficient PNAM for patients with BCLP.

Effect of Presurgical Nasoalveolar Molding on Nasal Symmetry in Unilateral Complete Cleft Lip/Palate Patients after Primary Cheiloplasty without Concomitant Nasal Cartilage Dissection: Early Childhood Evaluation

OBJECTIVE

The objective of this study was to assess the efficacy of presurgical nasoalveolar molding (PNAM) on long-term nasal symmetry and shaping after primary cheiloplasty in patients with unilateral complete cleft lip/palate (UCL/P).

DESIGN

This was a two-group, parallel, retrospective, randomized clinical trial.

SETTING

The setting for this study was the Chang Gung Craniofacial Center in Taoyuan, Taiwan.

PATIENTS

Patients were divided into one of the following two groups: infants with UCL/P who underwent PNAM (PNAM group, n = 42) and infants with UCL/P who did not undergo PNAM (non-PNAM group, n = 42).

INTERVENTIONS

Interventions included PNAM and primary cheiloplasty without nasal cartilage dissection.

MAIN OUTCOME MEASURES

In this study, 4- to 5-year postoperative full-face and submental oblique photographs were taken of all patients and scored from 1 to 5 points by 10 medical evaluators. The scores were statistically analyzed using repeated-measures analysis of variance, and P < .05 was considered to represent statistical significance.

RESULTS

After 1 to 3 months of PNAM but before primary cheiloplasty, the displaced nasal and alveolar cartilage showed obvious improvement. However, the scores in the PNAM and non-PNAM groups at 4 to 5 years postoperatively were 66.62 ± 14.25 and 66.31 ± 15.08, respectively. There was no significant difference between the two groups ( F = 0.009, P = .923).

CONCLUSION

PNAM as an early-stage adjunctive therapy for nasal deformity correction is beneficial before primary cheiloplasty, but it is insufficient to maintain long-term nostril symmetry after primary cheiloplasty without nasal cartilage dissection.

Nasoalveolar Molding Therapy for the Treatment of Unilateral Cleft Lip and Palate Improves Nasal Symmetry and Maxillary Alveolar Dimensions

OBJECTIVE

The aim of this study is to assess the esthetic and morphologic outcomes before surgery using nasoalveolar molding (NAM) therapy in children with unilateral cleft lip and palate.

DESIGN

A prospective analysis was performed.

SETTING

The study was carried out in the Congenital Malformations Craniofacial and Cleft Lip and Palate Unit, Hospital Virgen de las Nieves, Andalusian Health Service, Granada (Spain).

PATIENTS

Twenty consecutively enrolled infants ranging in age from 7 to 30 days with nonsyndromic unilateral cleft lip and palate treated from 2008 to 2012.

INTERVENTIONS

All patients were treated with NAM appliances to align the alveolar segments and reduce severity of the nasal deformity.

MAIN OUTCOME MEASURE

The extraoral nasal measurements were performed on casts and nasal photographs. The measurements consisted of bialar width (BAW), columellar deviation (CD), cleft nostril height (CNH), cleft nostril width (CNW), non-CNH, non-CNW, and the deviation of the columella to the horizontal line represented by bilateral pupil line (BIA). The authors have made the measurements following Barilla method. Also 2 intraoral measurements were taken.

RESULTS

Following NAM the extraoral records showed a statistically significant decrease in CD (P < 0.0001), CNW (P < 0.0001), and BAW (P < 0.001). Furthermore, statistically significant increases in CNH (P < 0.05) and BIA (P < 0.0001) were observed.Following Barilla measurements, the authors have found a high percentage of symmetry in all the nasal measurements after the NAM therapy.Intraoral results showed a statistically significant decrease in the gap between the greater and lesser alveolar segments and a statistically significant increase in maxillary arch width.

CONCLUSIONS

Nasoalveolar molding improves nasal symmetry and achieves an improvement of all maxillary alveolar dimensions, increasing alveolar rim width, reducing the size of alveolar cleft gap, and improving shape of the maxillary dental arch. As a consequence of reducing the alveolar and nasal deformities before surgery, it is expected that the primary repair will be easier for the surgeon and more successful.

An Intraoral Appliance to Retract the Protrusive Premaxilla in Bilateral Cleft Lip Patients Presenting Late for Primary Lip Repair

The protruding and deviated premaxilla in bilateral complete cleft lip and palate (BCL/P) patients causes a perplexing problem in achieving a tension-free primary lip closure. An innovative noninvasive active intraoral Fixed Pre-Surgical Cleft Orthopedic (FPSCO) appliance is presented that has enabled to successfully reposition the premaxillary segment to a more favorable position prior to the surgical repair in 4 BCL/P patients, who reported late for treatment with a mean age of 18 ± 3 months. All the patients had at least 1 deciduous tooth erupted in 3 cleft segments, 1 premaxilla (PM), and 2 lateral maxillary (LM) segments. This innovative approach is a noninvasive method of getting the cleft segments closer prior to chelioplasty, where conventional presurgical nasoalveolar molding (PNAM) is not possible, which needs to be done early in life as it requires circulating maternal estrogen levels to achieve results preferably possible in patients younger than 3 to 6 months. Bonding to erupted teeth with glass ionomer cement was implemented to secure the appliance. Nickel-titanium (Ni-Ti) closed-coil springs were used that delivered continuous forces of 150 g/5 oz per side to retract the premaxillary segment. The mean active period of treatment time was 3.5 ± 1.6 months and the retention period was 1.2 ± 0.6 months, following which cheiloplasty was performed.

A Comparative Evaluation of Efficacy and Efficiency of Grayson's Presurgical Nasoalveolar Molding Technique in Patients with Complete Unilateral Cleft Lip and Palate with Those Treated with Figueroa's Modified Technique

Background

Presurgical nasoalveolar molding (PNAM) has been used for aligning and not only for approximating the maxillary alveolar segments preoperatively but also for improving the nasal symmetry and therefore facilitates primary surgical repairs in cleft patients.

Aim

This study was conducted to compare the efficacy and efficiency of Grayson's technique with Figueroa's modified presurgical nasoalveolar technique in complete unilateral cleft lip and palate (UCLP) infants.

Materials and Methods

Twenty-two infants aged 10-15 days were randomly divided into two equal groups: Group I treated with Grayson's PNAM technique and Group II with Figueroa's PNAM technique.

Results

When we compared nasal asymmetry values preoperatively and postoperatively of Group I and Group II, it was found that the nostril height increased significantly on the cleft side and nostril width decreased significantly postoperatively on the cleft side. When we compared nasal asymmetry values postoperatively of Group I with Group II, all the values were nonsignificant. When we compared the digital maxillary cast analysis outcomes preoperatively and postoperatively in Group I and Group II, it was found that there was a significant reduction in the alveolar gap and there is a significant increase in the arch width. When we compared the efficiency of Group I with Group II, it was found that Group II was more efficient than Group II.

Conclusion

This study showed a morphological improvement in nasal symmetry and maxillary alveoli of infants with UCLP treated with both Grayson's PNAM technique and Figueroa's PNAM technique with Grayson's PNAM technique being more efficient.

Effects of early and late cheiloplasty on anterior part of maxillary dental arch development in infants with unilateral complete cleft lip and palate

Objectives. The objective of this study is to compare the impact of early and late reconstruction of complete unilateral cleft lip and palate on the growth and development of the front of the dentoalveolar arch. Methods. This study was carried out in the years 2012-2015 at the Clinic of Plastic, Reconstructive and Aesthetic Surgery in Banska Bystrica. Infants with unilateral complete cleft lip and palate were divided into 2 groups according to the timing of lip reconstruction. Group A consisted of infants with early lip reconstruction-realised in the first 14 days of life. Group B consisted of infants with later lip reconstruction-realised in the third month of age. Maxillary dental casts were obtained for each child in four periods-in the first 14 days of life, in the third month, in the sixth month and in the age of one year. These were followed by the identification, measurement and evaluation of anthropometric parameters. Results. Significant differences were occurred after the reconstruction of the lips in linear and angle measurements between infants in the A and B groups. Conclusion. The early surgical reconstruction of the lips in the first 14 days of life has a positive effect on the growth and development of the anterior segment of the dentoalveolar arch. Early lip reconstruction forms a continuous pressure on the frontal segment, resulting in the earlier remedy of anatomical properties and creates appropriate conditions for the best development of this area.

A modified nasoalveolar molding technique for correction of unilateral cleft nose deformity

INTRODUCTION

Traditional Figueroa nasoalveolar molding (NAM) requires weekly or biweekly adjustments to remove acrylic from the palatal plate to narrow the alveolar gap. These frequent adjustments create a burden for patients living far from a hospital. To minimize this burden, we developed a modified NAM technique using simplified lip taping and a passive palatal plate. Herein we present our clinical experience and outcomes using the traditional and modified methods.

MATERIAL AND METHODS

In this blinded, retrospective study of 66 patients with complete unilateral cleft lip and palate, 33 received the traditional NAM and 33 received the modified NAM. Pretreatment and posttreatment facial photographs and clinical charts were used to compare efficacy (nostril height ratio, nostril width ratio, columellar angle, nasal base angle), efficiency (molding frequency), incidence of complications (facial irritation, mucosal ulceration), and medical cost.

RESULTS

Traditional and modified NAM did not differ in treatment efficacy for nostril height ratio (0.88 ± 0.14 vs. 0.90 ± 0.12), nostril width ratio (2.22 ± 0.39 vs. 2.38 ± 0.50), columellar angle (73.5 ± 9.1 degrees vs. 71.3 ± 11.8 degrees), nasal base angle (5.1 ± 2.4 degrees vs. 5.9 ± 2.7 degrees), or alveolar gap width (2.0 ± 2.0 mm vs. 2.0 ± 1.7 mm) (all p > 0.05). Traditional NAM was less efficient, i.e., required more adjustments (8.6 ± 2.0 vs. 6.7 ± 1.1), and cost more (22016.4 ± 2012.7 New Taiwan dollars vs. 20137.6 ± 1173.4 New Taiwan dollars) (both p < 0.001).

CONCLUSIONS

Both NAM techniques similarly improved nasal deformities and reduced alveolar gaps, but the modified technique was more efficient and cost less in terms of insurance reimbursement and supplies (labial tapes).

Comparison of Early Onset Nasoalveolar Molding With Patients Who Presented for Molding Up to 1 Year of Age

PURPOSE

To compare the effectiveness of nasoalveolar molding (NAM) in infants with complete unilateral cleft lip and palate presenting before and after 6 months of age and justify its use in older infants presenting for treatment.

MATERIALS AND METHODS

The university NAM protocol was followed for 150 patients who were included in the study. NAM was performed by 1 month of age (group I, n = 50), at 1 to 6 months of age (group II, n = 50), and at 6 months to 1 year of age (group III, n = 50). Seven linear anthropometric measurements were compared using dentofacial models.

RESULTS

Statistical analysis before and after NAM showed that group I had 83, 176, 69, and 142% improvement in intersegment distance, nasal height, nasal dome height, and columella height, respectively. Group II had 53, 44, 30, and 67% improvement. Group III had 45, 38, 28, and 62% improvement.

CONCLUSION

Patients in all 3 groups showed improvement with the NAM protocol. Although patients who presented for treatment before 1 month of age benefited the most, those who presented at 6 months to 1 year of age benefited as much from NAM as those who presented at 1 to 6 months, thus validating its use in these patients.

Current status of presurgical infant orthopaedic treatment for cleft lip and palate patients: A critical review

Rehabilitation of cleft lip and palate (CLP) patients is a challenge for all the concerned members of the cleft team, and various treatment modalities have been attempted to obtain aesthetic results. Presurgical infant orthopaedics (PSIO) was introduced to reshape alveolar and nasal segments prior to surgical repair of cleft lip. However, literature reports lot of controversy regarding the use of PSIO in patients with CLP. Evaluation of long-term results of PSIO can provide scientific evidence on the efficacy and usefulness of PSIO in CLP patients. The aim was to assess the scientific evidence on the efficiency of PSIO appliances in patients with CLP and to critically analyse the current status of PSIO. A PubMed search was performed using the terms PSIO, presurgical nasoalveolar moulding and its long-term results and related articles were selected for the review. The documented studies report no beneficial effect of PSIO on maxillary arch dimensions, facial aesthetics and in the subsequent development of dentition and occlusion in CLP patients. Nasal moulding seems to be more beneficial and effective in unilateral cleft lip and palate patients with better long-term results.

Double-loop technique using titanium molybdenum alloy wire for fabrication of nasal stents in nasoalveolar molding therapy for cleft lip and palate patients

This article presents a technique for fabricating a modified nasoalveolar molding appliance using 0.032-inch titanium-molybdenum alloy wire for nasal stents incorporating a double loop. The nasal stents are included in the acrylic molding plate at the time the appliance is inserted. The acrylic retention button used in a conventional appliance is replaced by a simple retention hook fabricated using titanium-molybdenum alloy wire. This technique is an effective alternative to a conventional appliance, and it simplifies the appliance-modification process during follow-up visits.

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.

Limited evidence for the effect of presurgical nasoalveolar molding in unilateral cleft on nasal symmetry: a call for unified research

BACKGROUND

In the past two decades, presurgical nasoalveolar molding has been applied increasingly in the care of patients with a cleft to improve nasal symmetry and facilitate closure of the lip and secondary rhinoplasty. Many cleft centers do not apply presurgical molding, because its effect is disputed. This review aims to quantify the effect of nasal symmetry in the long term.

METHODS

A systematic review of the literature with the intention of performing a meta-analysis was performed. The search terms "cleft" AND ("molding" OR "moulding") were used in three databases. Twelve studies met the following inclusion criteria: (1) participants were humans with nonsyndromic unilateral cleft; (2) data concerning the effect of nasoalveolar molding on symmetry of the nose are reported or can be deduced; (3) article was written in English, German, or Dutch.

RESULTS

The heterogeneity of the study designs, outcome variables, outcome variable expressions, follow-up periods, and inadequate data reporting made it impossible to calculate effect sizes and to perform a meta-analysis. All studies had a low Grading of Recommendations Assessment, Development and Evaluation level. Five studies reported exclusively positive effects on nasal symmetry, six studies reported mixed effects, and one study reported exclusively no effects.

CONCLUSIONS

Results of studies of nasoalveolar molding are inconsistent regarding changes in nasal symmetry; however, there is a trend toward a positive effect. Studies concerning nasoalveolar molding in unilateral cleft lip, jaw, and palate are heterogeneous and lack adequate reporting. Recommendations for future research were provided to construct a consensus about the effect of nasoalveolar molding.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

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.

Long-Term Effects of Presurgical Infant Orthopedics in Patients with Cleft Lip and Palate: A Systematic Review

Objective

This study aimed to assess the scientific evidence on the efficiency of presurgical infant orthopedic appliances in patients with cleft lip and palate to shed light on a specific, contemporary discussion of whether the appliances have long-term advantages with respect to treatment outcomes.

Design

A systematic review.

Method

Two literature surveys from the five electronic databases were performed with a 1-month interval. Randomized controlled trials and controlled clinical trials (controls had no presurgical infant orthopedics) that had follow-up periods of a minimum of 6 years were included in the study. The exceptions to the follow-up limit were studies related to feeding and parent satisfaction.

Results

Of the 319 articles retrieved in the literature surveys, 12 were qualified for the final analysis. The level of evidence of these articles ranged from 1b to 4. Eight randomized controlled trials and four controlled clinical trials were available on eight treatment outcomes. The longest follow-up period of the randomized controlled trials was 6 years. No randomized controlled trials were found on active presurgical infant orthopedic appliances and on nasoalveolar molding appliances.

Conclusions

Based on the results, presurgical infant orthopedic appliances have no long-term positive effects on seven of the eight studied treatment outcomes in patients with cleft lip and palate. More randomized controlled trials need to be done to have evidence regarding the effects of presurgical infant orthopedics in different surgical protocols. Also, the encouraging results about the effect of nasolaveolar molding appliances on nasal symmetry have to be supported by future randomized controlled trials.

Influence of lip closure on alveolar cleft width in patients with cleft lip and palate

Background

The influence of surgery on growth and stability after treatment in patients with cleft lip and palate are topics still under discussion. The aim of the present study was to investigate the influence of early lip closure on the width of the alveolar cleft using dental casts.

Methods

A total of 44 clefts were investigated using plaster casts, 30 unilateral and 7 bilateral clefts. All infants received a passive molding plate a few days after birth. The age at the time of closure of the lip was 2.1 month in average (range 1-6 months). Plaster casts were obtained at the following stages: shortly after birth, prior to lip closure, prior to soft palate closure. We determined the width of the alveolar cleft before lip closure and prior to soft palate closure measuring the alveolar cleft width from the most lateral point of the premaxilla/anterior segment to the most medial point of the smaller segment.

Results

After lip closure 15 clefts presented with a width of 0 mm, meaning that the mucosa of the segments was almost touching one another. 19 clefts showed a width of up to 2 mm and 10 clefts were still over 2 mm wide. This means a reduction of 0% in 5 clefts, of 1-50% in 6 clefts, of 51-99% in 19 clefts, and of 100% in 14 clefts.

Conclusions

Early lip closure reduces alveolar cleft width. In most cases our aim of a remaining cleft width of 2 mm or less can be achieved. These are promising conditions for primary alveolar bone grafting to restore the dental bony arch.

Presurgical nasoalveolar molding assisted primary reconstruction in complete unilateral cleft lip palate infants

BACKGROUND

Various methods have been described for the primary surgical reconstruction of the unilateral cleft lip and palate deformity (UCLP) in infants. There have been several attempts at restoring the normal anatomy of the nose at the time of lip repair in the affected individuals with varying degrees of success. Presurgical nasoalveolar molding (PNAM) is a presurgical infant orthopedic procedure that attempts to target the nasal deformity leading to a more esthetic surgical repair.

OBJECTIVE

At our center we aimed to use PNAM to help in providing 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

The infant nasal cartilages are amenable to correction in the first few weeks of life when they retain their plasticity. Three infants with complete unilateral cleft lip palate (CUCLP) were operated upon after a course of PNAM. No nasal stents were use after repair to retain the results.

RESULTS

PNAM reduced the extent of the cleft deformity and improved the anatomic relationship between the affected structures. Postoperative recovery was uneventful. Subjective evaluation immediate post surgery and at the time of palate repair reveals adequate nasolabial esthetics. Long-term results of PNAM assisted repair are to be ascertained.

CONCLUSIONS

The use of PNAM enables in reducing the severity of the deformity the surgical team has to tackle thereby enabling in a better and esthetic primary repair.

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

Presurgical nasoalveolar molding (NAM) in the orofacial orthopedic treatment of unilateral clefts of the lip and palate aims to align and approximate the maxillary hemialveolar segments and simultaneously support and mold the deformed nasal cartilages, correct and center nasal tip projection, and lengthen the deficient cleft-side columella in early infancy, before the primary reparative lip surgery. A number of techniques of achieving these objectives have been described in the literature and are increasingly being practiced by cleft care teams around the world. However, a detailed description of the nasal stent is lacking in the literature and needs to be elucidated to facilitate greater usage of presurgical NAM in contemporary practice. This report fills this void by providing an analytical description of the different parts of the nasal stent; clarifies their desirable design features, anatomic correlations, and clinical importance; and illustrates in a step-by-step manner simple direct and indirect methods of incorporating a nasal stent, improvised by the author in his practice, that can be used with any of the contemporary NAM appliances and techniques. From the simple methods described, clinicians will be enabled to select one that may be most easily adaptable to their preferred appliance and clinical setting.

A preoperative appliance for a newborn with cleft palate

Cleft palate is a commonly observed congenital maxillofacial defect. One of the most important problems with clefts is the interference with feeding. An affected infant cannot produce negative pressure in the oral cavity and therefore cannot move the bolus backward to the pharynx. To obtain better nutritional intake prior to surgical correction, a palatal lift obturator is recommended. In this clinical report, a modified technique of obturator fabrication is presented. The new method uses a piece of tulle, a flexible and durable material that is frequently used in theater attire. With the help of this material, the bulb part is connected to the plate as a labile piece, and this connection acts like a natural velopharyngeal extension. Additionally, because of the softer property of the silicone elastomer, the posterior pharyngeal wall is less irritated.

Complications and solutions in presurgical nasoalveolar molding therapy

OBJECTIVE

To outline three main categories of nasoalveolar molding complications, describe their etiologies and manifestations, and prescribe preventive and palliative therapy for their proper management. Estimates of the incidence of each complication also are provided.

MATERIALS AND METHODS

Data were collected retrospectively from the charts of 27 patients with complete unilateral cleft lip and palate treated by the first author (D.L.-B.) at the University of Puerto Rico (n = 12) and the Medical College of Georgia (n = 15). Confidence intervals for the true incidence of each complication were calculated using exact methods based on the binomial distribution. A significance level of .05 was used for all statistical tests.

RESULTS

Of the soft and hard tissue complications considered, only one (tissue irritation) had an estimated incidence greater than 10%. Compliance issues were of greater concern, with an estimated incidence of 30% for broken appointments and an estimated incidence of 26% for removal of the nasoalveolar molding appliance by the tongue.

CONCLUSIONS

Although benefits outnumber the complications, it is important to address all complications in order to prevent any deleterious outcomes.

Three-dimensional facial morphology following surgical repair of unilateral cleft lip and palate in patients after nasoalveolar molding

OBJECTIVE

To evaluate three-dimensional (3D) facial morphology in patients surgically corrected for unilateral cleft lip and palate (UCLP) following pre-surgical nasoalveolar molding (NAM).

DESIGN

Prospective, longitudinal study. Digital stereophotogrammetry was used to capture 3D facial images, and x, y, and z coordinates of five landmarks were digitized to compute mean morphologies. The sample comprised 15 patients with left UCLP and 10 matched control subjects. Facial form differences at age 37 weeks, using principal components analysis and finite-element scaling analysis (FESA) were assessed.

RESULTS

Using the first two principal components, which accounted for 63% of the total shape-change, UCLP and control groups showed similar distributions in the modal space (p > 0.05). For the UCLP group, the mean 3D facial form was smaller and less protrusive when superimposed on the non-cleft mean. Using FESA, reductions in facial volume were found in the UCLP group, involving the columella (29%), labial tubercle (51%), lower lip (29%) and lateral aspects of the face (19%). The UCLP group also showed increases in size above the tip of the nose (25%) and laterally to the columella directly below the nares (29%).

CONCLUSIONS

Following surgical repair of UCLP in patients previously treated with NAM, 3D facial morphology was virtually indistinguishable from the non-cleft mean. Clinically, the apparent improvement in the facial soft tissues may mask dysmorphic skeletal growth, and further studies are required to characterize the underlying bony changes associated with the soft tissue changes reported here.

Presurgical nasoalveolar molding in patients with unilateral clefts of lip, alveolus and palate. Case study and review of the literature

INTRODUCTION

The case of a newborn female patient with unilateral cleft lip, alveolus and palate is presented with a markedly sunken nasal wing at the cleft side. This finding may lead to a very unsatisfactory aesthetic result after primary cheiloplasty and nasoplasty.

PATIENT AND METHOD

Five months prior to surgery, the patient was treated with a palatal plate and additionally with a nasoalveolar conformer for 4 months thereof. The device consisted of an acrylic pelotte (attached to the maxillary plate with a wire) which lifted the nasal dome and was activated regularly. Under this presurgical treatment, the cleft edges moved closer to each other by 1.8 mm at the alveolar ridge and by 4.5 mm in the palatal area. The nasal wing was lifted by 5 mm. This was enabling elevation of the nasal wing during primary surgery in the case described. Questions are raised as to the remaining effects on nasal symmetry until completion of growth and, on the other hand, as to the chances to reduce postsurgical alar relapse by continued nasal molding beyond primary surgery.

CONCLUSION

Presurgical nasal molding seems to improve aesthetics of the nose in patients with unilateral clefts of lip, alveolus and palate and distinctly flattend nasal wings.

Unilateral Complete Cleft Lip and Palate Repair Using Lip Adhesion Combined with a Passive Intraoral Alveolar Molding Appliance: Surgical Results and the Effect on the Maxillary Alveolar Arch

BACKGROUND

A number of combined maxillary orthopedic and surgical treatment protocols have been proposed for the initial phase of therapy for infants with a complete cleft lip and palate.

METHODS

Lip adhesion was used in combination with a passive intraoral molding appliance to treat a unilateral complete cleft lip and palate. The proposed protocols are lip adhesion, along with positioning of a passive alveolar molding appliance, at 4 to 6 weeks of age, then definitive cheiloplasty at 4 to 5 months of age, and palatoplasty at 12 months of age. Twenty-five patients with a complete cleft lip and palate were treated using this protocol between 1994 and 2003. The follow-up period was between 6 months and 10 years.

RESULTS

The alveolar gap, the length of the maxillary alveolar cleft, and the palatal gap were 10.1 +/- 4.2 mm, 6.1 +/- 0.9 mm, and 13.4 +/- 2.9 mm for lip adhesion, 3.1 +/- 1.4 mm, 2.6 +/- 0.8 mm, and 9.6 +/- 1.5 mm for definitive cheiloplasty, and 0.2 +/- 0.1 mm, 1.5 +/- 0.7 mm, and 8.3 +/- 1.1 mm for palatoplasty. For the following maxillary dental casts for 3 to 10 year olds, the intercanine width and canine arch lengths were within the normal value. The intermolar width and the molar arch length, however, decreased slightly compared with the control normal values.

CONCLUSIONS

Lip adhesion and a passive alveolar molding appliance achieved a normal position and stabilized the arch in a symmetrical platform.

Extraoral nasal molding in a newborn with unilateral cleft lip and palate: a case report

OBJECTIVE

The purpose of this case report is to introduce an extraoral nasal molding appliance (ENMA) and treatment approach for presurgical nasoalveolar molding in newborns with unilateral cleft lip and palate.

METHODS

A 15-day-old girl presented with complete unilateral cleft lip and palate. A circumferential headband supported the actual nasoalveolar molding device, which consisted of a nasal stent made from a 0.8-mm stainless steel helical spring. The spring was activated at 2-week intervals.

DISCUSSION

The shape of the cartilaginous septum, alar cartilage tip, medial and lateral crus and alveolar segments were molded to resemble the normal shape of these structures. ENMA can be helpful in any patient with unilateral cleft lip and palate because it is easy to fabricate, practical to activate, and comfortable to wear and use.